Introduction
Pregnancy is a unique condition that implies specific changes in a woman’s body to ensure it is ready for carrying and delivering a child. It is vital to ensure that during this period, a female does not suffer from conditions that might impact her and her child’s health. Otherwise, there is a high risk of complications and the development of pathologies in a fetus. For this reason, the enhanced understanding of various diseases, conditions, and how they might affect both the mother and the child is critical for working with pregnant women, providing appropriate care, and guaranteeing they can avoid severe complications and deliver a healthy baby.
Thus, obstetric cholestasis, or intrahepatic cholestasis, is a poorly understood disease occurring in the late second or third trimester of pregnancy (Biocca et al., 2018). It might severely impact the fetus and precondition the emergence of pathologies. For this reason, the provided essay focuses on investigating obstetric cholestasis and its most important aspects.
Thus, the main body of the research will offer information about the incidence of the conditions, pathophysiology, and definition. Moreover, the symptoms, risk factors, and complications of intrahepatic cholestasis will be discussed to acquire an enhanced understanding. The paper will also delve into the role of midwives in detecting and dealing with the condition. The impact on the fetus and the neonate will be evaluated. Finally, the peculiarities of a management plan and the mother/baby dyad will be discussed. The essay will promote an enhanced understanding of the selected problem.
Evaluating the Impact of Maternal Conditions on Neonatal Outcomes
Obstetric cholestasis (OC) or intrahepatic cholestasis of pregnancy (ICP) is one of the conditions that might be observed in a pregnant woman. It can be defined as pruritus of onset during pregnancy related to abnormal liver function in the absence of any liver pathology, which resolves on delivery (Kenyon & Shennan, 2009). For this reason, it might pose a significant therapeutic challenge to a clinician (Devalla & Srivastava, 2022). Usually, it might occur in late pregnancy and might be associated with severe risks and undesired outcomes. For this reason, it is vital to address the problem in time and ensure the issue is correctly managed.
Thus, the scope of the problem is evidenced by the high incidence rates. Recent statistics show that the global prevalence ranges approximately between 0.3 and 5.6% of pregnancies (Gardiner et al., 2019). At the same time, the numbers might vary depending on the region and ethnicity. For instance, in the UK, the prevalence is about 0.7%, while 41% of women with the condition belong to the Indian or Pakistani ethnicity (Kenyon & Shennan, 2009). In other regions, the incidence rates might grow to 15.6% (Gao et al., 2020). In twin pregnancies, the rates become even higher and might constitute around 22% (Kenyon & Shennan, 2009). At the same time, there is still little understanding of what factors increase the risk of OC’s emergence and development in pregnant women.
The OC has a specific pathophysiology impacting the development of the condition and changes in the work of women’s bodies. First of all, reproductive hormones, specifically estrogen, are one of the principal factors promoting the development of ICP in women (Smith & Rood, 2019). It reduces the expression of nuclear hepatic bile acid receptors (Devalla & Srivastava, 2022). Thus, intrahepatic cholestasis is characterized by a significant reduction in bile flow in the absence of overt bile duct obstruction (Hofmann, 2002). As a result, the bile constituents are accumulated in the liver and blood (Dixon & Williamson, 2016).
In such a way, the pathophysiology of the disease is linked to the bile formation and the functioning of the liver (Smith & Rood, 2019). Cholestasis is defined as a stagnation in bile flow, which might be dangerous for individuals and deteriorate the overall condition (Smith & Rood, 2019). In such a way, the condition is characterized by changes in liver function and bile.
The OC remains poorly understood as researchers lack data on how and why it emerges. At the same time, the existing body of research offers several risk factors that should be considered when investigating the cases of ICP in women. First, preexisting hepatobiliary disease is viewed as the first factor that increases the risk of acquiring OC (Mor et al., 2020). The statistics show that women with this factor are more likely to suffer from the condition and have adverse outcomes associated with the issue. This means that clinicians should pay more attention to this cohort.
Moreover, the personal or family history of ICP is another risk factor that should be considered. Statistics show that females who already had this condition during their previous pregnancies are more likely to have it during the new one (Mashburn et al., 2021). Additionally, in families with reported OC cases, females face a higher risk of acquiring the same condition (Mashburn et al., 2021). It means that there is a critical need to devote much attention to this group to ensure there is a lower risk of acquiring and suffering from the disease in the future. For this reason, this risk factor should be considered.
Finally, advanced maternal age is often viewed as a risk factor. Thus, the statistics show that older women are more likely to suffer from OC compared to younger ones (Mashburn et al., 2021). At the same time, ICP might be more severe in women who have experienced prior cholecystectomy and who use tobacco (Collins et al.,2022).
In some cases, diabetes might also be associated with the development of severe forms of OC in women and the emergence of various complications (Mashburn et al., 2021). In such a way, these risk factors can be linked to the emergence and development of OC in patients. However, in many cases, the triggering factor remains unknown.
Assessing Changing Risk Status Through Multi-Disciplinary Collaboration
The dangerous nature of OC is linked to numerous complications that might emerge in women suffering from the disease. First of all, ICP significantly increases the risk of preterm delivery, which might be associated with further problems in the fetus (Bicocca et al., 2018). The high concentration of bile acids triggers the development of negative processes in the woman’s body and promotes increased uterine contractility during preterm labor (Kenyon & Shannan, 2009). As a result, there is a risk of a prematurely born child and the associated problems.
Moreover, women with OC might acquire lung problems because of the negative impact of the disease (Kenyon & Shannan, 2002). The female might acquire mineral bone disease, dyslipidemia, and vitamin deficiency (Bicocca et al., 2018). At the same time, in severe cases, there is a high risk of the death of the baby before the delivery (Bicocca et al., 2018). It means that the OC might lead to the development of numerous complications in women and fetuses.
Additionally, ICP is characterized by comparatively high morbidity and mortality rates. Thus, clinical studies show that obstetric cholestasis might introduce critical complications to pregnancies (Devalla & Srivastava, 2022). The statistics show that up to 2% of patients suffer from the intrauterine death of a fetus (Gao et al., 2020). The primary cause of death is acute anoxia caused by the condition (Bicocca et al., 2018). Additionally, OC remains one of the leading causes of neonatal mortality, which explains the critical importance of its effective prevention (Devalla & Srivastava, 2022).
Furthermore, recent studies show that there is a correlation between the overall state of a woman, her previous health history, and other factors complicating the case, as well as the outcomes during pregnancy and delivery (Gao et al., 2020). It means females without the risk factors mentioned above are more likely to avoid preterm delivery and severe complications. In such a way, OC remains a critical problem affecting the state of women and triggering the emergence and development of multiple complications in pregnant women. In order to make sure that any potential negative consequences are taken into account and controlled, it is imperative that the issue be addressed.
The timely detection of the discussed condition is closely linked to women’s awareness levels and their ability to understand the first symptoms of the disease and address a clinician. Thus, OC is characterized by specific signs. First of all, these might include right upper quadrant pain, nausea, poor appetite, and sleep deprivation (Smith & Rood, 2019). These factors might indicate the first signs of the condition’s development. However, the problem is that the same symptoms might signalize a set of other similar diseases that are typical for pregnant women (Smith & Rood, 2019). For this reason, there is a specific complexity in correctly identifying symptoms and responding to them.
Moreover, the symptoms might include the development of mild jaundice in a pregnant woman. Statistics show it occurs in about 10%-15% of females, usually within 4 weeks of the onset of itching (Smith & Rood, 2019). It might be accompanied by nausea, dark urine, or light gray stool (Arthuis et al., 2020). These signs are typical for other diseases affecting the liver and its primary function. For this reason, a woman should respond to them and ask the clinician whether they can be considered the first signs of OC development. It is critical to diagnose the condition timely and ensure no severe damage is done to a woman and a fetus.
Finally, women with OC might suffer from steatorrhea due to the changed liver function. Fat malabsorption might be the cause of the condition (Smith & Rood, 2019). In some cases, it might promote the development of vitamin K deficiency (Smith & Rood, 2019). As a result, a patient might suffer from the deterioration in the body’s work and the problematic development of a fetus (Palmer et al., 2019). The signs given are central to diagnosing the disease and working with patients who suffer from ICP. At the same time, the variety of signs might be confusing for a therapist and a patient, meaning it is necessary to perform an additional investigation to ensure the correct diagnosis is determined.
The Midwife’s Role in Holistic Care: Ethical, Cultural, and Social Considerations
The complexity of the condition described above, its complications, and its symptoms mean that a pregnant woman requires additional support and consultation from a health specialist possessing enhanced knowledge of the problem. For this reason, midwives play a central role in assisting this category of patients. These health professionals are prepared to support and provide care for women during their pregnancy, labor, and birth (Bahri Khomami et al., 2021). Their primary function is to ensure that a female remains healthy during the whole term (Bahri Khomami et al., 2021). At the same time, if any undesired conditions emerge, their primary duty is to address the problem and guarantee that the woman is provided with the necessary car.
For this reason, midwives play a central role in detecting and managing the OC and ensuring the provision of the needed treatment. First of all, the correct understanding of symptoms and their analysis might be confusing and challenging for women who do not have the necessary knowledge. Under these conditions, midwives become the central figures in collecting information about the current patient’s health and determining whether the current data can be used to diagnose OC (Piechota & Jelski, 2020). Its timely detection is key to effective treatment and avoiding severe complications in the future. For this reason, midwives should ensure the link between the patients and health workers.
Finally, these specialists should identify high-risk pregnancies and inform multi-professional teams about the necessity of additional measures. It might require extra support during labor or specific measures to monitor the patient’s state during late pregnancy terms (Wood et al., 2018). In such a way, midwives are the central figures ensuring pregnant women avoid problems because of OC. They are also responsible for outlining the peculiarities of diet, care, and medication (Palmer et al., 2019). The practical cooperation between this healthcare specialist and the woman is key to attaining successful outcomes and reducing the risks associated with ICP in a woman. It guarantees reduced risks and higher chances of giving birth to a healthy baby.
The importance of care providers during OC is linked to numerous complications that might emerge. Thus, the maternal condition characterized by the reduced function of the liver and the changes in bile pose a severe threat to the fetus. The first and most obvious effect is preterm birth, which might be a serious challenge to the health of neonates (Posh et al., 2020). The complications might include breathing problems, heart and brain issues, increased risks of cerebral palsy, and blood issues (Anwar et al., 2022). Moreover, regarding the term, preterm birth might lead to the death of a fetus, which is one of the severe effects caused by the mother’s condition.
Furthermore, the fetus might start suffering from severe problems while being in the uterus. Lung problems are the most common type of complication caused by OC in mothers (Posh et al., 2020). The developing fetus breathes in meconium, a green substance that usually collects in the intestines of the baby (Hagenbeck et al., 2021). However, because of the mother’s cholestasis, it can move to the amniotic fluid and cause severe problems with the lungs (Jurk et al., 2021). Children born from mothers with OC might also have a lower birth rate compared to neonates born by mothers with normal health (Jurk et al., 2021).
Additional measures can be required to ensure the correct weight gain and the child’s survival (Kawakita et al., 2015). Finally, the OC in the mother can lead to severe complications, such as the death of the baby during the latest periods of pregnancy (Jurk et al., 2021). In such a way, the maternal condition of women with OC might have numerous impacts on the fetus and neonate. For this reason, there is a need for additional measures to monitor the health of a mother and a baby.
At the same time, the discussed condition might have short- and long-term effects on the neonate. As stated previously, the condition might have short-term impacts emerging during the delivery. The issues with lungs and breathing can result in the development of fetal distress (Jiang et al., 2021). It is characterized by a low heart rate and the lack of oxygen during delivery and the first stages of neonatal living (Hofmann, 2002). At the same time, there is a high risk of damage caused to the baby’s liver because of the high levels of maternal bile (Jurk et al., 2021). It means that a child might acquire problems similar to his/her mother’s and require additional care and treatment.
Furthermore, the research shows that in some cases, children born from mothers with OC during pregnancy might demonstrate some long-term effects. For instance, boys born from cholestatic pregnancies might have a higher body mass index compared to their peers (Jurk et al., 2021). Moreover, after fasting, the level of insulin is also higher in this cohort (Hofmann, 2002). At the same time, girls born from mothers with OC might have smaller body mass indexes and major parameters (Šimják et al., 2015).
Additionally, the research shows that children belonging to this cohort face a high risk of changed metabolism in adult life, which is associated with obesity and diabetes (Manzotti et al., 2019). It means that ICP remains a severe condition that might cause numerous long- and short-term effects on the life of a person. For this reason, it is vital to consider the possible complications and address them.
The complications mentioned above mean that mothers with OC and their babies should be provided with adequate care to reduce the risks of developing undesired conditions and improve the health of neonates. For this reason, there is a specific management plan that will help to control the health of a child in the immediate postnatal period. First of all, the midwife should ensure it breathes independently (Manzotti et al., 2019). Second, it is vital to ensure skin-to-skin contact with the mother to reduce newborn stress and start breastfeeding (Esan et al., 2020).
At the same time, it is critical to weigh and measure a baby to guarantee that he/she does not have serious problems with BMI (Esan et al., 2020). Many neonates born from OC pregnancies have vitamin K deficiency because of the peculiarities of their intrauterine development (Esan et al., 2020). For this reason, it is vital to make a vitamin K injection to avoid bleeding because of this substance deficiency.
In some cases, a quick blood test is needed to determine if the liver functions normally and if there are no issues with the bile. Finally, the Apgar scores should be collected to control the baby’s adjustment to living outside the womb (Stulic et al., 2019). These actions are important parts of the management plan as they guarantee that the baby will be provided with the necessary care if complications emerge (Walker et al., 2020). In such a way, the midwife becomes a central person critical for implementing the main aspects of the management plan and guaranteeing there are no severe issues.
Finally, the management of OC pregnancies requires increased attention to the mother/baby dyad. This unit shares a unique, intimate biological, social, and psychological relationship critical for the development of a child (Fadda & Lucarelli, 2017). Thus, the baby’s social, emotional, and neurological evolution is affected by the bond between a mother and a newborn (Fadda & Lucarelli, 2017).
The physical connection between mother and fetus is provided by the placenta, which ensures the exchange of nutrients and gases (Wolf et al., 2018). However, if the patient has some health issues, it might also serve as a source of emerging problems and complications. From a psychological perspective, the mother-baby bond is built immediately after birth, which impacts the further evolution of the baby (Fadda & Lucarelli, 2017). For this reason, the complexity of this relationship should be considered when providing care.
The mother-baby dyad care is a specific approach to working with patients immediately after delivery. This model ensures that a mother and a baby have access to necessary treatment immediately after birth (Fadda & Lucarelli, 2017). For cholestatic pregnancies, the mother/baby dyad becomes more important as the changes in the female body’s work impact the evolution of the fetus and its formation. As a result, the mother should care for the child during pregnancy and after birth. She can be assisted by midwives and healthcare specialists, guaranteeing the evolution of a child.
Conclusion
Altogether, the paper proves the significance of OC in pregnant women and the existence of numerous risks associated with this condition. It can be defined as a condition developing in pregnant women because of the changes in estrogen levels and specific alterations because of the fetus’ development. The abnormal liver function in the absence of any pathology is observed and influences the bile levels. The condition occurs during the late pregnancy trimesters and can promote the emergence of severe complications. For this reason, it is vital to address it and ensure that mothers and children are provided with appropriate care.
Although much attention is devoted to investigating the issue, there is still little understanding of why it emerges and how it can be prevented. For this reason, in many cases, it constitutes a serious therapeutic challenge to a clinician. Thus, the research offers specific risk factors that might increase the chance of acquiring OC and various complications. These include preexisting hepatobiliary disease, the higher age of a pregnant woman, and a previous history of ICP. Moreover, diabetes or tobacco smoking might be factors leading to more complex outcomes and complications. These aspects are usually linked to ICP and risks of problems during pregnancy.
The significance of the discussed problem is evidenced by its prevalence. Thus, globally, it ranges between 0.3 and 5.6% of pregnancies. However, some ethnicities have a higher risk of acquiring the condition. However, there is still a lack of understanding of why some nationalities have higher risks of acquiring OC. The condition might promote the emergence and development of specific complications and undesired effects. Thus, the risks include preterm birth, problems with the lungs in the fetus and newborn babies, and even the death of a child. This means that effective management of the problem and the provision of necessary care is critical for cholestatic pregnancies.
For this reason, cooperation between pregnant women and midwives is the top priority. These healthcare workers provide patients with the necessary knowledge about the issue and guarantee they can notice the first signs of the problem and discuss them with clinicians. Additionally, midwives are responsible for effectively managing neonates during the first 24 hours of their lives. They control the vitamin K levels, liver function, and the interaction within the mother/baby dyad. The first interactions between a child and a mother are fundamental for psychological and physiological development. For this reason, a midwife should guarantee they emerge and evolve appropriately.
In such a way, obstetric cholestasis should be viewed as a serious condition emerging in pregnant women. At the same time, there are still some gaps in understanding the mechanisms of its emergence and risk factors. For this reason, there is a need for further investigation of the problem and its evaluation. The new projects might be focused on outlining the risk groups and how they acquire the condition. Moreover, the investigation of the long-term effects of ICP among children might be required to realize whether the condition can have visible effects in their adulthood. It would help to create a clear vision of OC and introduce new, more effective ways of its treatment and management.
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