Pregnancy is an exciting but sometimes challenging time. You’re getting ready to have a new baby and at the same time your body goes through many changes, mainly due to pregnancy hormones. Sometimes these hormonal changes can be the cause of some imbalances.

During the late stages of pregnancy you’re more aware of every ache and pain.

But what about itchiness in pregnancy? Although it’s rare, some women experience intense itchiness due to cholestasis of pregnancy.

What is cholestasis of pregnancy – also known as obstetric cholestasis – and what can be done to manage it?

What is intrahepatic cholestasis of pregnancy?

Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder, a condition that only occurs during pregnancy.

It causes an abnormal build-up of bile acids in the liver. Normally, the gallbladder stores bile salts. To help with digestion, there is a bile flow from your gallbladder down to your intestines. Intrahepatic cholestasis of pregnancy happens when the normal flow of bile is slowed down. It affects liver function and it usually manifests with severe itching.

The name of this condition comes from the Greek chole, meaning ‘bile’, and stasis, meaning ‘standing still’.

Obstetric cholestasis is a rare condition that only affects pregnant women. It usually occurs in the later part of the second trimester or in the third trimester of pregnancy. It’s unlikely that pregnant women will develop cholestasis earlier in pregnancy.

What causes intrahepatic cholestasis of pregnancy?

The exact cause of cholestasis in pregnancy isn’t clear. There’s a strong genetic link, which means it can run in families. Because the condition is pregnancy diagnosed, health experts believe it’s a reaction to high estrogen levels.

What are the risk factors?

You’re more likely to develop cholestasis of pregnancy if:

You have had this condition in a previous pregnancy; this doesn’t necessarily mean you will develop pregnancy cholestasis in future pregnancies
Your sister or mother had this condition in any of their pregnancies
You have a multiple pregnancy: you’re carrying twins or triplets
You live in certain regions or countries, such as Scandinavia, Chile, Bolivia, Finland or Portugal
You’re of South Asian or Latino origin
You have a history of liver disease, such as hepatitis C
You have taken oral contraceptives
You have had in vitro fertilization (IVF)
You are over 35 years old.

Rates of ICP are about 1 in 140 in the UK and Australia, up to 1 in 26 in Bolivia, and only about 1 in 1000 in the US (with higher rates – up to 5% – in Latinas).

Cholestasis of pregnancy symptoms

The most common symptom of cholestasis of pregnancy is itching on the palms of the hands and soles of the feet – especially at night time.

Moderate, intense, or even severe itching all over the body can also be a sign of intrahepatic cholestasis.

Itchy skin in pregnancy can occur for other reasons apart from cholestasis of pregnancy – for example, stretching skin, PUPPS, or hives from an allergic reaction.

If you’re unsure whether your itchiness is from ICP, look out for these other symptoms of intrahepatic cholestasis:

Pain in your liver area (upper right abdomen)
Dark urine
Pale stool
Jaundice (yellow tinge to the skin or whites of the eyes)
Nausea and lack of appetite.

If you experience any of these symptoms, be sure to contact your healthcare provider right away. They are signs of changes in the liver condition and need immediate attention; this will prevent complications and any potential liver damage.

Cholestasis of pregnancy rash

Cholestasis of pregnancy doesn’t cause a rash or spots on your skin. However, the itching is intense and often worse at night.

If the itching is very severe you might scratch so hard you break the skin. This might appear as a rash later on, due to the scratching or if the broken skin has a reaction to soaps, lotions or sweat.

Causes of itching in pregnancy

Although intrahepatic cholestasis of pregnancy presents with moderate to intense itching as a main symptom, not every type of itching that appears during pregnancy is a sign of obstetric cholestasis.

An allergic reaction, pregnancy hormones, morning sickness, or even environmental factors can cause the itchiness of the skin.

You can read more about itching during pregnancy in Early Pregnancy Itching – 9 Types And Their Causes.

Cholestasis of pregnancy diagnosis

If you’re experiencing any of the symptoms of ICP, make sure you contact your health care provider straight away. To diagnose cholestasis you’ll have a blood test, to check your bile acids levels. Other liver function tests might be ordered as well.

For the most accurate results, you might need to fast for 8-12 hours before having this blood test.

Healthcare providers will usually diagnose ICP if your serum bile acids are over 10 mmol/L.

Follow-up management of cholestasis includes:

Blood tests (at least weekly) to check for rising levels of serum bile acids
Referral to the maternal-fetal medicine team, to keep a close eye on your health and your baby’s development. There will be frequent fetal monitoring of your baby; non-stress tests and biophysical profile ultrasounds might also be recommended to check your baby’s wellbeing.

What are the effects of ICP on baby?

The biggest concern for babies of mothers with ICP is an increased risk of preterm birth, fetal distress, and stillbirth.

Other risks include:

Higher incidence of meconium staining (baby passing stool before birth) in the amniotic fluid
Respiratory problems for baby, as the baby’s lungs might not be fully developed
Premature birth.

Although these risks are serious it’s important to remember most women with ICP have normal, healthy babies.

What are the effects of ICP on the mother?

The severe itching that accompanies pregnancy cholestasis can reduce sleep. This can really affect your mood and ability to function during pregnancy.

Keep reading for ways to deal with this annoying symptom.

For some women, severe intrahepatic cholestasis of pregnancy can have an effect on blood clotting. There might be a higher incidence of postpartum hemorrhage in pregnant woman with ICP, but more research is needed.

If you have ICP you also have a higher risk of developing gestational diabetes and preeclampsia.

Is delivery by 37 weeks necessary for cholestasis of pregnancy?

Because of the increased risk of stillbirth, most healthcare practitioners will plan an induction at 37 weeks gestation if cholestasis is diagnosed during the second or third trimester of pregnancy.

Recent research shows it’s possible to wait until 39 weeks to be induced, provided blood tests are frequently done to continue to check bile acid levels and results are available within 24 hours.

There is a significantly increased risk of stillbirth when bile levels are very high (>100mmol/L). If these levels continue to rise, inducing labor earlier than 37 weeks might be recommended.

The maternal-fetal medicine team will keep a close eye on your developing baby to assess any fetal risk and will take the necessary steps if there’s an indication the baby should be born early.

How serious is cholestasis of pregnancy?

ICP can be very damaging if left untreated. It can lead to serious complications for you and for your baby during pregnancy, and some research suggests it can also affect children later in life.

If you have a family history of cholestasis, let your doctor know and you can make a plan to monitor for symptoms.

You can read more in Obstetric Cholestasis-Everything You Need To Know.

Cholestasis of pregnancy treatment

The only definite way to treat cholestasis is to give birth. An early birth might be necessary in more severe cases to prevent permanent liver damage. The main goals of treating cholestasis are to manage symptoms and to prevent problems.

The medications you might be offered for ICP are:

Ursodeoxycholic acid (UCDA). This is the most common drug given for the treatment of cholestasis of pregnancy. This drug can reduce and relieve itching and can reduce levels of bile acids and liver enzymes
Steroids to reduce itching. These drugs have side effects and risks, and won’t have an effect on reducing bile acid levels
Vitamin K supplements might be offered if blood clotting is a problem. If you had ICP, it is also important your baby receives Vitamin K at birth.

Natural remedies for cholestasis of pregnancy

Here are some things you can try to help relieve the itching that comes with cholestasis of pregnancy:

Take liver support herbs, such as dandelion and blessed milk thistle. Always check with your healthcare provider and work with a trained herbalist before taking herbal medicines
Oatmeal baths and peppermint soaps can bring some relief
Apply calamine lotions and/or calendula salves. Calamine might have a drying effect on the skin
Stay cool: have cool baths or showers and sit in front of a fan
Use ice packs on affected areas
Wear loose clothing made of natural fibers, such as cotton, hemp or linen.

What happens after birth with cholestasis?

It’s recommended your baby be given the vitamin K injection after birth. This is because of the higher risk of blood clotting.

The itching and other symptoms of cholestasis generally disappear within 1-2 days after the baby’s birth.

You should have follow-up blood work at 2-6 weeks after birth. This will check your liver is functioning properly and confirm the diagnosis of ICP.

If you had cholestasis of pregnancy in a previous pregnancy there’s up to 50% chance it will occur in your next pregnancy. There’s an even higher chance of recurrence if the condition runs in your family.

You might be advised to avoid birth control pills with high estrogen, as this has the potential to trigger cholestasis again.

You also have an increased chance of developing gallstones and chronic liver disease in the future. Speak to your doctor about this and any other concerns you have.