For many women pregnancy is, overall, a positive experience, but it commonly comes with a number of discomforts and conditions that can also make it a tumultuous time. Some are minor and harmless, but others require close monitoring for the sake of your health and that of the baby.
Intrahepatic cholestasis of pregnancy is an uncommon, but well-documented disorder in pregnant women that can result in serious consequences. It develops, most often, in the third trimester, and is characterized by the intense, rashless itching that it causes.
It is a disease of the liver that is speculated to be caused by the increased level of hormones in the body that accompany pregnancy, which reach their peak in the final trimester.
Aside from the distress and discomfort the condition can cause the mother, it is a serious concern for the health of the baby. If unmonitored, complications can lead to premature labor or, at worst, stillbirth. As such, we strongly recommend that if you experience the symptoms listed in this guide you should seek medical attention immediately.
Read on, and we will inform you on the symptoms, causes and other concerns surrounding this issue.
The Symptoms of Intrahepatic Cholestasis of Pregnancy
Cholestasis of pregnancy is indicated by the presence of a number of symptoms, most common and well-known of which is intense and unbearable itching, which occurs without a rash. This itching is usually localized to the hands and feet, but may occur all over the body. It may feel worse at night, and disturb sleep.
The itching most often begins late in pregnancy, though may begin earlier, increasing in intensity until birth, after which it will fade over a few days.
A number of other symptoms are also known, less commonly, to occur alongside the primary itching, which may help with your doctor’s diagnosis, so it is worth being vigilant for them. These include:
- Jaundice (yellowing of the skin or eyes)
- Nausea and loss of appetite
- Fatigue
- Dark urine color
- Pale or light coloring of stool
Causes
While the exact cause of cholestasis of pregnancy isn’t entirely understood it has been observed that pregnancy hormones – estrogen, in particular – may affect liver function. This results in a slowing or stopping of the flow of bile, which is normally stored in the gallbladder and used to break down fats in digestion.
Due to this, a build-up of bile acids occurs in the liver, which then spill into the bloodstream. The presence of these acids are speculated to be what cause the intense itching characterized by the condition.
There may also be a genetic component that contributes to the prevalence of the disease, making some people predisposed to developing it, depending on their family background.
Additionally, it is speculated that environmental factors may play a role. More women are diagnosed with the disorder in winter, for example, and selenium deficiency has been linked to it, though it is not clear whether this is a cause or effect of the disease.
Diagnosis
The presence of severe itching, which is known to healthcare professionals are pruritus, will be one of the major indicators that will influence your doctor’s diagnosis. This will then be supported by a number of tests, which will measure your liver function and the level of bile salts present in the bloodstream.
Bile serum level is measured via a blood test, and cholestasis of pregnancy may be diagnosed when the total bile acids or serum bile acids are measured at 10 micromol/L and above.
Liver function is determined through measurement of a number of different items, though the enzyme Alanine Aminotransferase, or ALT, is one of the most sensitive of the liver functions and is helpful for diagnosis. Elevation may indicate presence of the disease.
Your doctor may also want to perform a physical examination.
More information on the specific tests performed may be found here, at ICPCare, which is a fantastic resource on the disease.
Who Is at Risk?
Between 1 to 2 pregnancies per 1000 are affected by this disease, making it quite uncommon, and there are a number of factors that increase a woman’s risk of developing it. These are:
- A family history of the disease
- Multiple-baby pregnancies (twins, triplets, etc.)
- Previous liver damage
If any, or multiple, of these apply to you then you should inform your doctor during check-ups.
Additional to these, it is worth noting that mothers of certain ethnic backgrounds may be more susceptible to the disease. These include women with Indian, Pakistani, Chilean, or Scandinavian backgrounds.
Possible Complications
There are many complications that may arise from cholestasis of pregnancy and, while most are not dangerous for the mother, they may be very serious for the baby.
Meconium staining is the process whereby the baby’s first stool, a green and sticky substance known as meconium, is released into the amniotic fluid and inhaled, resulting in respiratory distress after birth. This occurs when the baby is under stress and, in pregnancies where cholestasis of pregnancy is present, may result in a greater risk to the baby’s life unless delivery is induced early.
Premature birth is very common as a result of the disease. It may affect up to 20-40% of all women with cholestasis of pregnancy. This is due to the fact that the increased level of bile acids makes the uterus more sensitive to oxytocin, the hormone responsible for stimulating birth contractions. It is worth noting that, while early birth may be induced safely by healthcare professionals to treat the disease, delivering too soon comes with additional risks.
Stillbirth may occur more frequently in untreated cases of the disease, with up to 15% of all pregnancies with the disorder resulting in it. If treated, however, this falls to below 1%, which is the same as an uncomplicated pregnancy.
The exact cause of stillbirth in this disorder is not fully understood, though the chance increases with how late the pregnancy progresses, so it is highly recommended that birth is induced before its natural time.
Treatment
There are a number of treatments that your doctor may offer to both ease the symptoms of the disease and also to limit the potential complications that could occur. These include topical treatments, drugs and pre-emptive practices.
Ursodeoxycholic Acid, or UDCA, is the primary treatment for the condition and is delivered via a pill. It works by reducing the level of bile acids in the blood, reducing overall symptoms, such as itching, while also protecting the baby from distress that may lead to further issues. This results in prevention of premature aging of the placenta, as well as protecting the baby’s heart from damage by excess bile acids.
Early delivery is almost always induced in those who suffer cholestasis of pregnancy, regardless of whether administration of UDCA reduces blood bile acid levels to normal. The exact time of delivery is determined based upon the severity of the disease, with more severe cases warranting earlier treatment.
These treatments are combined with close monitoring of the baby’s condition. With these measures in place the risk of stillbirth is reduced to that of a regular pregnancy, so you should not worry excessively.
The Mayo Clinic has a short article here outlining some of the treatments you can expect, which may provide additional info.
Self-Care
Living day to day with cholestasis of pregnancy can be a trial, due to the intense and constant itching, as well as any anxiety you may face. Fortunately, there are many practices an expectant mother suffering the disease can do to reduce discomfort and treat symptoms.
A healthy diet is the first and foremost protection against complications in pregnancy overall, and many women also find that it helps with the severity of their itching. ICPCare has a helpful list of beneficial foods that are proven to provide the nutrients needed for a growing baby.
Reducing stress is another key factor to a healthy maternity, though is of particular note for those with cholestasis of pregnancy. Sufferers may be more susceptible to anxiety, because of the presence of the condition. Stress reduction practices such as meditation, yoga and others, have been shown to reduce itching and overall discomfort.
Cooling, anti-irritant lotions may also help. Anti-histamines aren’t shown to have particular effect in easing the itch, but skin-calming lotions may provide some comfort. This is not true for all women, and may depend upon the severity of symptoms. It is worth trying, however, as even short-term relief may mean a restful night’s sleep.
Prognosis
As mentioned, the prognosis for cholestasis of pregnancy is very good if the condition is treated. The incidence of stillbirth is reduced to below 1%, which is absolutely normal, and the symptoms in the mother often disappear within days of birth. This should offer peace of mind for those who suffer the disease, which is important as management of stress is a primary factor in a healthy pregnancy.
It should be noted, however, that occurrence of the disease is an indicator that it may re-occur in future pregnancies. The chance of this happening may be as high as 90%.
Common Questions
While we have tried to cover the topic in detail, you may still have some lingering questions about cholestasis of pregnancy. Below we will answer some of the most common questions that arise.
When Should I Be Worried About Itching?
This is a hard question to answer. Some itching is totally normal, and some may be indicative of diseases other than cholestasis of pregnancy, so you should not immediately assume the worst from a persistent itch. Primarily, itching in the disorder begins in the hands and feet, spreading to the belly. It can be of varying intensity, and does not present with a rash. It may also be worse at night.
While you should not worry excessively, our advice is this: if in doubt, book an appointment with a healthcare professional.
Why Don’t Antihistamines Relieve My Itch?
Regular itching is caused by histamine, which is an organic compound involved in immune response and inflammation. Antihistamines, as their name suggests, work by reducing the action of these compounds. The itching caused by cholestasis of pregnancy is speculated to be due to the increased level of bile salts in the blood, which are unaffected by antihistamines.
What Are the Risks to the Mother?
Prognosis is particularly good for a mother suffering the condition, with relatively few complications arising compared to those of the baby. The symptoms abate quickly after birth, though those who suffer have a decreased ability to absorb fat-soluble vitamins. This may lead to a deficiency, which can have negative consequences. As such, many healthcare professionals will prescribe vitamin supplements alongside other treatments.
My Itching Began in the First Trimester. Could I Still Have Cholestasis of Pregnancy?
Yes. Though the disease most often presents later in a pregnancy, it is not unknown to develop earlier. You should always be vigilant for symptoms and report them to a doctor if you are unsure.
Will My Baby Have Any Long-Term Issues After Birth?
Current research suggests that there is no increased risk of long-term health disorders in babies born from mothers suffering cholestasis of pregnancy.
Where Can I Find More Detailed Information?
There are plenty of resources out there with information on this well-documented condition. We have linked a number in this article, but if you are looking for detailed info we recommend this video by Allina Health, and this website by ICPCare. Both offer an in-depth look at the disease, with the latter providing additional resources for support and learning.
Final Thoughts
Cholestasis of pregnancy – a serious disease, but one that is easily treated. Hopefully, now that you’ve come to the end of our guide, you have a good overview of the condition and the information surrounding it. It is worth noting, however, that this is not intended as a replacement for professional medical advice. If you exhibit any of the listed symptoms, or simply want to know more than we have described, we recommend speaking to your doctor.