Itching during pregnancy and redness in some spots on the body are normal for women. Due to a stretched body, these symptoms happen. But a small percentage of women know about Cholestasis, and some have misinformation, which indicates the lack of awareness of the situation. Based on the research, around 3.44% of women have experienced stillbirth caused by ICP (intrahepatic cholestasis of pregnancy).
This article will let you know about cholestasis in pregnant women, its symptoms, risks, diagnosis, and what you can do to protect yourself. There is a saying that “Women are the key holders of the family”. So, if she is healthy, then she can keep others healthy, which is why Jaipur’s top Cradle Children’s Hospital wants women to take care of themselves, not for others, but for themselves, their own good.
What is Cholestasis of Pregnancy (ICP)?
Intrahepatic Cholestasis of Pregnancy (ICP), often known as Cholestasis, is a liver condition that increases the buildup of bile acids in the blood, resulting in severe itching. Bile acids are compounds that are synthesised from cholesterol in the liver. It emulsifies the fat by breaking it into a portion that can be absorbed by the body easily. This is important for the absorption of essential vitamins like A, K, E, and D.
Women start to experience symptoms in the third trimester, and they often go away after giving birth. Without any rash, pregnant women often experience itching in their hands and feet.
It is also known as intrahepatic cholestasis of pregnancy, obstetric cholestasis (OC), gestational cholestasis, and pregnancy-related cholestasis. Additionally, based on the medical context, these conditions are classified as biliary stasis, acholuria, and bile duct obstruction, depending on their underlying causes.
But How Does It Differ From The Changes That Happen In Pregnancy?
Due to increased blood supply to the skin, the stretch to an extent, like in the abdomen, where women started to experience itchiness, which most of them experience. This causes rashes and redness around the area because of the dry skin. But cholestasis in pregnancy happens due to hormonal and genetic factors, where the bile level increases in the bloodstream, and it does not leave any rashes.
How Common Is It & Its Contributing Factors?
Around 2 to 4% of women experience these issues during their pregnancy. Itching often worsens at night, and it can bother you so much that it starts to impact your sleep cycle. The prevalence of cholestasis in women is detected as 3.3% or more than that, and women are dealing with the issues.
Cholestasis of Pregnancy Symptoms
- Itchiness around different parts of the body during pregnancy is common, but cholestasis is not just normal itching; it can cause challenges in your pregnancy and impact the growth of the fetus.
- Some main symptoms to watch out for:
- Along with itchiness in your hands, feet, and other parts of the body, some started to experience nausea, darker urine, pale brown poop, loss of appetite, pain around the belly, and fatigue. But the itchiness does not come with rashes like others.
- Skin started to turn yellowish, but remember, not everyone has jaundice due to cholestasis. Between 14% to 25% experience these symptoms.
- Due to nutrition malabsorption, sleep disturbance, altered central nervous system (CNS) function, and hormones, pregnant women lack physical energy. But when these factors, along with a triggered immune system and inflammation, happen, this impairs bile excretion.
Why Does It Get Worse Later in Pregnancy?
Bile is the main component that causes this issue, as it starts to store in the gallbladder and is unable your functions to break down the fat during digestion.
Pregnant women are more prone to this because of the increased progesterone and estrogen levels, which impact the ability of the liver to transport bile.
Now the question is, why the third trimester?
So the answer is simple. As pregnancy approaches, hormonal fluctuation reaches its peak level, increasing estrogen and progesterone, inhibiting the function of key proteins in the liver cells, and increasing bile build-up.
Why Is It Easy To Miss?
Due to the overlap with normal pregnancy symptoms, and not having any rashes, it makes you think that this is normal, but it is not. Cholestasis in pregnancy is not common, and it happens in very few cases because of several factors, which we have discussed earlier.
Causes of Intrahepatic Cholestasis of Pregnancy
Role of Hormones:
- Interference with bile transport- due to the hormones, the bile transportation, which is regulated by the contraction of the gallbladder, was interrupted. CCK (cholecystokinin) and secretin are the ones that facilitate the flow. But this got disrupted by hormones and impaired the flow, which led to the buildup of the bile acid.
- Elevated estrogen and progesterone- to support the development of the fetus, hormones increase, and due to these elevated hormones liver’s ability to transport bile acid from the liver cells decreases, inhibiting the bile salt export pump (BSEP). These start the accumulation of the bile acid because of the inability the excrete the acid into the bile ducts, and spill into the bloodstream rather than the liver.
- Selenium deficiency- due to selenium deficiency, the chances of cholestasis are also increased. It impaired antioxidant defence, inflammation damages hepatocytes, and impairs the liver’s ability.
Contributing Factors:
- Genetic predisposition- genetic (ABCB4 or ABCB11 genes) play an important role when it comes to diseases or health complications. 20% to 25% of cases happen because of the genetic role, while ABCB4 is the one that have a higher contributing factor. If someone has a family history of this issue, then the chances are that the future generation carries ICP with them.
- Multiple gestation- we know how one pregnancy can lead to hormonal fluctuation. Then think about what multiple gestation can do. Due to multiple pregnancies, women’s hormonal levels increase. It also impacts the mother’s hepatic (liver) metabolism.
- Environmental concerns- air pollution, reduced sunlight exposure, seasonal changes (especially in winter). This also runs in genes, which is linked to a specific mutation.
- Pre-existing liver disease- liver issues reduce the structural and functional capacity and impair the ability to process bile. When pregnancy stress is added along with hormonal fluctuation, the chances of the condition increase by 29.4 times. While hepatitis C has a 4-fold higher risk of having ICP.
- Gallbladder issues- health problems like stones or other gallbladder-related issues also influence the level of bile acid.
Diagnosis of Intrahepatic Cholestasis of Pregnancy
By Yourself:
- Although it is diagnosed by conducting some specialised tests, you can recognise the symptoms that indicate ICP.
- You started to experience severe itching on your hands and soles of your feet, and it became worse at night. Also, dark, pale stool and urine, pain in the upper abdominal area, nausea, and no rashes are some of the things that you should not ignore.
By Doctors:
- Clinical Examination- The First doctor checks your family medical history to know if this is genetic or not. Then, if you have jaundice symptoms, a physical examination is conducted to check for the issue or liver tiredness.
- Blood Test
- Serum Bile Acid Test: Before this test, doctors suggest not consuming anything for at least 8 to 12 hours or consuming only water. Then, through a blood sample and a check for bile acid value. Elevated bile acids confirm the diagnosis. Here are the measuring numbers-
– Normal: <10 µmol/L
– Mild ICP: 10–39 µmol/L
– Moderate: 40–99 µmol/L
– Severe: ≥100 µmol/L
4. Liver function test- in ICP, ALT (alanine aminotransferase and AST (aspartate aminotransferase) are often elevated. Through ultrasound, the analysis is conducted to determine the condition.
If Cholestasis Is Found, Then What-
To ensure the health of the fetus, regular fetal monitoring is conducted, which includes non-stress tests and biophysical profiles. And if the condition persists, then early delivery is recommended to prevent stillbirth.
Risks & Complications of Intrahepatic Cholestasis of Pregnancy For Mother and Baby
For Mother:
- Postpartum Haemorrhage- as ICP reduces the bile flow, which is essential to absorb healthy fat and vitamins for digestion, the mother is unable to get the fat-soluble vitamins, increasing the risk of Vitamin K deficiency. This deficiency is unable to create blood clots, which is necessary after delivery, further increasing the risk of bleeding.
- Long-term Risk- cholestasis increases the risk related to the liver and gallbladder in the future.
- Preeclampsia- intrahepatic cholestasis of pregnancy (ICP) causes high blood pressure and protein in the urine, which is a key reason behind preeclampsia. Although ICP does not directly lead to the issue, it definitely increases the risk of having these health complications combined with others. As per studies, one in 3 women has high protein in urine due to cholestasis.
For The Baby:
- Meconium in Amniotic Fluid- You might have heard that the baby pooped in the amniotic fluid before birth. This is because of the high bile acid. This can lead to complications for the baby, like it can block the airway, which can cause issues for the baby to inhale oxygen, irritate the lungs, and, due to meconium in the lungs, it can lead to meconium aspiration syndrome (MAS). It also comes with the treacherous risk of sudden fetal demise.
- Selenium Deficiency Poses Risks- Selenium helps in fetal development, but in deficiency, it poses a significant risk to the baby. It increases the risk of preterm birth. Elevated bile acid can cause cardiac arrhythmias (irregular heartbeat), stillbirth, and respiratory distress syndrome in the baby.
- High BMI- children who are born to women with ICP have a higher risk of developing high body mass index and dyslipidaemia at their early age, around 15.
- Preterm Birth- due to complications, the chances of preterm birth increase. Sometimes, even doctors suggest giving birth before 37 weeks to ensure the baby’s safety.
Intrahepatic Cholestasis of Pregnancy Treatment & Management
- Medications: This is the prime treatment of cholestasis, and it is ursodeoxycholic acid (ursodiol), which lowers the level of bile acids and diminishes itching.
- Symptom Relief: Symptoms are relieved by cool or lukewarm baths and using mild skin moisturisers. Antihistamines may be used, although the degree of response is variable.
- Fetal Monitoring: The well-being of the fetus should be monitored through a series of non-stress tests and ultrasounds performed on a scheduled basis.
- Timing of Delivery: It is usually suggested to deliver early because there is a risk of stillbirth, and the period considered is around 36–37 weeks of pregnancy, especially in cases with high bile acid levels.
- Lifestyle Support: A healthy diet is not a joke because it can prevent several health problems, and cholestasis in pregnancy is one of them. Limiting sugary products, hydrating yourself, and eating nutrition-rich food are the keys. Along with that, during pregnancy, make sure to take proper rest and don’t let yourself towards sleep deprivation.
Management: What Pregnant Women Can Do: Self-Care & Precautions
- First, if you are noticing any symptoms or having persistent itching, especially in your hands and feet, then make sure to call your doctor. If the issue is ignored or delayed in getting treatment, then you are risking the life of your baby or putting them into a life with syndromes or diseases.
- Here are some lifestyle Tips that can prevent you from getting ICP:
- Use only fragrance-free, mild skin products.
- Avoid hot showers and tight clothing.
- Take regular rests and drink plenty of water.
- Prenatal care includes regular visits that are necessary not only for monitoring liver function but also for the well-being of the fetus.
How Does the Intrahepatic Cholestasis of Pregnancy Impact Future Pregnancies?
- Apart from that, if you had ICP in your first pregnancy, and now you are planning your next pregnancy, then before that, make sure to get clarification from your gynaecologist. They will let you know the precautions you need to take for a healthy and successful pregnancy.
- The recurrence rate of ICP is between 60% to 70% in subsequent pregnancies. History should be discussed with a healthcare provider before conceiving again. Early bile acid testing and monitoring can be planned.
Busting Myths About Intrahepatic Cholestasis of Pregnancy
Now, it is time to know about myths and facts, because rather than believing in superstition or misconceptions, it is better to know the facts.
Myth 1: Cholestasis or ICP happens only in the third trimester of pregnancy.
Fact: Most women experience this during the 2nd or 3rd trimester because of the elevated hormones, but there are cases of early issues even in the 5th week or 1st trimester.
Myth 2: If medication reduces the level of bile acid to normal, then no need for early delivery.
Fact: There are no studies that can prove the fact that reduced bile acid does not impact the baby. Although it does lower the risk of preterm labour but the risk is still there.
Myth 3: Cholestasis of pregnancy can damage the liver permanently.
Fact: NO, it does not. Usually, it goes away after a few days of delivery, but if someone is still having those similar issues, it is best to talk to your gynaecologist. Because there are cases of postpartum haemorrhage, issues with liver functions, and ongoing itching can occur.
Myth 4: Itching only occurs in the hands and feet.
Fact: It can happen in any part of the body, although feet and hands are the first indication of Cholestasis.
Myth 5: It only happens to women, especially during pregnancy.
Fact: It can happen to anyone, men and women, and even some women who are not even pregnant. This health complication is totally related to bile acid. Pregnant women are highly vulnerable due to their hormonal changes, which impact their bladder and bile acid values.
Final Thought:
Many of you may not be familiar with cholestasis of pregnancy, but now you are. So if you or someone you know started to experience symptoms like itching, nausea, yellowing of the skin and whites of the eyes, and foul-smelling urine, then the body is indicating that it needs medical attention. Cradle Children Hospital wants women to know about their bodies more precisely so that, through early detection, complications can be prevented, for the mother and the baby.
If it is not just about this condition, women should get themselves checked quarterly or monthly. Whether it is about overall or reproductive health, taking care of themselves should be their priority.
Moreover, if you want to know more about pregnancy, women’s health, or children’s health, then Cradle Children’s Hospital can guide you.
Get in Touch With Us.
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FAQs
What if I have a rash all over my body? Does it count as Intrahepatic cholestasis of pregnancy?
First of all, ICP does not come with rashes. So, if you have rashes, then it indicates that you might have another issue.
Is it fatal?
Not all the time, but if it is left untreated for a longer period of time, then the chances of liver damage is high. It can cause infection, nutritional deficiency, severe ICP, and liver damage.
Why does itching persist at night and become bearable in the day?
Due to circadian fluctuation because of the pregnancy hormones and increased endogenous opioids accentuate the feeling of itch.
Can I still have a healthy baby even after having cholestasis?
Yes, you can. With regular monitoring and management through lifestyle modification and medication, women can protect their baby.
