If you're itchy but don't have a rash, you need to read this.

By Emily Shiffer
December 24, 2019

Your body goes through some pretty radical changes during pregnancy. From the good (extra full lips) to the bad (heartburn), to the seriously insane (your brain structure permanently changes), you can certainly expect to feel, well, weird.

If you start to experience intense itching during your pregnancy, it might seem like NBD—just another weird pregnancy side effect. But, actually, this could be a red flag for a condition called cholestasis that needs to be addressed ASAP by your doctor. Here's everything you need to know.

What is cholestasis of pregnancy?

Intrahepatic cholestasis of pregnancy (ICP), more colloquially known as cholestasis, is a liver disease, says Micah Garb, M.D., ob-gyn at Northwestern Medicine Lake Forest Hospital. "It occurs when the metabolism of bile ('chole') in the maternal liver is slowed significantly ('stasis'), causing a backup of bile acids."

Bile, an alkaline fluid produced in the liver that helps your body digest fat, is normally removed from your body via stool. When the bile flow in the liver slows down or stops, bile acids can build up not only in the liver but throughout your body. (Related: This Is Your Brain On Pregnancy)

"In ICP, bile and its breakdown products build up in the mother's liver and blood, get deposited in her skin, palms, and soles, and also end up in the placenta," says Meera Garcia, M.D., chief of general obstetrics and gynecology at New York-Presbyterian Hudson Valley Hospital and assistant professor of ob-gyn at Columbia University Vagelos College of Physicians and Surgeons. This build-up of bile acids reduces blood flow to the placenta, which can lead to decreased fetal movements, fetal distress, preterm labor (aka early birth), and even in-utero death of the baby due to the bile and bile salts building up in the placenta, says Dr. Garcia. For mothers, ICP can increase the risk of hemorrhaging (internal bleeding), likely due to decreased vitamin K absorption caused by cholestasis.

"Cholestasis is associated with a nearly threefold increase in the risk of stillbirth, a 3-fold risk of increased spontaneous preterm birth, and a twofold increase in admissions to neonatal ICUs," adds Dr. Garb.

Cholestasis impacts 1 in every 1,000 pregnancies, according to the American Liver Foundation. And "ICP seems to have a genetic predisposition, and it can run in families. It's seen more frequently in northern Europeans and in native Americans of Chile," says Dr. Garcia. "Hispanic women also seem to have a higher chance of developing ICP during pregnancy."

What are the symptoms of cholestasis?

"The predominant symptom is intractable itching without a rash—it can be awful," says Dr. Garb. "The itching usually involves the palms of the hands and the soles of the feet and is worse at night."

Other symptoms include pain in the right upper abdominal quadrant (home of the gallbladder), nausea, insomnia, appetite loss, dark urine, steatorrhea (oily, really bad smelling stools), and jaundice (yellow discoloration of the skin and eyes).

ICP is more likely to occur in the third trimester but can happen as early as eight weeks into pregnancy, according to the American Liver Foundation.

But know that if you're itchy but do have a rash, it's likely not ICP. (Related: What's Causing Your Itchy Skin?)

"Pregnant patients should remember that rashes and associated itching are common in pregnancy and can be treated with over-the-counter and topical medicines," says Dr. Garcia. "But if you have itching without a rash, especially on their palms and soles, that worsens at night, then they should immediately speak with their physicians about this possibility." (Also read: Why You Have Itchy Skin At Night)

What causes cholestasis?

You can thank your pregnancy hormones. "There are high levels of estrogen and progesterone in a pregnant woman's body, which are necessary to maintain the pregnancy for nine months," says Dr. Garcia. "But high levels of estrogen and progesterone can limit the ability of certain proteins in the liver to get rid of waste products. For example, the bile salt export pump (BSEP) protein can be adversely affected by high levels of estrogen and progesterone, and if the BSEP cannot get rid of bile and bile salts effectively, they build up in the pregnant woman's body, causing the symptoms noted above." (Related: One Woman Shares All the Unexpected Ways Pregnancy Can Change Your Body)

While the exact cause of cholestasis is still uncertain, researchers believe there's a link between it and other liver diseases, such as nonalcoholic fatty liver disease. Other causes include genetics and environmental factors like nutrition and seasonal timing of pregnancy, according to ICP Care, an educational resource on the condition. More women are diagnosed with ICP in winter months (likely due to reduced exposure to sunlight), and selenium deficiency has been linked to ICP (although it's unknown whether this is a cause, effect, or correlation of the condition).

How is cholestasis diagnosed and treated?

Once you inform your doctors of your symptoms, the first step is usually a blood test.

"When a pregnant patient complains of itching with no rash in the third trimester, she will likely have her blood drawn to check the level of bile salts and undergo liver function tests," says Dr. Garcia. You may also start a drug called ursodeoxycholic acid (aka Ursodiol or Actigall, which work by reducing the bile acids in the bloodstream) even before your test results are back.

If the tests confirm that it's cholestasis, you'll likely need extra monitoring and ultrasounds for the rest of your pregnancy, since, technically, there's no cure for ICP besides delivery. Your doctor may also induce your labor early to protect both you and your baby from potentially negative and serious side effects. (Speaking of: 7 Moms Share What It's Really Like to Have a C-Section)

"Delivery is usually induced three to four weeks prior to the due date, although this will vary depending on the severity of a particular case," says Dr. Garb.

Is there anything you can do to prevent cholestasis?

Unfortunately, no. "Once you're pregnant, this is a possibility," says Dr. Garb. (Related: 4 Ways to Change Your Workout While Pregnant)

Knowing your family history and talking with your ob-gyn about any itching without a rash is key. And women that have experienced ICP before should also be vigilant, as ICP can recur in future pregnancies in 60 to 90 percent of women, according to the American Liver Foundation.

Women who experience cholestasis should also seek extra treatment after the baby is born. "Women who have had ICP in pregnancy should be seen by a hepatologist (a liver specialist) after delivery to be evaluated for any lasting liver damage," says Dr. Garcia.

Women with ICP have a higher chance of developing liver disease, gallstones, or liver cancer, and are often recommended to have a liver function test once a year.

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