Cholestasis of pregnancy: a pathology of the liver in pregnancy
Cholestasis of pregnancy is a disease that affects the liver of pregnant women and causes severe and unbearable itching that makes life very difficult for women. The risks of this pathology are high and therapy is essential: childbirth is often induced in advance to avoid the risk of fetal death. Watch the video and find out how the baby develops in the mother's womb, week after week!
Symptoms of gravidaric cholestasis
The main symptom of cholestasis gravidarum is intense and persistent itching, which usually starts in the hands and soles of the feet and then spreads to the face, trunk and limbs, although it does not cause a skin rash. During the night the itching can increase and the pregnant woman can get scratches and grazes, scratching. In pregnancy, the woman often accuses this symptom due to increased water retention or because the swelling of the body produces skin tensions, which give sensations of itching, but, unlike that caused by pregnancy cholestasis, it is a mild limited symptom a few more tense areas, such as the abdomen and thighs. In this pathology, moreover, itching is associated with dark, hyperchromic urine, a slight jaundice visible in the sclera (whites of the eyes), sometimes on the skin, due to poor absorption, with the presence of undigested fats in the light gray faeces and pungent odor. Other symptoms that may occur less frequently are feelings of nausea, fatigue, vomiting and loss of appetite. If not treated properly, cholestasis of pregnancy, also called hepatogestosis or intrahepatic cholestasis of pregnancy (IGC), can have serious consequences. From clinical analyzes, the typical data of this pathology is the increase in the levels of bile acids or liver transaminases AST, aspartate aminotransferase, and ALT, alanine aminotransferase. An alteration of the biliary stasis enzymes, alkaline phosphatase and gamma-glutamyltransferase (gamma-GT) can also be found.The specialist may request an ultrasound to investigate the cause of the pathology.
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The causes and risk factors of hepatogestosis
Cholestasis of pregnancy has multiple triggers. The excess of bile salts, which pours into the bloodstream and tissues, irritates the peripheral nerves and causes intolerable itching. Other causes are involved in its pathogenesis: hormonal, genetic, environmental factors. As for hormonal factors, their importance can be noted from the manifestation of the pathology almost always in the last three months of gestation, when there is a noticeable increase in estrogen and progesterone. And, moreover, when these hormonal levels return to normal with childbirth, the symptoms of pregnancy cholestasis also disappear. In addition, the disease appears especially in twin pregnancies, when the liver is burdened by much more estrogen. Genetic factors are also important. Some women with mothers or sisters who have had the same condition during pregnancy seem more likely to develop it. As far as environmental factors are concerned, it seems that the disease occurs in a more severe form in winter and is also influenced by the type of diet. The states in which there is a greater frequency of this pathology are Chile, Bolivia and Scandinavian countries. In these populations 2.0% of pregnant women can suffer from it. Instead, in the rest of Europe and North America the percentage is 0.5-1.5 of pregnant women. Therefore, cholestasis of pregnancy varies according to the ethnic group you belong to and the area in which you live. According to some studies, even a selenium deficiency could affect the development of this pathology. Other predisposing factors are hepatitis prior to pregnancy, cholelithiasis (ie the presence of stones inside the gallbladder) or urinary tract infections. The women most at risk for predisposition to pregnancy cholestasis must be kept under control especially in the period in which the estrogen values are highest, that is from the seventh month to delivery. Let us now analyze the effects on the mother and the fetus.
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During pregnancy it is advisable to check the bilirubin and transaminase values with laboratory analyzes. Primary bile acids and their conjugates are mostly present as bile salts, which exert an important purifying action, helping to expel cholesterol and making fats and fat-soluble vitamins soluble, facilitating their digestion and absorption. Jaundice in women with cholestasis of gravity appears rarely. It is not a very serious problem for the pregnant woman, apart from possible gallbladder stones. After all, pregnancy is a particular period of life in which transient pathologies can occur, such as gestational diabetes, metabolic syndrome and hypertension. The effects on the baby, on the other hand, can be quite serious: fetal suffering, intrauterine death, neonatal asphyxia or neonatal death due to the toxic effect of bile acids. The excess of these acids in the blood can reduce the pulmonary surfactant produced by the fetus, which allows the baby to develop lung maturity and the ability to breathe independently after birth. In addition, the first stool of the fetus (meconium) may enter the amniotic fluid that surrounds it, with possible asphyxiation after childbirth. For the mother there are possible complications regarding a "post partum haemorrhage, due to a bad absorption of vitamin k, which plays a role in blood clotting. In fact, in the last month of pregnancy the specialist can prescribe it for delivery. , to avoid the risk of reducing bleeding resulting from a deficiency Vitamin K can be administered with Phytomenadione (Vitamin K1) and Menadione (Vitamin K3).
Therapies against the accumulation of bile acids in the bloodstream
After a diagnosis of cholestasis of pregnancy, drug therapy is rapidly begun, with the aim of bringing the birth to the thirty-seventh week. The most common therapy for this alteration of bile acids in the liver consists of a drug based on ursodeoxycholic acid, which can be administered even in high doses without harmful effects on the unborn child and also helps to soothe the itching). With drugs and regular examinations, the disease can be monitored until the specialist believes that it is possible to induce childbirth. Bile acid values usually return to normal three months after delivery. The pregnant woman with cholestasis of pregnancy must avoid or limit fatty foods and fried foods, prefer unprocessed, steamed, grilled or boiled dishes, lean fish and meat, fresh cheeses and extra virgin olive oil, eat vegetables and fruit every day and drink plain water.
Induction of childbirth reduces the risk of fetal death
When the pregnant woman suffers from hepatogestosis, as soon as the pulmonary development of the unborn child is completed, that is towards the thirty-sixth / thirty-seventh week of gestation, delivery can be induced. With this solution the risk of fetal death is reduced. Among the complications for the fetus and for the newborn we remember for a preterm birth the following: amniotic fluid with meconium, abnormal heart rhythm of the fetus, difficulty in breathing of the newborn. For these events, admission to a neonatal intensive care unit is required. After childbirth, women who have had cholestasis of pregnancy are not recommended to take the contraceptive pill, since as an estrogen-progestogen it could produce the same effects as this pathology. Cetirizine and loratadine, oral antihistamines, can help reduce excess itching, which causes severe discomfort and nervousness in the pregnant woman. In case of hepatogestosis, the gynecologist can prescribe the future mother to take S-Adenosyl-Methionine, an amino acid that together with folic acid prevents neural tube defects and associated with ursodeoxycholic acid, regulates the levels of acids biliary and relieves the severe problem of itching. An alternative to ursodeoxycholic acid is cholestyramine, which, by binding to the bile acids, does not allow their reabsorption. Everything is expelled with the feces. This drug is usually not recommended during pregnancy as it does not absorb essential vitamins and could adversely affect the coagulopathies of the mother and fetus. If its prescription is necessary, the specialist will increase the vitamin support with vitamins A, D, E and K to make up for their natural lack of absorption.
