Intrahepatic Cholestasis Of Pregnancy: Symptoms & Causes

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Obstetric cholestasis (OC) or intrahepatic cholestasis of pregnancy (ICP) is a rare liver condition that affects 0.5% to 2% of pregnant women(1). The condition is more commonly seen in Araucanian Indians and females of Scandinavian ancestry (2).

Women dealing with ICP have reduced bile flow in the intestine, which eventually accumulates bile salts in the blood, causing itchy skin and other symptoms. ICP can occur due to several reasons, but the symptoms disappear after delivery in most cases.

This post informs you about ICP, including its causes, symptoms, diagnosis, treatment options, and recommended dietary changes to manage it.

What Is Obstetric Cholestasis?

Obstetric cholestasis is a condition that reduces the normal outflow of bile from the liver.

Normally, the liver produces bile, which flows through the bile ducts into the intestine, where it helps in digesting the food.

But in the case of obstetric cholestasis, the bile flow into the intestines is reduced. This builds up the bile salts, which leaks into the bloodstream and increases the amount of bile salts in the blood.

The excess salts make your skin very itchy, causing a condition called pruritus. This usually occurs in the last three months of pregnancy, and sometimes even sooner. But the good thing is that raised bile salts and pruritus disappear after delivery, and do not cause any long-term complications for the mother or the baby (3).

What Causes Obstetric Cholestasis?

The exact cause of cholestasis during pregnancy is not known. However, it is known to be affected by the following factors (4):

1. Hormonal: An increase in the pregnancy hormones, estrogen and progesterone, can affect liver function. Studies show that obstetric cholestasis usually occurs in the last trimester when the estrogen levels are higher. It is also common in twin and triplet pregnancies when the hormonal levels are high.

2. Genetic: In some cases, obstetric cholestasis may runs in families (but can skip some generations). Those with a genetic predisposition to OC can also inherit a problem associated with bile production and passage through the bile ducts. OC may not be a major concern unless you are pregnant, as an increase in hormonal activity during pregnancy can result in hormonal changes.
   

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3. Environmental factors: OC is more common during winters, and the incidence is high when combined with nutritional factors like selenium deficiency (4).

Whatever might be the cause, this condition occurs only during pregnancy.

What Are The Symptoms and Signs Of Intrahepatic Cholestasis Of Pregnancy/ Obstetric Cholestasis?

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The most common symptom of obstetric cholestasis is itching, which usually develops without a rash. It may start after 24 weeks of pregnancy when the hormone levels are at their peak. However, most women may have severe itching during the last trimester of pregnancy. The following characteristics of itching can be seen during cholestasis of pregnancy.

• It occurs on the palms and soles, but it can also affect other areas of the body.
• The itching gets worse at night and tends to worsen, until you have your baby.
• The itch can be mild to severe.
• Severe itching can affect your sleep pattern, your mood, and concentration.

Other symptoms, although rare, include (5) :

• Tiredness
• Feeling sick or ill
• Dark urine color
• Pale stools
• Food aversions
• Mild jaundice, characterized by yellow urine, skin, or whites of the eye
• Pain around the liver, usually in the right upper quadrant
• Nausea
• Depression
• Fatigue

Occasional, mild itching is normal. But if you develop a constant itch that turns worse in combination with the above symptoms, you should see your doctor immediately.

A mother of two recalls the symptoms that led to her getting diagnosed with cholestasis during her second pregnancy. She says, “I suddenly began experiencing severe itching around 36 weeks. Now, when I say that my palms & soles were itchy, I don’t mean that I randomly scratched every now and then. The itching intensified at night, and I would be awake and scratching at myself for hours every night. I’d use a rough washcloth and rub it against my hands & feet for hours on end. A few times, I scratched myself with my wig brush because the stiff bristles felt good, even if they made my skin red and sore. Nothing gave me any relief other than eventually passing out from exhaustion, and even then, I’d wake up scratching.

“(When she visited a doctor), the doctor mentioned that itchy hands and feet could be a symptom of cholestasis of pregnancy (CP or ICP), and he wanted me to go to the lab right away to get blood drawn. My liver function, as indicated by enzyme levels, and my bile acid levels were what he specifically wanted to see. I went to the lab late that day, and the results indicated that a specific enzyme was four times over the upper normal level (i).”

How Is Obstetric Cholestasis Diagnosed?

Obstetric cholestasis is diagnosed through blood tests. Your doctor will discuss your symptoms, your family history, and medical history, and recommend some tests to measure the bile acids and liver enzymes.

These tests will check for obstetric cholestasis and also detect other causes of itching.

1.  Bile acid test: This is the most specific test for OC. It measures the levels of bile acids in the bloodstream. The normal range is 0-10 micromol/L, and any reading above this range detects the presence of OC (6).

2.  Liver function test (LFT): It checks the functioning of the liver by measuring the different enzyme levels. The primary enzymes including, alanine transaminase (ALT) and aspartate transaminase (AST), will rise abnormally in the case of OC.
   

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Sometimes bile acid levels rise while the ALT and AST remain normal. In other cases, there may be elevated liver enzymes while the levels of bile acids remain normal. In both cases, your bile acids are tested if there is recurrent itching (7).

What Are The Risks Of Obstetric Cholestasis?

For the mother-to-be, obstetric cholestasis can lead to vitamin K deficiency and affect the body’s ability to clot blood. There is an increased risk of bleeding as it takes a longer time to stop. However, the research behind this is indefinite. Your doctor will suggest vitamin K supplements to treat the clotting problem (8).

You may undergo more antenatal appointments so that the doctor can examine you carefully. The medical tests involve:

• Tracking the baby’s movements
• Listening to the baby’s heartbeat
• Fetal monitoring using ultrasound scans to track the growth and well-being of the baby.

For the unborn baby

• Your baby may pass their first stool (meconium) while still in the womb. It could, therefore, cause breathing problems post birth.
• You may go into preterm labor if your doctor advises an early delivery.
• There is an increased risk of stillbirth, which is why the doctor suggests induced labor at around 37 to 38 weeks (9).

Quick fact

Intrahepatic cholestasis of pregnancy raises risk of issues, such as preterm delivery and fetal distress, when associated with fasting serum bile acid levels of more than 40 μmol/L (4).

How Is Obstetric Cholestasis Treated?

The primary goal of the treatment is to relieve itching. The following measures may help to alleviate itching associated with obstetric cholestasis (11):

• Cold water baths
• Soaking feet and hands in ice water
• Applying calamine lotion on itchy regions
  

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• Applying creams containing extracts of calendula and chamomile. These are said to reduce itching and redness caused during pregnancy.
• Using mild soaps and detergents
• Choosing mild bath shower gels instead of heavy, perfumed ones containing harsh formulations
• Avoiding hot water baths
• Wearing loose-fitting cotton clothes
• Following a healthy balanced diet (cut down on oily and fatty foods)
• Resting whenever you get tired
• Avoiding hot and humid weather conditions
• Avoiding alcohol and drugs as they are toxic to the liver and cause irreversible damage to it

Quick tip

Aqueous creams containing menthol can safely provide relief from the itching (20).

Medical Treatment For Managing Cholestasis During Pregnancy

Medication is usually aimed at decreasing the bile salt levels, relieving itching, and protecting the baby. Your doctor is likely to prescribe the following medications for obstetric cholestasis.

• Ursodeoxycholic acid (ursodiol), which eliminates the itching, and normalizes the liver and bile acids (11).

Nevertheless, using ursodeoxycholic acid in the treatment does not decrease unfavorable outcomes for newborns. A UK-based research study primarily assessed a comprehensive measure incorporating perinatal mortality, premature birth, or admission to a neonatal unit. Out of the 322 babies who received ursodeoxycholic acid, about 23% had one of these negative outcomes. On the other hand, in the group of 318 babies who received a placebo, about 27% had one of these negative outcomes. This suggests that using ursodeoxycholic acid did not significantly reduce the probability of negative outcomes.

• Steroids (dexamethasone) with careful management. They aid in the maturity of the baby’s lungs (12).
• Vitamin K supplements to help with blood-clotting (6).

Note:

Do not use antihistamines, aveeno, and oatmeal baths.

Diet For Intrahepatic Cholestasis

The primary goal of the pregnancy cholestasis diet is to place less strain on the liver, and for that, you should be taking foods containing lecithin, which is unsaturated fat that helps absorb fats in the bile. A low-fat diet may make it easy for the intestine to absorb vitamins and minerals from the food. Include:

• A mix of organic fruits and vegetables with colorful pigments such as carrots, beets, potatoes, pumpkin, red cabbage, and cauliflower for easy digestion.
• Foods containing omega-3 fatty acids (tuna, salmon, mackerel, sardines, shrimp, oysters, linseed, and cod liver oils) and omega-6 fatty acids (leafy greens, nuts, fish, and soybeans) to combat illnesses.
• High protein foods, including nuts, beans, fish, and eggs.
• A low-fat diet of rice, wheat, corn, oats, and rye.
• Virgin olive oil, sunflower oil, and canola oil.
• Healthy alternatives such as honey spread, hummus, and fruit jams.
• More water to flush away toxins from the system.
• Fresh lemon juice in warm water to neutralize the bile acids.

This diet helps minimize bile production in the liver and promotes liver health. Besides a healthy diet, other natural remedies can be used to deal with obstetric cholestasis.

Natural Remedies For Obstetric Cholestasis

Before going for medical treatment options, you can try the following measures to lower the discomfort associated with obstetric cholestasis. These remedies also reduce the chances of developing the condition. Do check with your doctor about them.

1. Guar gum: Guar gum is a fiber component of the seed of the guar plant. Research shows that oral intake of guar gum relieves cholestasis. It binds to the bile, thereby preventing an increase in serum bile levels (13). You should ask your doctor about it.

2. Activated charcoal: This is a potent treatment method where activated charcoal traps chemicals and toxins in the body, allowing them to flush out before they get absorbed. In a study, it was found that an eight-day treatment of activated charcoal reduced bile concentrations in pregnant women with ICP (14). Ask your doctor first.

3. Dandelion root: It is a safe remedy for gallstones, one of the significant causes of cholestasis. The vitamins and nutrients in dandelions aid in cleansing the liver and stimulating proper bile flow (15).
   

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4. Vitamin D and calcium: Research findings show that metabolic bone diseases are a complication of cholestatic liver disease (16). Therefore, it is also essential that you consume calcium-rich foods and calcium supplements. Vitamin D, which you can get by spending some time outdoors, also plays a key role in absorbing calcium (17).

Along with these natural remedies, maintaining a consistent exercise or meditation routine can help reduce stress levels, which may worsen itching when elevated.

While taking these measures helps manage the condition better, medical supervision is necessary for a few weeks to months, even after delivery.

Obstetric Cholestasis Or Intrahepatic Cholestasis Of Pregnancy After Delivery

A follow-up check-up is done around six to eight weeks after the baby is born. Your doctor will check if the itch is still there and if the liver is working normally.

• If you are using birth control pills, you may be told to stop them as the estrogen in them can trigger cholestasis again. The doctor may suggest an alternative contraceptive.
• You may be at risk of developing chronic liver disease and gallstones in later life.
• There is a 45-70% chance that obstetric cholestasis recurs during subsequent pregnancies (4).

Infographic: Which Conditions May Mimic Intrahepatic Cholestasis Of Pregnancy?

Symptoms such as pruritus and jaundice can be seen in various health conditions in pregnancy, requiring prompt medical care. Mistaking them for intrahepatic cholestasis of pregnancy can delay the adequate treatment on time. Check out the infographic to know common health conditions that mimic intrahepatic cholestasis of pregnancy.

Illustration: Momjunction Design Team

Learn more about Cholestasis in Pregnancy to better understand its symptoms, treatment techniques, and diagnostic processes. Discover insights and beneficial strategies for successfully managing this condition.

Illustration: Intrahepatic Cholestasis Of Pregnancy: Symptoms & Causes

Image: Stable Diffusion/MomJunction Design Team

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Dr. Mozhgan SayyadMD

Dr. Mozhgan Sayyad specializes in obstetric and gynecological cases, and her area of interest includes cosmetic gynecology. An associated member of the Royal College of Obstetrics and Gynecology and a member of the European Society of Aesthetic Gynecology, Dr.

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Rebecca MalachiBSc

Rebecca is a pregnancy writer and editor with a passion for delivering research-based and engaging content in areas of fertility, pregnancy, birth, and post-pregnancy. She did her graduation in Biotechnology and Genetics from Loyola Academy, Osmania University and obtained a certification in ‘Nutrition and Lifestyle in Pregnancy’ from Ludwig Maximilian University of Munich (LMU).

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Swati PatwalM.Sc. (Food & Nutrition), MBA

Swati Patwal is a clinical nutritionist, a Certified Diabetes Educator (CDE) and a toddler mom with more than a decade of experience in diverse fields of nutrition. She started her career as a CSR project coordinator for a healthy eating and active lifestyle project catering to school children.

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Aneesha AmonzMSc

Aneesha holds a Bachelor's degree in Biotechnology from USTM, Meghalaya and Master’s degree in Applied Microbiology from VIT, Vellore. With two years of experience, she has worked on different research projects in the field of Food Sciences.

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