Symptoms

Itching (also called pruritus)

• The itch in intrahepatic cholestasis of pregnancy (ICP) typically presents in the third trimester, but it can start as early as 7-8 weeks of pregnancy.

• It can be mild that you hardly notice it, or so severe that you scratch your skin until it bleeds. It can be constant or intermittent.

• Although the itch typically affects the hands and feet, it may occur anywhere on your body.

• Many women find that the itching is worse at night and disturbs their sleep.

• There is research to show that the level of bile acids does not correlate with the intensity of itch. This means that it is possible to experience severe itching but still have low bile acid levels, and conversely have very high bile acid levels with very little itching. Two other substances, lysophosphatidic acid and sulfated progesterone metabolites, have been shown to have a more direct link to the itch.

• There is no rash associated with the itch, but there may be marks on your skin from scratching (also called excoriation marks).

• Although the symptoms of ICP are distressing for you, they should resolve rapidly after your baby is born.

• Research now shows that ICP has a longer-term impact than was first thought: some women may have an increased risk of developing liver disease, such as gallstones, and other conditions such as Type 2 diabetes. Their children may also have a higher risk. More research is needed to fully understand these latest findings.

Mild scratch marks

Other symptoms

• Some (but not all) women with ICP develop other symptoms associated with cholestasis. These may include jaundice (yellowing of the skin and whites of the eyes), dark urine and pale stools.

• It is not uncommon for women with ICP to feel generally unwell and tired, and to lose their appetite.

• Right Upper Quadrant (RUQ) pain. You might notice that you develop a tenderness or experience pain on your right-hand side, just underneath your rib cage. Women have reported this pain during their ICP pregnancy, but the liver doesn’t actually have any nerve endings so it’s not this that is causing the pain. One thought is that the liver may be pressing against the membrane (called the capsule) that surrounds it, and as the capsule does have nerve endings this is what the pain could be. But it may also be due to other factors, such as gallstones or even how the baby is positioned inside you. It can also be linked to other serious pregnancy complications, so you will need a doctor to examine you to see what could be the cause. Not much has been written about why this kind of pain sometimes occurs in ICP, but as more and more women are reporting it on our forums, we know that it can be a problem. It would certainly seem to need further research so that specialists can learn more about it, especially as we also know that it sometimes continues to be a problem for a small number of women after the baby has been born.

References

Girling J, Knight CL, Chappell L; on behalf of the Royal College of Obstetricians and Gynaecologists. Intrahepatic cholestasis of pregnancy. BJOG 2022; 1–20. https://doi.org/10.1111/1471-0528.17206.

Abu-Hayyeh et al. Prognostic and mechanistic potential of progesterone sulfates in intrahepatic cholestasis of pregnancy and pruritus gravidarum. Hepatology 2015; https://doi.org/10.1002/hep.28265.

Dixon PH, Williamson C. The pathophysiology of intrahepatic cholestasis of pregnancy. Clin Res Hepatol Gastroenterol 2016; 40(2): 141–53. https://doi.org/10.1016/j.clinre.2015.12.008.

Kremer AE Martens JJ, Kulik W, Rueff F, Kuiper EM, van Buuren HR, van Erpecum KJ, Kondrackiene J, Prieto J, Rust C, Geenes VL, Williamson C, Moolenaar WH, Beuers U, Oude Elferink RP. Lysophosphatidic acid is a potential mediator of cholestatic pruritus. Gastroenterology, 2010; 139: 1008–1018. https://doi.org/10.1053/j.gastro.2010.05.009.

Wikström Shemer EA, Stephansson O, Thuresson M, Thorsell M, Ludvigsson JF, Marschall HU. Intrahepatic cholestasis of pregnancy and cancer, immune-mediated and cardiovascular diseases: a population-based cohort study. J Hepatol 2015; 63(2): 456–61. https://doi.org/10.1016/j.jhep.2015.03.010.

Williamson C, Geenes V Intrahepatic cholestasis of pregnancy. Obstet Gynecol 2014; 124: 120–133. https://doi.org/10.1097/AOG.0000000000000346.

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