There is no cure for OC. Doctors will monitor your condition, treat symptoms and may advise delivering your baby early.
Monitoring your liver function
Following diagnosis of OC, doctors may carry out liver function tests on a weekly basis to monitor your condition. This may involve more trips to hospital, which can be either reassuring or unsettling at this time. If your itching persists, doctors are advised to run these tests every one or two weeks.
If measured levels return to normal, doctors may consider that you do not have OC and revise their diagnosis. A very rapid increase in levels can occur in OC, but may also indicate other conditions that your doctor will wish to investigate1.
Relieving the itch and lowering your bile salts
Topical creams such as calamine lotion and aqueous cream with menthol, are safe and may provide some temporary relief from itching for some women.
A number of medications may be used in your treatment. As yet, a specific medication to manage OC is not available, although clinical studies are in progress. Medication is currently aimed at reducing the build-up of bile salts in your blood, to relieve the itching and to protect your baby. Some of the medications listed below are primarily used for other conditions and agreement about their effectiveness in OC is still being discussed and investigated.
- Ursodeoxycholic acid (URSO or UDCA) is a naturally occurring bile acid which accounts for 1% of circulating bile acids in your body. It provides protection for the liver by displacing more harmful bile acids, improving the flow of bile and decreasing the delivery of bile acids to the baby10.
URSO is the most commonly prescribed medication to relieve itching caused by OC. It is still being evaluated for use in pregnancy and is prescribed with ‘informed consent’ (that is, taken with the knowledge that it is not licensed).
One study has shown that URSO is particularly effective in OC cases with higher levels of bile salts (greater than 40µmol/L)14. URSO has been used for many years and although there have been no reports of adverse effects for the unborn baby when the mother takes URSO, there have been no studies to look into this and wider research studies need to be carried out.
(Decadron) is a steroid sometimes prescribed for a few days to increase the maturity of the baby’s lungs so the baby can be delivered earlier2. It has also been previously used to attempt to reduce the mother’s level of hormone production and to help relieve itching. However, continuous use of steroids in pregnancy is now thought not to be good for the baby15 and very few clinicians will treat OC with this drug.
Chlorpheniramine (Piriton) is an antihistamine that may be prescribed to help you sleep at night by making you drowsy but is not considered to have any effect on your itching.
- Cholestyramine has been proven to reduce itching in some women but does not improve liver function or bile salt levels and may lead to vitamin K deficiency1. It also binds bile acids and so should not be taken at the same time as URSO. For these reasons it is not in clinical use.
Other drugs are currently being investigated for use in OC including heparin, rifampicin and nor-UDCA. Results of these investigations are due to be completed in 2011.16
The role of vitamin K
Vitamin K is a fat-soluble vitamin, absorbed in your diet, that is essential for blood coagulation (clotting).
Absorption of fats can be reduced in OC and this could affect the uptake of vitamin K1. A lack of vitamin K can affect your bloods clotting mechanism and could result in increased blood loss during delivery. Many doctors will check how your blood is clotting and if necessary prescribe a daily supplement of vitamin K, in the form of an oral water-soluble tablet, to try and reduce the risk of a severe bleed after delivery. However, there is no research at present to confirm that taking oral vitamin K will do this, but neither is it thought to harm your baby.
Following the birth, it is recommended that your baby be given vitamin K, usually in the form of an injection. This is standard practice for all newborns (whether from an OC pregnancy or not) as many are deficient in vitamin K17.
Deciding whether to deliver early
If you have OC, the practice in most obstetric units is to monitor you closely (checking your liver enzymes and bile salt levels) and for your baby to be delivered between 37-38 weeks of pregnancy. At the moment it is not known for certain whether early delivery is the best way to manage your pregnancy.
It is not possible to predict stillbirth based on your liver enzyme and bile salt levels1. Research has shown that mothers with fasting bile salt levels greater than 40µmol/L are at most risk of going into premature labour and their babies showing symptoms of distress18. However, complications for the baby have occurred in mothers whose bile salts are below 40µmol/L.
Bile salt levels usually rise as the pregnancy continues. The weekly monitoring of your blood tests will help your doctor to see if levels are rising and make decisions about any increased risks.
Your obstetrician should discuss fully the possible risks and benefits of early delivery with you13. Some premature babies may need to be admitted to a special care baby unit.
Other monitoring may include having regular tests to monitor your baby’s heartbeat (cardiotocography or CTG) and scans (to look at oxygen flow and the growth of your baby). Neither of these procedures have been shown to be able to predict a baby that may be at risk from OC, however, many women find it reassuring to have them.
With ‘active’ management (such as monitoring, symptom treatment and early delivery) the risk of stillbirth for women with OC is thought to be the same as that for normal pregnancy (around 1%)1. It is not currently known which aspects of ‘active’ management are of most benefit. A UK trial is currently trying to establish whether ursodeoxycholic acid and/or delivery between 37-38 weeks of pregnancy contribute to improving outcomes for the baby3.
Aftercare
You and your baby should receive the standard health checks after birth. After the delivery the itching should disappear relatively quickly. There are no known developmental problems for the baby. The risk of developing neonatal jaundice is the same as for other babies. It is thought that there is no major damage caused to the liver of either mother or baby.
Women with a previous history of OC are more likely to have gallstones and some other forms of liver impairment in later life19. Specifically a small proportion of women who have had OC may develop autoimmune forms of liver disease, such as autoimmune hepatitis or primary biliary cirrhosis (see our disease specific publications for more information on these conditions).
Some women who have had OC also develop cholestasis outside of pregnancy when taking some medications such as antibiotics or the contraceptive pill (see the ‘Looking after yourself’ section for advice).
You should have a blood test before you are discharged from hospital to check your LFTs and bile salts are reducing, however, LFTs can be raised for the first 10 days after birth in normal pregnancy.
You should have a follow-up post natal check related to your OC at around six to twelve weeks to confirm that symptoms have resolved and the diagnosis was correct. At your appointment your doctor will be keen to establish that the itching has gone away and carry out an LFT and serum bile salt test to see if these have returned to normal. Levels should improve over time but it may take up to 12 weeks for LFTs to go back to normal.
If there are any abnormal results you will need to have further tests. These are to determine whether your liver is taking extra time to settle down or, more rarely, whether you have an underlying liver problem.
If the latter is the case, you may be referred to a hepatologist (liver specialist), or perhaps a gastroenterologist (specialist in disorders of the digestive tract) with knowledge of liver problems.
In general, if you continue to itch after six months, a referral to a liver specialist should be sought.