Itching in pregnancy is common, and most of the time it is nothing more than stretched skin. Occasionally, though, it is the first sign of obstetric cholestasis, a liver condition that carries a real risk to an unborn baby if it is missed or poorly monitored. Our medical negligence team here at McCarthy + Co Solicitors LLP has seen how devastating the consequences can be when this warning sign is not taken seriously, so we have put together this short guide to explain what should happen and what sometimes goes wrong.
What is Obstetric Cholestasis?
Obstetric cholestasis, also known as intrahepatic cholestasis of pregnancy, is a liver disorder in which bile acids build up in the blood instead of flowing normally to the gut. It often develops in the third trimester and resolves after birth. Estimates of how common it is vary somewhat between studies, with the British Liver Trust putting the figure at around 1 in 150 pregnancies, and the Royal College of Obstetricians and Gynaecologists citing roughly 7 in 1,000 in the UK.
Symptoms and how it should be diagnosed
The hallmark symptom is itching without a rash, often affecting the palms and soles and worsening at night. Because mild itching in pregnancy is so common, this symptom is frequently, and sometimes wrongly, put down to normal pregnancy discomfort. The correct response, once a patient reports persistent itching, is a bile acid blood test alongside liver function tests. A bile acid reading of 19 micromol per litre or above, combined with itching and no other explanation, points to obstetric cholestasis, and testing should then be repeated, usually weekly, to track how the condition is progressing.
Why ongoing monitoring is vital
A diagnosis is only half the job. What happens afterwards, in terms of monitoring and the timing of delivery, is where outcomes are genuinely won or lost. A large individual patient data meta-analysis covering more than 5,000 women found that stillbirth risk rises sharply once bile acid levels climb above 100 micromol per litre, with affected women found to be over thirty times more likely to experience a stillbirth than those with lower readings. Broadly, current guidance points to something like the following:
- bile acids under 40 micromol per litre carry a risk close to that of an uncomplicated pregnancy
- bile acids between 40 and 99 micromol per litre still call for closer monitoring, even though risk is not markedly increased before around 38 to 39 weeks
- bile acids of 100 micromol per litre or above are associated with a materially higher stillbirth risk, usually managed with planned early delivery
These figures are precisely why regular retesting, careful record keeping, and a clear plan for delivery timing are not optional extras. They are the core of safe care for this condition.
When a missed or poorly monitored case becomes negligence
Not every stillbirth or premature birth associated with obstetric cholestasis will have resulted from a mistake. But a claim may arise where a clinician failed to act to a reasonable standard of care, for example by:
- dismissing reported itching without arranging a bile acid test
- failing to repeat bile acid testing at appropriate intervals once a diagnosis was made
- not acting on rising bile acid levels with closer monitoring or a revised delivery plan
- delaying delivery in a severe case beyond what current guidance recommends
- failing to refer a patient to obstetrician-led, rather than midwife-led, care once the diagnosis was confirmed
Where any of these failures can be shown to have caused or contributed to a stillbirth, a premature birth, or another form of harm to mother or baby, that failure may amount to medical negligence.
Speak to our medical negligence team
Losing a baby, or watching your child cope with the effects of a premature birth, is an experience no parent should have to carry alone, particularly when proper monitoring might have changed the outcome. The medical negligence team here at McCarthy + Co Solicitors LLP will review your maternity records carefully, explain plainly whether we believe your care fell short, and advise you on your options. Arrange a time to speak with a solicitor by completing our confidential online form.
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