Cholestasis of Pregnancy: Why You Can’t Ditch the Itch

Headaches, heartburn, itchy skin… pregnancy can cause a whole host of annoying symptoms! But that itchy skin is worth paying attention to. In some rare cases, it could be more than a nuisance. It could be the result of cholestasis of pregnancy, a condition with serious consequences, especially for baby.

In this post, we’ll explain exactly what cholestasis of pregnancy is, plus:

  • How to tell if your itching in pregnancy is cholestasis of pregnancy
  • Treatment options for cholestasis of pregnancy
  • And how have an empowered birth even with a diagnosis of cholestasis

What is Cholestasis of Pregnancy?

Cholestasis of pregnancy is a liver condition that most commonly arises in the third trimester, but can happen as early as 8 weeks. (source)

Cholestasis of pregnancy causes intense itching, primarily on the palms and soles of the feet, though the itching can spread to other parts of the body. The itching is reportedly more intense at night, after sunset. (source)

Unlike PUPPS, cholestasis of pregnancy isn’t accompanied by a rash, though intense scratching can cause skin damage that resembles a rash.

First Things First: Don’t Freak Out!

The vast majority of pregnant mamas have nothing to worry about when it comes to itching skin during pregnancy.

Your  skin is stretching a lot to accommodate that tiny human in there, and that can cause itching. Other women may have PUPPS, an uncomfortable but generally harmless skin rash. PUPPS affects somewhere between 1 and 130 and 1 and 300 pregnant women.

Cholestasis is a rare condition, so chances are slim that it’s causing your pregnancy itching. Still, it’s worth discussing any incessant itching with your healthcare provider—just in case.

How Common is Cholestasis of Pregnancy and Who is at Risk?

The good news: It’s a rare condition. Only 0.3-0.5 percent of women will develop cholestasis of pregnancy.

The bad news: There are certain genetic and lifestyle factors (some that aren’t so controllable) that make you much more likely to get cholestasis of pregnancy.

Here’s what puts you at higher risk:

Heritage

Hispanic women have up to 15 percent chance of developing cholestasis of pregnancy. Researchers aren’t entirely sure why this is, but attribute it largely to genetic factors that cause elevated serum bile acids during pregnancy.

Medical conditions

Mother’s with a Hepatitis C infection have a 6 to 16 percent chance of cholestasis of pregnancy. And diabetic mothers are more likely to have impaired organ function, leading to cholestasis of pregnancy.

Carrying multiples and in vitro fertilization

Moms carrying multiple babies are at an increased risk for cholestasis. And pregnancies that are a result of in vitro fertilization (IVF), which have a higher chance of producing multiples, are also more at risk for cholestasis of pregnancy.

In fact, women with cholestasis who conceived via IVF have been shown to have even higher bile levels—the primary indicator of cholestasis—than women with cholestasis of pregnancy who conceived naturally. (source)

“Compared to the SC (spontaneous conception) group, the IVF (In vitro fertilization) group had a higher incidence of early-onset ICP (cholestasis of pregnancy) and more frequent clinical symptoms, including skin pruritus (severe itching), skin scratch, and jaundice. — source

Hormonal birth control

High estrogen levels, like those caused by hormonal birth control, can lead to cholestasis of pregnancy. Experts think this is because estrogen interferes with bilirubin and bile acid secretion. When bile acid builds up in the body this impairs liver function, causes toxicity, and can lead to cholestasis. (source)

It was previously believed that only abnormal estrogen levels were to blame, but current research also points the finger at progesterone. (source) Some birth control raises estrogen levels, while others raise progesterone.

Genetics

Some women have genetic abnormalities that trigger bile flow from their BSEP (bile salt export pump). This deficiency then causes a toxic bile buildup that leads to cholestasis of pregnancy. Elevated hormone levels also come into play.

“The hormones estrogen and progesterone (and products formed during their breakdown), which are elevated during pregnancy, further reduce the function of BSEP, resulting in impaired bile secretion and the features intrahepatic cholestasis of pregnancy.” (source)

Additional research suggests certain hereditary changes in bile excretion and abnormal reaction to estrogen may be to blame for some ICP cases. 

Leaky gut

There may be a link between impaired gut function and cholestasis of pregnancy. Researchers followed women with a history of ICP and found they were much more likely to die from gastrointestinal disease.

And researchers in Chili discovered that some pregnant moms with cholestasis of pregnancy, especially those with high bilirubin levels, weren’t digesting fat well. Other study participants had leaky gut. The research indicated that gut microflora, gut health, and digestion issues were all tied to cholestasis of pregnancy.

Liver function

Women with a history of chronic liver disease are at higher risk for cholestasis of pregnancy. Research suggests hormonal changes and the physical stress of pregnancy can cause a resurgence of liver problems, but even women without a history of liver disease can develop a liver problem during pregnancy, leading to cholestasis.

What are the Signs and Symptoms of Cholestasis of Pregnancy?

The most common symptom is severe itching in the hands and feet.

In addition, you may have some, none, or all of these symptoms of cholestasis of pregnancy (source):

  • Intense itching in other areas of the body
  • Intense itching that occurs at night
  • Dark urine
  • Pain in the gallbladder area (one study showed 13 percent of women with cholestasis had gallstones)
  • Nausea and/or lack of appetite
  • Excessive fatigue
  • Generally not feeling well
  • Mild depression
  • Pale poop, or undigested fat in stool

How is Cholestasis of Pregnancy Diagnosed?

Cholestasis isn’t very common, so women aren’t routinely screened for it.

If you have a history of liver problems or develop symptoms of cholestasis of pregnancy, especially itching without a rash, your healthcare team may run some tests, including a blood draw and a urine test to check for signs of cholestasis and rule out other possible causes like urinary tract infection, gallbladder disease, and hepatitis. (source)

Your doctor may perform these tests to confirm if you have cholestasis or not:

ALT test: High serum levels of alanine aminotransferase (ALT) can indicate a liver problem. This test on its own won’t confirm cholestasis, but it helps your doctor better understand what’s going on in the liver.

Total bile salts test: This test measures the levels of serum bile salts. Those with high levels will be diagnosed with cholestasis of pregnancy.

Vitamin K deficiency test: In very rare cases cholestasis of pregnancy can cause a vitamin K deficiency. Your doctor can test for a vitamin K deficiency and prothrombin time (the time it takes your blood to clot) to see if an increase in vitamin K is needed.

If the test results come back at abnormal levels, you’ll receive a cholestasis diagnosis

Potential Complications of ICP for Mom

Cholestasis of pregnancy typically resolves within 48 hours of delivery, but in rare cases can last for months afterward.

Follow up testing is recommended for all women at 3-6 months postpartum. If laboratory parameters do not return to normal within 6 months, your doctor will want to perform more tests to determine if there is an underlying condition which may have contributed to the development of cholestasis of pregnancy.

Cholestasis of pregnancy also increases mama’s risk of:

How Does Cholestasis of Pregnancy Affect the Baby?

Cholestasis of pregnancy can have serious side effects for baby, including preterm birth, fetal distress, and stillbirth.

Here are some ways cholestasis of pregnancy directly influences baby’s wellbeing:

Liver function

Baby relies on mama’s liver function, but cholestasis also affects baby’s organ function. A baby has elevated bile acid when mama’s high bile acid levels cross through the placenta. (source) This is thought to cause structural damage to the placenta, which is responsible for delivering oxygen and nutrients to the developing baby (source, source). There’s also evidence high bile acid in the infant damages lung function, leading to higher rates of respiratory distress at birth.

Lower birth weight

This study showed babies born to mothers with cholestasis of pregnancy have lower birth weight. Early onset ICP occurring in the first trimester causes even lower birth weight than late-onset cholestasis.

Heart defects

When bile acid levels are too high in mom, it affects baby’s heart function, which can cause sudden intrauterine deathThis study and this one found significant differences in the heart valve function and an increase in respiratory distress for babies of moms with severe cholestasis of pregnancy.

Fetal distress and meconium staining

Cholestasis of pregnancy frequently causes fetal distress, leading to baby passing their first bowel movement (meconium) in utero. This study showed that 86 percent of babies who died from cholestasis of pregnancy had passed meconium, indicating fetal distress. Meconium aspiration is rare (95 percent of cases clear on their own), but it’s still a serious issue.

Premature birth

Early-onset cholestasis of pregnancy (in the first trimester) is rare, but can be more serious for baby. In this study, adverse events were more likely for moms and babies with early-onset cholestasis compared to those with late-onset cholestasis. Threatened pre-term birth and premature birth were significantly higher in the early-onset group.

What Does Cholestasis of Pregnancy Mean for My Natural Birth Plan?

Since baby has to be monitored very closely, you will likely have to give birth in a hospital.

Even mild cases of ICP can be deadly. In this study 28.5 percent of the babies that died because of cholestasis of pregnancy were from mild cases. It’s important to note the study involved a small sample size and more research is needed, but it indicates precautions still need to be taken in any case of cholestasis of pregnancy.

Labor induction

Pre-term birth is very common in ICP, but induction is usually recommended if baby isn’t born early on their own. Toxic bile salt levels, which are thought to be the cause of the high stillbirth rates from cholestasis, rise as the pregnancy continues. This means the possibility of stillbirth increases the longer the pregnancy continues. (source)

In these cases, induction typically occurs around 37-38 weeks. In this study, 12 out of 21 deaths due to cholestasis of pregnancy occurred before 37 weeks. In a retrospective study from 2017, one hospital reported a significant improvement in fetal outcomes after they adopted new ICP guidelines. The new strategy involved inducing labor earlier.

“This strategy included inpatient admission, continuous fetal heart rate monitoring, with delivery between 36 and 37 weeks. This decreased still births from 3.4 percent to 0 percent with no increase in NICU admission or C-section delivery.” — source

The best time to induce will depend on the health of the baby, mama’s serum bile acid levels, and other factors. It becomes a balancing act of waiting for baby to mature enough to thrive outside the womb, and preventing stillbirth. Work with your doctor to see what’s the best plan for your pregnancy.

How to Have a (Mostly) Natural Birth With Cholestasis

While your birth will look different than you might have planned, it is still possible to incorporate natural methods into your birth plan. Using laboring positions that keep you off of your back helps decrease fetal destress, which is common during cholestasis. And doing things like delayed cord clamping, having your partner catch the baby, or choosing alternatives to common newborn procedures are still possible in most cases.

If you and your healthcare provider decides a C-section is the best, then you can look into a “gentle Caesarean.” This involves natural methods like immediate skin-to-skin and inoculating baby with vaginal flora for optimal gut health.

Can Cholestasis of Pregnancy Be Treated?

Yes… and no.

Conventional medicine has discovered ways to relieve the itching, but nothing has been shown to definitely improve the outcome for baby. (source)

Conventional Remedies for Cholestasis

Ursodeoxycholic acid (UDCA)

UDCA is standard treatment for cholestasis of pregnancy and, of all the conventional treatments, is the most successful. Although the form taken is a synthetic drug, UDCA is a natural component of human bile. It’s thought to displace more toxic bile acids from the total amount of bile acid. UDCA also increases bile flow and may protect the liver. (source, source)

Studies have shown mixed results with UDCA. This meta-analysis of 12 studies found that UDCA improved test markers for mom and improved outcomes for baby. The authors concluded that there was still insufficient evidence of its positive effects. Other studies have shown UDCA doesn’t improve fetal outcomes.

SAMe

S-adenosyl methionine (SAMe) is made naturally in the body and regulates cellular function. A synthetic version is sold as a supplement in the U.S., but it’s available as a prescription drug in Europe. (source) Studies with SAMe supplementation have shown mixed results for treating cholestasis of pregnancy. Some women had no more itch and their ICP test markers improved with SAMe, while others saw little to no improvement. (source)

Several studies have shown when SAMe supplements and the drug UDCA are used together the positive results are greatly increased, compared to using either treatment alone. (source)

Natural and Herbal Remedies for Cholestasis of Pregnancy

The following herbs support liver function, improve bile flow, and reduce the toxic level of serum bile acids. These are considered generally safe to use in pregnancy, but it’s always a wise idea to check with your midwife or natural healthcare practitioner before taking any herbs.

Milk thistle seed

Milk thistle seed regulates liver detox, and protects and regenerates liver cells. It’s commonly used for liver diseases like hepatitis and jaundice, both of which can be associated with cholestasis of pregnancy. Milk thistle seed enhances hormone detox, which is helpful when hormones are imbalanced in pregnancy. (source)

Dandelion root

This common plant has been used as a nutrient tonic during pregnancy for centuries and is beneficial for liver and gallbladder function. It stimulates digestion, increases bile flow, promotes regular bowel movements, and removes excess water from the body. (source)

Yellow dock

This herb enhances digestion of fat and protein, which is impaired during cholestasis of pregnancy. It gently detoxes the liver and helps avoid constipation. When the body isn’t able to properly excrete waste, toxins end up being reabsorbed into the body.

Because yellow dock has a mild laxative effect on the intestines it is sometimes contraindicated during pregnancy, depending on the individual situation. However it hasn’t clinically been linked with uterine contractions or other adverse events during pregnancy. You can ask your midwife if it would be helpful in your situation. (source)

Turmeric

Turmeric is high in the active ingredient curcumin, which helps protect the liver and encourages bile flow. It enhances fat digestion and has been used to treat various liver conditions, including hepatitis and jaundice. It’s anti-inflammatory actions can be soothing to itchy, irritated skin. Turmeric should be used in moderation during pregnancy, but sipping a golden milk latte is a great way to incorporate a little into your routine. (source)

Guar gum

In this study guar gum prevented serum bile acids from increasing and relieved itching. This meta-analysis, however, found insufficient evidence for guar gum treatment and reported it caused digestive issues.

Charcoal

Charcoal binds to toxins in the body and can help the body flush out excess bile. A preliminary study found that charcoal given to pregnant women significantly reduced total bile acid concentration compared to the control group. The findings were promising, but no further research on using charcoal for cholestasis of pregnancy has been done.

N-acetylcysteine

N-acetylcysteine (NAC) is produced naturally by the body and upregulates glutathione production. Glutathione is the liver’s main detox hormone and is necessary for healthy liver function. NAC supplementation won’t treat cholestasis of pregnancy, but it does help support proper liver function for a healthier body. (source)

Bitters

Bitter foods and beverages help to stimulate healthy bile flow and improve digestion. Urban Moonshine makes a bitter remedy that’s safe for pregnant women. You can also try 1 tsp. of raw apple cider vinegar in water before meals. Lemon, dandelion greens, fermented foods like sauerkraut, kim chi and yogurt are also excellent for digestion. Beet kvass is especially effective and nourishing for the liver.

Nutrients That Improve Cholestasis of Pregnancy

Some studies have linked nutrient deficiencies with cholestasis of pregnancy. The connection depends on regional factors, genetics, and diet, but it’s still a good idea to make sure you’re getting adequate nutrition.

Experts recommend focusing on several different nutrients during cholestasis of pregnancy to help improve pregnancy outcome. The following nutrients support healthy liver function, which is impaired in those with cholestasis:

  • Antioxidants: These aid in liver detoxification. Fresh berries, dark chocolate, and dried goji berries are excellent sources.
  • Vitamin B: Liver issues, like cholestasis, can cause vitamin B deficiencies. Increase your intake of foods, like liver (no more than 4 oz. per week), poultry, nutritional yeast flakes and red meat. (source)
  • Glutathione: This is the livers natural detox hormone. Foods high in sulfur, vitamin C and E, and selenium boost the body’s glutathione production. Cabbage, kale and garlic are high in sulfur. Bell peppers and citrus provide vitamin C. Brazil nuts are very high in selenium. Wheat germ oil, sunflower seeds, and almonds are excellent sources of vitamin E. 
  • Choline: Choline prevents fat from accumulating in the liver and the need for it increases during pregnancy. (source) This can be found in high amounts in grass-fed animal liver, wheat germ, and eggs. (source)
  • Folate: Folate is thought to prevent liver damage. (source) It’s found in foods like leafy greens, lentils, asparagus, and broccoli. (source)
  • Magnesium: Magnesium helps prevent constipation, which stalls proper detox and body function. These foods are high in magnesium and here are the best magnesium supplements.
  • Vitamin K: Severe deficiencies during cholestasis of pregnancy are rare, but it’s still a nutrient necessary during pregnancy. Eating vitamin K-rich foods (like parsley, Swiss chard, and kale) and be sure your prenatal contains this vitamin.
  • Selenium: Deficiency has been linked with certain cases of cholestasis of pregnancy. This study of Chilean women found that ICP rates were higher in the winter, when selenium rich foods are naturally less available. When serum selenium levels rose, rates of ICP went down. Eat two Brazil nuts a day to get your recommended amount of selenium.
  • Vitamin C: This study of over seven thousand women found a significant inverse relationship between vitamin C levels and gallbladder disease. Vitamin C is needed for proper bile flow. Insufficient bile flow causes a buildup of toxic bile, which can lead to cholestasis and/or gallstones. Kiwi, guava, mango, and bell peppers are all high in vitamin C. You can also add camu camu powder to yogurt or smoothies.

How to Soothe the Itch

The following natural remedies help bring relief to itchy skin caused by cholestasis of pregnancy.

A soothing bath

  • Add calendula, chamomile, lavender and/or colloidal oatmeal to a warm bath. These soothing plants all have anti-inflammatory properties.

Anti-itching soap

Some moms have success using this special Pine Tar soap to calm the itching.

Nettles tea

A natural antihistamine, nettle leaf tea may help to reduce some of the discomfort.

Remember…

In the vast majority of cases, your itching skin is nothing to worry about! It’s common to feel itchy when your skin is stretching so much. Moisturizer, hydrate, and try not to scratch too much. Hang in there, mama! 😘

How About You?

Did you have cholestasis of pregnancy? How did you manage the condition?

About the Author

Genevieve Howland is a childbirth educator and breastfeeding advocate. She is the bestselling author of The Mama Natural Week-by-Week Guide to Pregnancy and Childbirth and creator of the Mama Natural Birth Course. A mother of three, graduate of the University of Colorado, and YouTuber with over 75,000,000 views, she helps mothers and moms-to-be lead healthier and more natural lives.

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