Pregnancy brings with it a whole host of changes due to the growing fetus and the hormones that support it.
In the latter half of pregnancy there is a surge in placental hormones that alter the function of the liver. It’s capacity to store bile increases and bile movement becomes sluggish. The metabolism thus slows down.
When the liver doesn’t function properly and is unable to remove the bilirubin from the blood, the bilirubin levels rise.
Jaundice in pregnancy occurs when there is excess bilirubin in circulation.
What is bilirubin?
“Bilirubin is a yellow pigment produced as a waste product in the body. This is taken up by the liver and excreted in the bile. The bile (which contains bile acids, cholesterol and bilirubin besides other salts) flows from the liver to the gallbladder and further empties into the intestine.
“The normal bilirubin levels range upto 0.1 to 1.2 mg/dl. Jaundice in pregnancy occurs when bilirubin levels are greater than 2 mg/dl. The increase in bilirubin causes yellowness of the eyes, skin and urine. This typically starts to show when it is higher than 3mg/dl, “ explains Dr. Anita Sabherwal Anand, Consultant Obstetrician-Gynecologist at Sitaram Bhartia Hospital in South Delhi.
“Jaundice in pregnancy may occur due to medical conditions or factors associated with pregnancy.”
Jaundice in pregnancy can occur due to:
- Liver damage, due to infections, drug toxicity, pregnancy associated conditions like cholestasis, pre-eclampsia and auto-immune hepatitis or medical conditions like cirrhosis or cancers.
- Haemolysis, which is the damage to red blood cells due to various causes and which leads to an increased production in bilirubin.
- Obstruction to the flow of bile with gallbladder diseases like blockage in the bile duct due to its narrowing or stones or tumors.
According to a study published in the Journal of Indian Medical Association, the incidence of jaundice during pregnancy was seen to be 1 in 429.
What is the most common cause of jaundice in pregnancy?
The most common cause of jaundice in pregnancy is infection or Viral Hepatitis.
“Viral Hepatitis occurs when the liver is infected with viruses known as Hepatitis A, B, C, D or E. These cause inflammation and damage of the liver cells leading to accumulation of bilirubin in the blood.”
Hepatitis A and E are caused by consuming contaminated food and water, often from roadside eateries and unhygienic places.
The common modes of transmission of Hepatitis B, C and D are blood and blood products, invasive medical procedures using contaminated and sexual contact.
Hepatitis B can be transmitted from mother to baby at birth as well.
“Hepatitis A and E can cause brief infections after which people recover. Hepatitis B, C and D, however, may cause persistent infections in the body that are difficult to eradicate and often lead to slow damage of the liver. ”
What are other causes of jaundice in pregnancy?
There are situations specific to pregnancy that increase the risk of jaundice in pregnancy. These are:
- Cholestasis of pregnancy: This condition is characterized by stasis of bile in liver and overflow of bile salts into circulation. It predominantly presents in the third trimester and the mother complains of itching all over the body particularly in the palms and soles. There is associated liver cell damage leading to increase in liver enzymes named transaminases in blood. The liver transaminases (SGOT and SGPT) levels are usually two times the normal level in the blood and bilirubin is usually mildly raised.
- Pre-eclampsia and HELLP syndrome: This condition is associated with high blood pressure and excess protein in the urine. In some mothers, this can cause liver damage and elevated liver enzymes with jaundice.
- Hyperemesis gravidarum: This occurs primarily in the first trimester and there is severe uncontrolled vomiting. It may be associated with liver dysfunction and mild jaundice.
- Acute fatty liver of pregnancy: This is a very rare complication of pregnancy, seen in late third trimester. This may occur due to unknown causes and is associated with severe vomiting, fever, pain in the abdomen and rapid liver damage.
Is jaundice harmful during pregnancy?
Jaundice in pregnancy in the majority of cases is mild and can be managed successfully.
However, in certain situations like pre-eclampsia or HELLP and other medical illnesses, it can be associated with unfavorable outcomes in the mother and baby depending upon the severity of liver damage.
Maternal complications include
- severe liver damage leading to liver failure and death
- neurological complications
- renal shutdown and
- tendency to bleed
The risks to the baby include
- preterm labour and preterm delivery
- inadequate oxygenation and growth of baby
- death of baby in womb and stillbirth
- transmission of infections like viral hepatitis B and E from mother to baby
Delivery complications may include
- induction of labour
- fetal distress and
- muconium stained liquor
- higher chances of cesarean
- heavy bleeding before or after delivery,
- blood transfusion and
- ICU admission
How is jaundice in pregnancy diagnosed?
“Your gynecologist will suspect jaundice in pregnancy if she notices yellow discolouration of eyes and skin or if you complain of passing dark yellow to orange urine and relatively light coloured stool, “ says Dr. Anita, “so be sure to let your doctor know in case you think anything appears unusual.”
It is common to experience symptoms like
- Nausea or vomiting, little appetite, fatigue and fever in case of infections
- Intense itching all over the body in the case of cholestasis
- Pain in the upper abdomen and heartburn which doesn’t subside with antacids in the case of gallstones
- Mental confusion, delirium and decreased consciousness with swelling all over the body, which happens with severe liver diseases
Your doctor will suggest blood tests to determine and confirm the cause of jaundice.
- Liver function tests which include bilirubin and liver enzymes (transaminases). They are very high in viral hepatitis, moderately high in cholestasis and pre-eclampsia.
- Bile acid levels in suspected cases of cholestasis of pregnancy.
- Ultrasound of the abdomen to evaluate the status of the liver, presence of gallstones, severity of the damage in certain medical disorders like cirrhosis and acute fatty liver of pregnancy
- Other blood parameters to confirm the cause of jaundice and medical status of the mother include viral markers for viral hepatitis, platelet count and clotting tests for pre-eclampsia and HELLP syndrome. A complete blood work up may be required in complicated cases.
Once diagnosed, treatment becomes essential to avoid complications.
How is jaundice in pregnancy treated?
The treatment depends entirely on the cause of jaundice in pregnancy.
The aim of treatment is to manage the condition, prevent medical complications and treat the underlying cause.
The common conditions that cause jaundice in pregnancy require supportive therapy.
Treatment may include
- intravenous fluids for hydration and nutrition
- anti-vomiting medication
- fever medication
- drugs like ursodeoxycholic acid tablets for cholestasis of pregnancy
- critical and multidisciplinary care for severe liver diseases.
In viral hepatitis, adequate nutrition and hydration with supportive antibiotics to prevent add-on infections usually is sufficient. These infections are self-limiting.
In cholestasis of pregnancy, managing nausea, heartburn and itching are important while in pre-eclampsia controlling blood pressure with medications is essential.
In all conditions, the well-being of the fetus, through check-ups, ultrasounds and heart beat monitoring is performed regularly.
Occasionally, the delivery may be planned, at times even pre-maturely, in order to treat some cases of jaundice in pregnancy.
Is normal delivery possible with jaundice in pregnancy?
“If the mother and baby are healthy and there are no complications, a vaginal delivery would be preferred, “ says Dr. Anita.
“But if complications develop, before or during labour, a cesarean section may become safer.”
How to Cope with Jaundice in Pregnancy: Anjana’s story
When Anjana Shetty began to have itchy hands in her third trimester, she dismissed it as dry skin brought on by the winters. She used coconut oil to lessen the itching. But it continued for a few days and her entire body started to itch.
She consulted her doctor for a permanent treatment option that would ease the itching.
“Anjana displayed classical symptoms of Intrahepatic Cholestasis of Pregnancy (ICP),” says Dr. Anita, her gynecologist.
“Tests confirmed our suspicions and she was diagnosed with the condition.”
A week later, it was observed that Anajana’s eyes had turned yellow.
“Since ICP affects the functioning of the liver, it may, in a few cases lead to jaundice as it did with Anjana.”
Anjana was taken aback that a minor ailment like itching turned out to be a liver problem.
Jaundice in pregnancy due to ICP is usually very mild.
Anjana was concerned that the condition may have resulted from something she may have done or eaten, so she asked her doctor, “What did I do wrong that damaged my liver?”
The doctor addressed the question by informing her that ICP occurs in pregnancy due to the effect of the hormones and the growing fetus on the liver which slows down it’s function and increases the bile acids in the blood.
It does not indicate an infection or damage to the liver.
Anjana was relieved to hear that. She further asked “How can my condition be treated?”
The doctor answered, “Medications can help clear the bile acids and reduce the itching.”
“The best treatment of the condition is the delivery of the baby.”
Anjana raised her eyebrows and asked whether the doctor was referring to a preterm delivery.
Dr. Anita reassured her saying, “The delivery will be decided considering the maturity of the baby, and may be done around 38-39 weeks preferably. “
“An early delivery may be required in certain cases or in complicated cases with very high levels of bile acids.”
Anjana asked what she could do and what she could eat with the condition.
What should we eat in jaundice during pregnancy?
There is no specific food for jaundice in pregnancy. It is best to follow a healthy normal diet, which consists of vegetables, beans, legumes, whole grains like whole wheat and rice, fresh fruits and nuts. Try to exclude deep fried and junk food.
Anjana had heard somewhere that coffee should not be consumed in jaundice. She asked the doctor about it.
Dr. Anita smiled and said, “It is a myth that coffee should be avoided. You can have coffee, but limit it to one cup a day. Ensure you drink lots of fluids including water, coconut water and herbal tea.”
Anjana adhered to the advice she was given. She didn’t skip a single prenatal visit and took the prescribed medication. As a result of these steps, her ICP was well controlled.
She was offered induction of labour at 38.5 weeks and delivered a healthy baby boy without any complication.
At the time of discharge from the hospital, Anjana wondered whether there was any way to prevent jaundice in her next pregnancy.
How can I prevent jaundice during pregnancy?
Jaundice can affect anyone during pregnancy, and there are no specific ways to prevent it.
ICP is particularly the result of pregnancy hormones and it can occur again in the next pregnancy in 25% cases.
It is important, however, for pregnant women to
- strictly follow basic hygiene practices; avoid eating from roadside outlets
- wash hands after and before every meal
- Avoid oily and deep fried foods that build bad cholesterol and
- Get all necessary vaccinations on time to stop the spread of infectious diseases
Anjana made a mental note of how to prevent jaundice during pregnancy, and vowed to follow her doctor’s advice religiously.
You May Like to Read:
- What You Need to Pack in Your Hospital Bag for Delivery
- Normal Labor and Delivery: 11 Questions (and Answers) You Must Know
- Jaundice in Babies- When Should Parents Worry?
Medically Reviewed by Dr. Anita Sabherwal Anand
Senior Consultant, Obstetrics & Gynecology at Sitaram Bhartia Hospital