Itching During Pregnancy
The most commonly reported Intrahepatic Cholestasis of Pregnancy symptom is itching, and in many cases it is the only symptom reported. Itching during pregnancy can vary greatly from one affected woman to another, and it is important to remember that there really is no such thing as typical symptoms of cholestasis. Many times the itching is moderate to severe, but not in all cases. Itching may start mild and progress to more severe as the pregnancy progresses. Some pregnant women have presentations that are more common than others, however.
- Location of itching – the most commonly affected areas include the hands and feet. However, itching hands, wrists, ankles, arms, legs, scalp, or all can happen. Some women have itchy skin everywhere except their hands and feet. The itching does not need to be on the hands or feet to be Cholestasis of Pregnancy.
- Severity of itching – the severity of the itching can vary greatly and does not correlate with the severity of the disease. Some women experience moderate itching with extremely severe Intrahepatic Cholestasis of Pregnancy, and others experience extreme itching with mild Intrahepatic Cholestasis of Pregnancy. Some women itch so frantically that they draw blood, but this does not happen to all affected women. While itching may sound like a minor symptom, in women with severe itching, quality of life can be dramatically affected. In some cases, sleep can be so severely disrupted that women get only a few hours of sleep a day. In the most troubling cases, women have had suicidal thoughts or actions.
- Fluctuations in itching – some women find that itching follows a cyclical pattern. Commonly, itching can be worse at night rather than during the day, or even absent during the day. The reason for this is not completely understood but it has been suggested that it may be related to the diurnal fluctuations in other hormones, particularly cortisol. Other women find that their itching does not follow this pattern. Given that all itching does not follow a typical pattern, itching in pregnancy should always be discussed with your OB provider as further evaluation with bile acid testing may be recommended.
- No Rash – Intrahepatic Cholestasis of Pregnancy itching is not caused by a rash. In some cases, however, a rash may develop as a result of intense scratching which may damage the skin. In these cases it is important to note whether the itching caused the rash, or if the rash caused the itching. Itching that is most prominent on the abdomen and is associated with a rash may be PUPPP, another pregnancy-specific condition which does not put the baby at risk. Please keep in mind that it is possible to have both PUPPP and ICP.
Some itching in pregnancy can be normal. It is important to remember that some doctors may overlook itching during pregnancy due to Intrahepatic Cholestasis of Pregnancy as it is a normal side effect of pregnancy.
While most women only report itching as a symptom in their ICP pregnancy, there are other symptoms which may occur.
Liver Pain (Right Upper Quadrant Pain or RUQ pain)
Intrahepatic Cholestasis of Pregnancy sometimes causes pain in the area of the liver. The liver itself does not have nerve endings that sense pain, but the gall bladder, bile ducts, and a capsule surrounding the liver can sense pain. This pain is most commonly felt under the ribs on the right side. Less commonly the pain can be felt radiating to a spot in the back beneath the tip of the right shoulder blade. RUQ pain is not commonly reported because it is often mistaken for pain from the baby pushing against the ribs. This pain can vary. Some women feel a dull throbbing pain, others a sharp stabbing pain.
For some women the pain has been described as debilitating, however it is important to remember that most women with ICP will not feel pain in the area around their livers. RUQ pain can be caused by many things other than Intrahepatic Cholestasis of Pregnancy, and it should always be discussed with your doctor.
There are many biochemical changes which take place in the body during Intrahepatic Cholestasis of Pregnancy. These sometimes cause the urine to become dark. Dark urine may range in color from apple juice-colored to dark brown. This can happen even when water intake is adequate.
Under normal circumstances, bile gives the stool its distinctive color. In some ICP pregnancies, the flow of bile is so thoroughly disrupted that stool appears pale gray, or clay-colored.
Nausea/lack of appetite
Some women with Intrahepatic Cholestasis of Pregnancy find it difficult to eat due to a severe loss of appetite. It can be difficult or even impossible to force down enough food to maintain adequate weight gain. Some women even lose weight despite their best efforts. Others have nausea and/or vomiting.
While it is normal to feel tired during pregnancy, fatigue related to Intrahepatic Cholestasis of Pregnancy can be extreme due to the important role the liver plays in many metabolic processes. This fatigue can be exacerbated due to stress and lack of sleep.
It is uncommon to develop jaundice with Intrahepatic Cholestasis of Pregnancy. It is estimated that 10% or less of women affected by ICP will become jaundiced. However, if you notice a pale yellow color to the skin and/or eyes, seek medical attention.
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.
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