7 Key Cholestasis of Pregnancy Symptoms Every Expecting Mother Should Know

Cholestasis of pregnancy, also known as intrahepatic cholestasis of pregnancy (ICP) or obstetric cholestasis, is a liver condition that occurs during pregnancy, typically in the third trimester. This condition affects the normal flow of bile, causing bile acids to accumulate in the bloodstream instead of being properly eliminated from the liver. While cholestasis of pregnancy is relatively rare, affecting approximately 1-2% of pregnancies, it’s crucial for expecting mothers to recognize its symptoms early, as the condition can pose risks to both mother and baby.

The hallmark symptom of this condition is intense itching, particularly on the hands and feet, which often worsens at night. Understanding the full range of symptoms can help pregnant women seek timely medical attention and receive appropriate monitoring throughout their pregnancy. Early detection and proper management are essential for ensuring the best outcomes for both mother and child.

1. Intense Itching Without Rash (Pruritus)

The most characteristic and often the first symptom of cholestasis of pregnancy is severe itching, medically known as pruritus. This itching is notably different from the mild skin stretching discomfort many pregnant women experience.

Key characteristics of cholestasis-related itching include:

• Location: Most commonly affects the palms of the hands and soles of the feet, though it can spread to other parts of the body including the arms, legs, and abdomen
• Intensity: The itching is typically severe and relentless, often described as unbearable or maddening
• Timing: Usually worsens significantly at night, which can lead to severe sleep disruption and exhaustion
• No visible rash: Unlike other skin conditions, there is typically no rash, hives, or visible skin changes accompanying the itching
• Onset: Generally begins in the third trimester, though it can occasionally start earlier, usually after 28 weeks of pregnancy

The itching occurs because bile acids accumulate in the bloodstream and deposit in the skin tissue. Some women describe the sensation as feeling like they want to scratch their skin off, and the discomfort can be so severe that it significantly impacts quality of life and daily functioning.

2. Dark Urine

Women with cholestasis of pregnancy often notice that their urine becomes noticeably darker than usual, sometimes appearing amber, brown, or tea-colored. This occurs due to the buildup of bilirubin, a yellowish pigment that is normally processed by the liver and excreted in bile.

When bile flow is impaired, bilirubin levels increase in the bloodstream, and excess bilirubin is filtered by the kidneys and excreted in the urine, causing the darker coloration. This symptom may appear alongside or shortly after the onset of itching.

Important considerations:

• Dark urine should not be confused with concentrated urine from dehydration, which appears darker yellow but not brown or amber
• The color change is usually consistent and doesn’t improve with increased water intake
• This symptom warrants immediate medical evaluation, especially when combined with other signs of cholestasis

3. Pale or Clay-Colored Stools

Another telltale sign of cholestasis of pregnancy is a noticeable change in stool color. Stools may become pale, light-colored, clay-colored, or grayish in appearance, which is significantly different from the normal brown color.

This change occurs because bile, which gives stool its characteristic brown color, is not reaching the intestines in normal amounts due to the impaired bile flow. Instead of being excreted through the digestive tract, bile components are backing up into the bloodstream.

What to look for:

• Stools that are lighter than usual, ranging from light tan to almost white or gray
• The color change is typically persistent rather than occasional
• May be accompanied by changes in stool consistency

While this symptom may seem less concerning than severe itching, it’s an important indicator of bile flow obstruction and should be reported to your healthcare provider.

4. Jaundice (Yellowing of Skin and Eyes)

Jaundice, characterized by a yellowish tint to the skin and the whites of the eyes (sclera), can develop in some women with cholestasis of pregnancy, though it’s less common than itching. This occurs when bilirubin levels in the blood become significantly elevated.

Characteristics of jaundice in cholestasis:

• Appearance: A yellow or greenish-yellow discoloration, most easily visible in the whites of the eyes and then spreading to the skin
• Severity: Can range from mild (barely noticeable) to moderate; severe jaundice is less common
• Timing: Usually develops after other symptoms like itching have already appeared
• Progression: May become more pronounced if the condition is not monitored and managed

Jaundice indicates that liver function is being significantly affected, and its presence should prompt immediate medical attention. It’s worth noting that only about 10-15% of women with cholestasis of pregnancy develop visible jaundice.

5. Fatigue and General Malaise

Extreme fatigue and a general feeling of being unwell (malaise) are common symptoms of cholestasis of pregnancy. While fatigue is a normal part of pregnancy, the exhaustion associated with cholestasis is often more pronounced and debilitating.

This fatigue results from multiple factors:

• Sleep deprivation: Severe nighttime itching prevents restful sleep, leading to chronic exhaustion
• Liver dysfunction: Impaired liver function can contribute to overall feelings of unwellness
• Elevated bile acids: High levels of bile acids in the bloodstream can cause systemic effects including fatigue
• Physical and emotional stress: The constant discomfort and worry about the condition takes a toll on energy levels

Women often describe feeling completely drained, unable to perform normal daily activities, and experiencing a persistent sense of not feeling like themselves. This fatigue doesn’t improve with rest and may progressively worsen as pregnancy continues.

6. Nausea and Loss of Appetite

Some women with cholestasis of pregnancy experience digestive symptoms including nausea, reduced appetite, and general gastrointestinal discomfort. These symptoms can be particularly concerning as they may lead to inadequate nutrition during a critical time of fetal development.

Digestive symptoms may include:

• Persistent nausea that differs from typical morning sickness, often occurring later in pregnancy
• Decreased desire to eat or aversion to foods that were previously enjoyed
• Feeling full quickly or experiencing discomfort after eating
• General abdominal discomfort, particularly in the upper right quadrant where the liver is located
• Occasional vomiting, though this is less common

These symptoms occur because the liver plays a crucial role in digestion, particularly in fat digestion through bile production. When bile flow is impaired, digestive function can be affected. Additionally, elevated bile acids can trigger nausea and appetite changes.

7. Upper Right Quadrant Abdominal Pain or Discomfort

Some women with cholestasis of pregnancy experience pain or discomfort in the upper right portion of the abdomen, where the liver is located. This symptom can range from mild discomfort to more pronounced pain.

Characteristics of this abdominal discomfort:

• Location: Primarily in the upper right side of the abdomen, just below the ribs
• Quality: May be described as a dull ache, pressure, fullness, or tenderness in the liver area
• Triggers: May worsen after eating, particularly fatty meals
• Duration: Can be constant or intermittent
• Associated symptoms: Often accompanied by other cholestasis symptoms like itching

This discomfort results from liver inflammation and stretching of the liver capsule due to bile accumulation. While not all women with cholestasis experience this symptom, those who do should report it to their healthcare provider, as it can help in diagnosis and monitoring of the condition.

Main Causes and Risk Factors of Cholestasis of Pregnancy

While the exact cause of cholestasis of pregnancy is not completely understood, researchers believe it results from a combination of genetic, hormonal, and environmental factors that affect liver function during pregnancy.

Primary Contributing Factors:

1. Hormonal Changes: The high levels of pregnancy hormones, particularly estrogen and progesterone, can affect the liver’s ability to transport bile acids. These hormones reach peak levels in the third trimester, which explains why cholestasis typically develops during this time.

2. Genetic Predisposition: There is a strong genetic component to cholestasis of pregnancy. Women with a family history of the condition are at significantly higher risk. Specific genetic mutations affecting bile acid transporters have been identified in some women with cholestasis.

3. History of Liver Disease: Women who have previously experienced liver problems or have chronic liver conditions may be more susceptible to developing cholestasis during pregnancy.

4. Multiple Pregnancy: Women carrying twins, triplets, or more are at increased risk, possibly due to higher hormone levels associated with multiple pregnancies.

Additional Risk Factors:

• Previous history of cholestasis: Women who had cholestasis in a previous pregnancy have a 60-90% chance of recurrence in subsequent pregnancies
• History of liver damage from other causes: Such as hepatitis C or other liver conditions
• Geographic and ethnic factors: Higher prevalence in certain populations, including women of Scandinavian, Chilean, and South Asian descent
• In vitro fertilization (IVF) pregnancy: Some studies suggest a slightly higher risk
• Advanced maternal age: Women over 35 may have slightly increased risk
• Carrying a male fetus: Some research suggests a marginally higher occurrence, though findings are mixed

Frequently Asked Questions

When does cholestasis of pregnancy typically start?

Cholestasis of pregnancy most commonly begins in the third trimester, usually after 28 weeks of pregnancy, though it can occasionally start earlier. The symptoms typically appear suddenly and worsen as the pregnancy progresses. The itching and other symptoms usually resolve within a few days to weeks after delivery.

Is the itching from cholestasis different from normal pregnancy itching?

Yes, significantly different. Normal pregnancy itching is typically mild, localized to the belly where skin is stretching, and often accompanied by visible dryness or a rash. Cholestasis itching is intense and relentless, primarily affects the palms and soles without any rash, worsens dramatically at night, and can be so severe it interferes with sleep and daily activities.

Can cholestasis of pregnancy harm my baby?

Yes, cholestasis of pregnancy can pose risks to the baby, which is why early detection and close monitoring are crucial. The condition is associated with increased risks of preterm birth, fetal distress, meconium in amniotic fluid, and in rare cases, stillbirth. However, with proper medical supervision, monitoring, and management, most women with cholestasis deliver healthy babies. Your healthcare provider will likely recommend more frequent monitoring and may suggest early delivery between 36-38 weeks.

Will cholestasis of pregnancy go away after delivery?

Yes, cholestasis of pregnancy typically resolves completely shortly after delivery. Most women notice their itching begins to improve within a few days after giving birth, and symptoms usually disappear entirely within a few weeks postpartum. Liver function tests generally return to normal within 2-6 weeks after delivery. However, the condition is likely to recur in subsequent pregnancies.

How is cholestasis of pregnancy diagnosed?

Diagnosis is made through blood tests that measure bile acid levels and liver function. Total bile acid levels above 10 micromol/L are generally considered abnormal, with levels above 40 micromol/L indicating severe cholestasis. Your doctor will also check liver enzymes (ALT and AST) and bilirubin levels. The diagnosis is typically made when you have characteristic symptoms (especially intense itching without rash) combined with elevated bile acid levels.

Can I prevent cholestasis of pregnancy?

Unfortunately, there is no proven way to prevent cholestasis of pregnancy, especially if you have genetic predisposition or other risk factors. However, maintaining good overall health before and during pregnancy, avoiding substances that stress the liver, attending all prenatal appointments, and reporting any unusual symptoms promptly can help ensure early detection and appropriate management if the condition develops.

Should I be concerned if I only have itching without other symptoms?

Yes, you should definitely contact your healthcare provider if you experience severe itching during pregnancy, even without other symptoms. Intense itching, particularly on the palms and soles that worsens at night, should always be evaluated, as it can be the only initial symptom of cholestasis. Early diagnosis through blood testing is important for proper monitoring and management. Never dismiss severe pregnancy itching as normal without medical evaluation.

Can diet changes help with cholestasis symptoms?

While dietary changes cannot cure cholestasis of pregnancy, some women find that eating a low-fat diet may help reduce digestive discomfort and nausea. However, dietary modifications do not lower bile acid levels or eliminate the risks associated with the condition. Always consult with your healthcare provider before making significant dietary changes during pregnancy, and never rely on diet alone to manage this condition—proper medical monitoring is essential.

References:

• Mayo Clinic – Cholestasis of Pregnancy
• American College of Obstetricians and Gynecologists (ACOG) – Intrahepatic Cholestasis of Pregnancy
• NHS – Intrahepatic Cholestasis of Pregnancy
• March of Dimes – Intrahepatic Cholestasis of Pregnancy
• National Center for Biotechnology Information – Cholestasis of Pregnancy