Pregnancy is a time of incredible change—but sometimes, these changes come with unexpected symptoms. If you’ve been dealing with intense itching, especially on the palms of your hands and the soles of your feet, it may not just be a harmless side effect. It could be a sign of cholestasis of pregnancy.
This is a liver condition that affects how bile flows in your body—and one that requires careful medical attention.
What Is Cholestasis of Pregnancy?
Cholestasis of pregnancy—also called intrahepatic cholestasis of pregnancy (ICP)—is a liver condition that affects a small percentage of pregnant women, usually in the third trimester when pregnancy hormones reach their peak. While it may not be as commonly discussed as other pregnancy concerns like gestational diabetes or preeclampsia, cholestasis is a serious and potentially dangerous condition that deserves attention.
At its core, cholestasis is a bile flow disorder. Normally, your liver produces bile to help digest fats and carry away waste products. This bile flows through tiny ducts into the digestive tract. In cholestasis, this process slows down or becomes blocked. Instead of being excreted properly, bile acids build up in your bloodstream, causing a range of symptoms—most notably, an intense, often unbearable itching.
But what’s happening behind the scenes?
Pregnancy hormones—particularly estrogen and progesterone—are believed to interfere with the liver’s ability to move bile efficiently. This hormonal disruption can slow or block bile flow, especially in women who may already have a genetic predisposition. The result? A backup of bile acids in the blood that the body can’t clear quickly enough.
Unlike common pregnancy discomforts, cholestasis isn’t just uncomfortable—it’s a medical condition with real risks, particularly for the baby. While the itching may be the only symptom a mother feels, the effects of excess bile acids on the developing fetus can be serious. That’s why recognizing cholestasis and responding to it promptly is so important.
ICP isn’t contagious or caused by anything the mother did wrong. It’s a physiological reaction to the complex hormonal and metabolic shifts that come with pregnancy. Fortunately, with early diagnosis and careful monitoring, outcomes are generally positive—but untreated, cholestasis can increase the risk of complications like preterm birth, fetal distress, and even stillbirth.
In short, cholestasis of pregnancy is not just an itchy skin issue—it’s a liver condition that calls for prompt evaluation, collaborative care, and careful timing of delivery to protect both mother and baby.
Common Symptoms
The hallmark symptom of cholestasis of pregnancy is itching—but not the kind of occasional skin irritation many women experience during pregnancy. This is a deep, persistent, often maddening itch that typically begins on the palms of the hands and soles of the feet. It may start subtly but can quickly become more intense and widespread, often affecting the arms, legs, and torso. Many women describe it as worse at night, making it hard to sleep and adding to the already heavy fatigue of late pregnancy.
What makes this itching unique—and medically significant—is that it occurs without a visible rash. While other pregnancy conditions like PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy) also cause itching, those usually involve raised, red bumps or patches. In cholestasis, the skin often looks completely normal, even though the itching can be severe.
Beyond itching, several other symptoms may appear, though not all women experience them. These include:
- Dark urine: Bile pigment building up in the bloodstream can darken the color of your urine, even when you’re well-hydrated.
- Pale or clay-colored stool: A lack of bile reaching the intestines can result in unusually light-colored bowel movements.
- Fatigue: The hormonal and metabolic stress on your liver, paired with disrupted sleep due to itching, can leave you feeling unusually drained.
- Nausea or poor appetite: The same bile acids that irritate the skin can also affect digestion and trigger nausea.
- Right upper belly pain: Some women experience a dull, aching sensation under the ribs on the right side, near the liver—though this is less common.
- Jaundice: In rare cases, the skin and whites of the eyes may take on a yellowish tint due to a buildup of bilirubin, another substance the liver helps to process.
Symptoms can vary in intensity and don’t always follow a clear pattern. Some women only experience mild itching, while others find it debilitating. Importantly, the severity of symptoms doesn’t always correlate with the level of risk to the baby—which is why early detection and monitoring are key.
If you’re pregnant and experiencing any of these symptoms—especially severe itching without a rash—it’s important to speak with your OB/GYN. Lab testing can help distinguish cholestasis from other conditions and guide next steps in keeping you and your baby safe.
What Causes It?
What Causes Cholestasis of Pregnancy?
While the exact cause of cholestasis of pregnancy remains unclear, research suggests that it’s the result of a complex interplay between hormones, genetics, and individual health history—all uniquely amplified during pregnancy.
At the heart of the condition is impaired bile flow. Under normal circumstances, the liver produces bile to help digest fats and eliminate waste products. This bile travels through a series of ducts into the intestines. But during pregnancy, especially in the third trimester, elevated hormone levels—particularly estrogen and progesterone—can disrupt the liver’s ability to transport bile effectively. The result is a back-up of bile acids into the bloodstream, which can lead to intense itching and pose risks to the developing baby.
Let’s break it down further:
Hormonal Influence
Pregnancy hormones surge dramatically, especially as the due date nears. Estrogen and progesterone, in particular, are thought to alter the function of bile transport proteins in the liver. For reasons not entirely understood, some women’s livers are more sensitive to these hormonal shifts, leading to reduced bile flow and the characteristic symptoms of cholestasis. This hormonal component also explains why symptoms often resolve rapidly after delivery, when hormone levels quickly drop.
Genetic Factors
There’s a strong genetic component to cholestasis of pregnancy. Women with a family history of the condition—such as a mother or sister who experienced it—are at significantly higher risk. Certain gene mutations, especially those affecting bile salt export pumps (like ABCB11), have been associated with ICP. This suggests that inherited differences in liver function or bile metabolism may make some women more susceptible.
Environmental and Ethnic Factors
Interestingly, the condition is more prevalent in certain ethnic and geographic populations:
- Women of South Asian, Hispanic, or Scandinavian descent have higher reported rates.
- In some parts of Chile and Bolivia, for instance, the incidence can be as high as 15%, compared to less than 1% in most parts of the U.S. This geographic variability hints at the influence of both environmental triggers and genetic predisposition.
Who’s at Higher Risk?
You may be more likely to develop cholestasis of pregnancy if:
- You’ve had it before: Women who experienced ICP in a previous pregnancy have a high likelihood of recurrence in future pregnancies—often earlier and more severely.
- You have a family history: A close relative with cholestasis increases your risk, even if you haven’t had liver issues before.
- You’re carrying multiples: Twin or triplet pregnancies come with significantly higher hormone levels, which can tip the balance and overwhelm the liver’s ability to handle bile flow.
- You have a history of liver disease: Pre-existing liver conditions can compromise bile regulation even further.
- You’re from a higher-risk ethnic background: As mentioned, women of South Asian, Hispanic, or Scandinavian origin may have a greater genetic predisposition.
While cholestasis of pregnancy cannot always be predicted or prevented, understanding who is more at risk can help providers monitor more closely and act early—especially if symptoms like itching begin before lab values are elevated.
How It’s Diagnosed
If cholestasis is suspected, your OB/GYN will likely order:
- Liver function tests (LFTs) to assess how your liver is working
- Serum bile acid tests, which are the most specific for diagnosing cholestasis (fasting)
- Other labs to rule out conditions like hepatitis
It is important to know that itching may start before lab abnormalities appear, so symptoms always matter—even if initial tests are normal.
Why It Matters: Risks to Baby
While cholestasis usually resolves after delivery and is rarely dangerous to the mother, it can pose serious risks to the baby, including:
- Preterm labor
- Fetal distress
- Stillbirth, especially if untreated or unmonitored
- Meconium-stained amniotic fluid (can lead to breathing problems at birth)
Because of these risks, careful monitoring is critical.
How Is It Treated?
Management usually includes:
- Ursodeoxycholic acid (ursodiol) to reduce bile acids and relieve itching
- Regular non-stress tests or biophysical profiles to check on baby’s well-being
- Early delivery (often at 37 weeks) to reduce the risk of stillbirth
You may also be advised to avoid certain medications, maintain hydration, and keep follow-up appointments more frequently as your due date approaches.
What Can You Do?
If you’re pregnant and experiencing unexplained itching—especially if it’s keeping you up at night or concentrated on your hands and feet—don’t ignore it. Talk to your provider. Early diagnosis and management can make a huge difference.
Final Thoughts
Cholestasis of pregnancy can sound scary, but with prompt diagnosis and close monitoring, most women go on to deliver healthy babies. Trust your body, trust your instincts, and stay informed. You know your body best—if something feels off, speak up.
If you’re experiencing symptoms or have questions, reach out to your OB/GYN.
And if you are in Sidney, Montana—I am here to help.