Itching and Cholestasis of Pregnancy

One enduring pregnancy myth is that women with itchy palms, stomachs, or breasts will give birth to a baby boy. The truth is, dry and itchy skin is common and perfectly normal during pregnancy. However, a constant, debilitating, and unpleasant sensation that evokes the desire to scratch so bad that it often leads to skin tearing is not normal. In some cases, it may become so extreme that it leads to insomnia. If there are no preexisting skin conditions that may explain the itch, then it might be pruritus caused by cholestasis of pregnancy. And if symptoms such as dark urine, chalky-colored bowel, jaundice, nausea, and loss of appetite accompany the pruritus (or itching), it is time to tell your doctor about it.

What is Cholestasis?

Cholestasis is the decrease in bile flow due to impaired bile production and release by the liver. This is a liver issue rather than a gallbladder one. That said, it can also possibly be due to the obstruction of bile ducts which prevents normal bile flow. Cholestasis per se can be brought about by a variety of things.

At the bile duct level:

  • Gallstones
  • primary biliary cirrhosis
  • primary sclerosing cholangitis
  • tumor

At the liver cell:

  • inflammation
  • hormones
  • drugs
  • alcohol
  • viral hepatitis
  • sepsis (an extreme reaction to an infection)

Some hereditary conditions also cause cholestasis. These pre-existing conditions may increase the likelihood of an individual developing cholestasis of pregnancy.

How Cholestasis Causes Itching

The exact cause of intense and uncontrollable itching among gallbladder and liver patients is still unknown. Pruritus in cholestasis is said to be fluctuating, intermittent and often triggered or made worse by food allergens.

Possible explanations include:

  1. Accumulation of bile acids in the tissues of cholestasis patients

According to some skin tests among volunteers, bile acids elicit a local itch when injected into the skin. It is therefore hypothesized that bile salts directly affect the nerves under the skin and influence the release of histamine and proteases. All these may subsequently cause the itching. This is also why antihistamines are said to be effective in reducing the itchy feeling among patients. Histamine, incidentally, is also released in the presence of food allergens.

  1. Accumulation of toxins and other substances in the blood as a result of poor bile flow

As we know, the liver and the skin are two of the body’s major detoxifying organs. If bile circulation is poor or if there are issues with the biliary system, then the body’s waste cannot be efficiently expelled. Substances that accumulate in the blood plasma and other tissues as a result of cholestasis can cause intense itching. Unfortunately, the specific natures of these substances and their mechanisms have yet to be understood.

  1. Altered central neurotransmission

There is evidence suggesting that the central opioidergic tone is increased in cholestasis. (This, of course, refers to the body’s natural opioids such as the endorphins that create a natural high when running.) This means that our bodies become hypersensitive and reactive to opioids (internal or external sources) when we have poor or decreased bile flow. Liver disease also contributes to the increased availability of opioids in the body. Opioids suppress the stimulation of pain-transmitting neurons while activating the pruritus pathway, making people itch and scratch until the skin is torn or damaged.

Cholestasis of Pregnancy

Cholestasis during the prenatal period is also called intrahepatic cholestasis of pregnancy (ICP). It is a pregnancy-specific liver disorder characterized by pruritus. As biochemical processes in the body change to accommodate the needs of the growing baby and to prepare the body for post-partum child-rearing, pregnant women become at risk of cholestasis development. This often happens during the third trimester when the levels of estrogen and progesterone are highest.

In our blog 7 Ways to Avoid Gallstones During Pregnancy, we explained various changes during pregnancy may lead to gallbladder and biliary issues. Slowing down of the digestive process, relaxation of smooth muscles leading to poor gallbladder contraction, and increased reproductive hormones are just some of the possible reasons why pregnant women are at risk of cholestasis.

Cholestasis of pregnancy may cause the following conditions:

 

  • Pre-eclampsia – Characterized by high blood pressure and organ damage, most often in the liver and kidneys
  • Fetal diseases – Heart and lung issues in babies among mothers with ICP have been recorded.
  • Preterm labor – ICP may cause early birth and other delivery complications

Cholestasis of pregnancy may also co-exist with some conditions such as acute fatty liver of pregnancy and gestational diabetes.

The good news about ICP is its reversibility. It is usually resolved within 2-8 weeks after delivery, as the body’s biochemical processes return to normal.

What to do about it?

The exact mechanism of ICP is not yet known. Unfortunately, it can happen to individuals with healthy liver before pregnancy. Therefore, there is no foolproof way to avoid it. Nevertheless, studies suggest that the following natural means may help reduce the risk of cholestasis development during pregnancy:

  1. Selenium and glutathione supplementation – When women with ICP were observed, lab tests showed low selenium and glutathione levels. Glutathione is a powerful antioxidant dependent on the body’s selenium levels. So support through dietary and supplementary intake may help reduce ICP risk, and may especially be useful for those pregnant during wintertime, when serum selenium levels are lower.
  2. Stress Management – Estrogens and bile acids cause oxidative stress. Additional stress due to lack of sleep, poor diet, worries, and sedentary lifestyle may worsen it and lead to cholestasis of pregnancy.
  3. Leaky gut management – Increased gut permeability has been reported in a group of ICP patients and it is hypothesized that the absorption of bacterial endotoxins increases the likelihood of cholestasis. For leaky gut diet and tips how to manage it, read our complete blog post.
  4. Detoxification support – Since oxidative stress may contribute to cholestasis development, eating foods rich in natural antioxidants may help.

If you are trying to conceive or just worried about cholestasis in general, taking natural choleretics and cholagogues may help support a healthy bile flow. These are agents that promote bile production and release. Examples are Bile Salts Booster, Gallbladder Formula Elite, and Beet Root Capsules.

To help in detoxification you could try Bentonite clay (found in Mediclay-FX) which is also known to relieve itching when applied topically. It has been used for decades as a home remedy for skin allergies and rashes.

During pregnancy, consult your doctor first before taking supplements or medication.

References:

Bergasa, N. V. (2005). The pruritus of cholestasis. Journal of hepatology, 43(6), 1078-1088.

Geenes, V., & Williamson, C. (2009). Intrahepatic cholestasis of pregnancy. World journal of gastroenterology: WJG, 15(17), 2049.

Hashimoto, T., & Yosipovitch, G. (2019). Itching as a systemic disease. Journal of Allergy and Clinical Immunology, 144(2), 375-380.

Imam, M. H., Gossard, A. A., Sinakos, E., & Lindor, K. D. (2012). Pathogenesis and management of pruritus in cholestatic liver disease. Journal of gastroenterology and hepatology, 27(7), 1150-1158.

Pillarisetty, L. S., & Sharma, A. (2019). Pregnancy Intrahepatic Cholestasis.

Tivoli, Y. A., & Rubenstein, R. M. (2009). Pruritus: An updated look at an old problem. The Journal of clinical and aesthetic dermatology, 2(7), 30.

Zollner, G., & Trauner, M. (2008). Mechanisms of cholestasis. Clinics in liver disease, 12(1), 1-26.

 

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