- Most people experience itching as the only symptom of Intrahepatic Cholestasis of Pregnancy (ICP).
- The location and intensity of the itch can vary and does not correlate with severity of the disease.
- Some affected individuals may experience other, less common, symptoms.
For most people with Intrahepatic Cholestasis of Pregnancy, itching is the only symptom. ICP is not typically associated with a rash, but sometimes a rash can develop as a result of intense scratching. It’s also possible to have ICP and an unrelated rash, such as PUPPP (pruritic urticarial papules and plaques of pregnancy). The intensity of itching can vary greatly, and does not correlate with the severity of the disease1, meaning you may have intense itching with either low or high bile acid levels. Conversely, you may have milder itching with either low or high bile acid levels. The intensity of itching appears to be related to the level of a chemical called lysophosphatidic acid. Many (but not all) patients experience increased itching in the evening and night. The reasons for this are not fully understood, but may be related to cyclical changes in hormones such as Cortisol.
Classically, Intrahepatic Cholestasis of Pregnancy itching has been described as occurring on the palms of the hands and soles of the feet. While this is common, it is not true for all affected individuals. Sometimes the itching is concentrated elsewhere on the hands and feet, on wrists, ankles, arms, legs, or scalp2. Often the itching is generalized. ICP should never be ruled out because of an unusual presentation of itching.
Some itching in pregnancy can be normal, and not all itching is a sign of Intrahepatic Cholestasis of Pregnancy. However, it is important to keep in mind that a normal bile acid test does not rule out eventual diagnosis3. You should continue regular testing as long as you are experiencing symptoms of ICP.
Right upper quadrant pain
A minority of patients experience pain in the area of the liver, under the right ribs4. The reason for this pain is not clear, and people who have had their gallbladders removed still, on occasion, report continued pain. The pain may range in intensity from mild to debilitating, and may radiate to the back, under the right shoulder blade.
Biochemical changes in your body may cause urine to darken. Often this is exaggerated in the morning and it is not remedied by adequate water intake.
Pale stool/greasy stool
During normal digestion, bile gives our stool its color. Intrahepatic Cholestasis of Pregnancy can, in some cases, interfere with the flow of bile to such an extent that bile does not reach the intestines to give the stool its typical appearance, causing it to be pale gray clay colored. It is also possible to have greasy stool (steatorrhea)5, due to poor fat digestion, because bile plays an important role in this process. These symptoms may also indicate gallstones, which are a common find in ICP pregnancies.
Malaise refers to a general feeling of poor health. Some patients with ICP report various degrees of malaise. While it is normal to feel fatigue during pregnancy, these symptoms are more pronounced in some people with Intrahepatic Cholestasis of Pregnancy. Digestive symptoms such as vomiting and diarrhea can also occur.
Jaundice, yellowing of the skin and eyes, is very uncommon, occurring in 10% or less of patients. The yellowing seen in jaundice is dramatic, and unmistakable when it occurs. When it does, the associated elevated bilirubin is usually mild.
Mild depression may develop as a result of biochemical changes in the body, hormonal changes, lack of sleep, and/or the inability to escape the itch. Please discuss any depressive thoughts or feelings with your doctor immediately.
- Kremer AE, Martens JJWW, Kulik W, et al: Lysophosphatidic acid is a potential mediator of cholestatic pruritus. Gastroenterology 2010;139:1008-1018. https://pubmed.ncbi.nlm.nih.gov/20546739/
- Geenes V, Williamson C: Intrahepatic Cholestasis of pregnancy. World J Gastro 2009;15:2049- 2066. https://pubmed.ncbi.nlm.nih.gov/19418576/
- Kenyon et al. Pruritus may precede abnormal liver function tests in pregnant women with obstetric cholestasis: a longitudinal analysis. Br J Obstet Gynaec 2001;108:1190-1192. https://pubmed.ncbi.nlm.nih.gov/11762661/
- Pusl T, Beuers U: Intrahepatic cholestasis of pregnancy. Orphanet J Rare Diseases 2007;2:26. https://pubmed.ncbi.nlm.nih.gov/17535422/
- Reyes et al. Steatorrhea in patients with intrahepatic cholestasis of pregnancy. Gastroenterology 1987;93:584-590. http://www.ncbi.nlm.nih.gov/pubmed/3609667
3. Kenyon et al. Pruritus may precede abnormal liver function tests in pregnant women with obstetric cholestasis: a longitudinal analysis. Br J Obstet Gynaec 2001;108:1190-1192. https://pubmed.ncbi.nlm.nih.gov/11762661/