It's 3 a.m., and you are very pregnant. You hoist yourself out of bed and waddle to the bathroom (for what feels like the millionth time). You get back in bed and notice that you feel itchy. Unable to sleep, you turn to your handy smart phone and type "itching in pregnancy" searching for a good lotion to try, but instead you are horrified by to read that you either have dry skin or a rare condition that could kill your baby. Good luck going back to sleep.
The majority of women (70%) will experience some form of skin itching during pregnancy. Most cases of itching are due to the usual annoying but not life-threatening culprits like dry skin, allergies, or eczema. Rarely the itching can be due to a condition called intrahepatic cholestasis of pregnancy (also known as IHP or simply "cholestasis"). In cholestasis of pregnancy the mom's liver begins to malfunction and liver byproducts called "bile acids" begin to build up in her body. The bile acids cause severe skin itching in the mom, but they also cross the placenta and cause all kinds of problems for the baby like preterm delivery, meconium stained fluid and in some cases, even still birth.
Cholestasis of pregnancy usually starts with itching on the palms of the hand and the soles of the feet and then the itching begins to spread to other parts of the body, especially the belly. It usually starts out being mildly annoying but progresses quickly in severity, often to the point women are clawing at themselves until they bleed. Most women have trouble sleeping due to the intensity of the itching. Hydrocortisone cream or diphenhydramine may offer some temporary relief with, but as soon as the medications wear off the symptoms come back. Occasionally, moms will also develop upper abdominal pain or jaundice (yellowing of the skin and whites of the eyes).
If you have itching in pregnancy and are worried about cholestasis, there are a few symptoms that are NOT associated with it:
- Rash. Women with cholestasis may have marks from scratching themselves, but there is no actual rash.
- Itching goes away. Cholestasis symptoms may improve with lotions or antihistamines, but they will always come back with a vengeance. If your skin itches for a day or two and then completely resolves, that is not cholestasis.
- Before 20 weeks. Cholestasis usually occurs in the third trimester. Occasionally it happens in the late second trimester, but it doesn't occur before 20 weeks.
Cholestasis risk factors
The overall chance of getting cholestasis in pregnancy is low (~ 1%). We are unsure of exactly what causes it, but there are some risk factors that can increase your chances:
- Pregnant with twins
- Having had cholestasis in a previous pregnancy
- Family members who have had cholestasis
- Hispanic ethnicity (specifically Chilean)
- History of Hepatitis C
- Maternal age greater than 35
Diagnosis and treatment
If you have persistent itching that goes on for several days and doesn't resolve with the usual soothing lotions, follow up with your doctor. Cholestasis is diagnosed with a blood test that measures your bile acid levels and liver functions. Occasionally the symptoms can start can before the disease shows up in your blood, so if you labs are normal and the symptoms keep worsening you may need your labs repeated in a week or two.
Pregnancies with cholestasis are at an increased risk of stillbirth, and the risk of stillbirth is not reduced by medications or monitoring the baby on ultrasound. I know, that is one scary sentence. This is the big challenge of treating cholestasis of pregnancy: deciding when is the best time to deliver the baby. We want baby to fully develop and not have complications from being born too early, but we don't want the baby to be exposed to the bile acids for too long and face the worst outcome of all, sudden stillbirth. Luckily, newer data is showing that the still birth rate is associated with the actual bile acid level. Women whose bile acids are more than 10 times normal ( > 100) are at more of a risk of stillbirth (3%), whereas milder cases are likely not at an increased risk over a normal pregnancy. While cholestasis can still be a challenging condition, this newer data is helping know which moms to deliver early and which can be monitored to closer to term.
Itching in pregnancy is a super common and should not prompt an immediate panic attack. But if you slather on the lotion and the itching keeps getting worse over several days, see your provider to make sure it’s not something more significant.