Returning to Homeostasis in the Face of Cholestasis
- Tonya Bridges
- Apr 8
- 15 min read
Returning to Homeostasis in the Face of Cholestasis of Pregnancy
Tonya Bridges
September 15, 2018
Have you ever heard the old saying “I’m eating for two!”? Women will commonly eat whatever rich, sweet and delicious desserts, in double amounts, as a treat (and with the excuse) of being pregnant and eating for two. More often than not the concept of nutrition in pregnancy is overlooked by providers, resulting in everything from small issues to very extreme toxic reactions in pregnancy. One of these extreme examples is Intrahepatic Cholestasis of Pregnancy (ICP)[1], or “Obstetric Cholestasis,” where the pregnant mother develops an extremely itchy sensation which alerts her caregivers of the liver based issue.
The common assumption in the medical community is that ICP has no cure except early delivery, resulting in the common practice of induction.[2] I will investigate whether this is truly the most effective approach, what the research reveals, and what nutritionists have found to be effective treatment of this diet related disease of pregnancy. Nourishing the body in pregnancy, can not only prevent, but potentially reverse ICP, leading to a normal delivery, rather than the commonly prescribed 36-37 week induction.
Currently, ICP is considered an incurable disease of pregnancy within the obstetric medical model of care[3]. A woman suffering from ICP will most commonly present symptoms in her last trimester with severe, and nearly maddening, itching. This itching, known as Pruritus, usually starts on the palms of the hands and feet and often moves to the belly and other parts of the body. Pruritus is a result of the excess bile salts in her system, due to an overburdened liver. It is thought that excess hormones from pregnancy stagnates the liver, leading to this disease. If a mother is presenting with extreme itching for 2 visits in a row, the provider will test her level of bile salts to see if this is ICP. Once diagnosed, the resulting common medical treatments are threefold: topical treatment of Pruritus, specific medications to counter the bile salts in the body, and early Induction by 36 weeks.
The most universal treatment of ICP is artificially induced preterm labor, scheduled no later than 36-37 weeks[4]. Since ICP usually dissipates after a few days post birth, mothers are encouraged to comply with induction to end the itching and minimize the potentiality of fetal demise due to the toxic state of her liver. While early birth may end the mother’s itching, induction of a premature baby does hold considerable risks for both mother and child. The most notable side effect of early induction is failed labor due to an unripe cervix, leading to major surgery, a cesarean section[5]. Occasionally mothers will have toxic side effects due to the amount of drugs used in induction on their already overtaxed liver leading to greater issues such as postpartum eclampsia[6]. Excessive bleeding is also very common with induction, as well as infection and uterine rupture. The Mayo clinic has listed several common risks to babies who undergo early inductions such as low heart rates in labor due to the stress of medications used, as well as post birth issues with lung and kidney performance. Since preterm babies are often immature, it is common that they are taken to NICU and are unable to go home with the mother when she is released after birth, which interferes with healthy bonding and adds stress on both mother and child as they try to heal and adjust.
During pregnancy, the first line of treatment begins with topical measures, addressing the itching externally. This includes suggesting icing of particularly bothersome patches, cool baths or adding oatmeal to a bath to help soothe the skin and make the itching feel less intense. Other common suggestions are using anti-itch creams or lotions to temporarily reduce the itching sensation. Most often external treatment does not help since the cause of the itching is an internal issue of an overtaxed liver, therefore treating the issue topically is unrealistic.
Since topical treatments often do not work, treatment with Ursodeoxycholic Acid (UA) is the next step, especially if the mother presents with ICP/OP and is still too early for induction. Unfortunately, even as high amounts of this acid can reduce symptoms, there are risks involved with use of these Class B drugs during pregnancy. Everything from diarrhea, constipation, upset stomach, indigestion, dizziness, vomiting, cough, sore throat, runny nose, back pain, muscle pain, joint pain and hair loss have been noted as side effects.
While there are currently no specific studies done by the medical community relating to nutritional healing of ICP, there are plenty of indications pointing to nutrition as a common factor.[7] Medical studies and corresponding peer reviews reveal inflammation[8] and certain nutrient deficiencies in women who present with cholestasis in pregnancy[9]. Although the medical community does not use these findings in their treatment, the clues lead us to the truth about diet, lack of nourishment of the endocrine system and resulting liver strain leading to a diagnosis of ICP due to the intense itching, which drive women to seek help.
The most notable deficiency found in many ICP studies is a low serum selenium concentration and glutathione peroxidase activity[10]. This is notable since selenium is a required nutrient for proper thyroid and endocrine function, which affects hormone levels and the body’s ability to process them effectively. Not only is it an important antioxidant and integral nutrient for body function, it is also very important in processing glucose and combating gestational diabetes.
Another study showed that poor carbohydrate/glucose metabolism was found to be associated in the course of ICP[11]. Serum samples collected 2 hours after breakfast demonstrated higher glucose concentrations in women with intrahepatic cholestasis when compared with healthy control subjects. Even greater glucose concentrations were found in the 24-hour glycemic profile collected 2 hours after breakfast and after supper. These results suggest that in the course of cholestasis in pregnancy, visible changes occur in the carbohydrate metabolism of the pregnant woman. This could very well go hand in hand with a deficiency of Selenium as well as excess simple carbohydrates in the diet.
Vitamin D deficiency was also found as commonly associated with ICP[12]. This is since pregnant women who are deficient in Vitamin D[13] are at a greater risk of developing a myriad of issues including high blood pressure, preeclampsia, diabetes and even increased food allergies in the unborn child.
There is also an important association in ICP to a woman’s inability to digest particular fats, such as animal based saturated fats. This results in negative impacts on the pregnant woman and her body’s ability to process fats effectively[14]. When her liver is overburdened with estrogen, it can inhibit her bile flow production and ability to process these fats. Vitamin K is often used and is very helpful in assisting the body in processing oils[15].
Naturopaths, herbalists and nutritionists know about liver nourishment and the kinds of dietary changes and nutritional support needed during pregnancy which can prevent a pregnant mother from developing ICP, and potentially reverse the course of cholestasis and the resulting unbearable itch. When the liver is overtaxed, the skin system takes on the burden of detoxification for the body which creates the insatiable itching and rashes. Diet, exercise and nourishing remedies are key to supporting a healthy liver function during pregnancy when the body is under heavy strain, as it processes the mother’s waste, extra hormones and body systems, as well as creating the child within her womb.
While prevention by eating healthy during the entirety of pregnancy is best, many do not realize how they will respond to the extra load pregnancy takes on their body, particularly in relation to their liver, until they are well into their second or third trimester. It is vital a woman adjust her diet and attentively nourish her system, especially if she notices itching beginning to take root. Here are some important ways she can do that.
Eating a healthy diet with plenty of vitamins and minerals, such as Selenium, Calcium, Magnesium and Vitamin D is of utmost importance for pregnant mothers, especially in the winter months when sunlight is limited. Just two Brazil nuts per day can provide the body’s requirements for selenium. Eliminating processed sugar intake, empty calories and simple carbohydrates is very important for treating ICP and decreasing the potential of toxic reactions in the body. Healthy unprocessed vegetable based oils, such as sunflower, olive oil, flax, peanut and sesame while eliminating animal based saturated oils is crucial as the body is unable to process those oils with ICP[16]. Studies also show Lecithin, another healthy oil, is extremely necessary and helpful[17]. Nourishing the body by increasing dark greens and eating a wide variety of vegetables and fruit, nuts, seeds and complex whole foods are mandatory in combating malnourishment resulting from ICP. Walking and exercise is imperative to reducing triglycerides and maintaining healthy blood sugar levels, while benefiting from the natural Vitamin D from the sun.
When a woman is struggling with Pruritus, diet changes and exercise alone may not be enough to reverse the toxic reaction in the body. It is important to support the liver functions, and dumping excessive hormones which suppress its activity, by taking milk thistle tincture and dandelion infusions, several times a day[18]. This is more effective when she increases her dietary fiber to flush the excess hormones that are released from the liver into her lower digestive tract so it does not reabsorb and cause further stress on her body.
Some herbalists will recommend a tea that is also high in Vitamin K to assist a woman in healing and nourish her body during her last trimester. This tea often includes: 2 parts dandelion leaf, 2 parts nettle leaf, 2 parts red raspberry, 1 part alfalfa and 1 part oat straw. This can also be made into a decoction each day by pouring 2 parts water over 1 part mixed herb in a quart jar, then cover with a tight lid and steep for 5+ hours, or overnight, before straining and drinking throughout the day. Using a powdered Cal/mag citrate as a supplement is also key to combating ICP. Other valuable natural treatment recommendations include essential fatty acids from Evening Primrose or flax oil supplements, guar gum, activated charcoal and SAMe[19].
Nourishing the body in pregnancy, and supporting the endocrine system can prevent and potentially reverse intrahepatic cholestasis of pregnancy (ICP) and it’s resulting Pruritus, leading to a normal delivery, rather than resorting to induction by 36-37 weeks[20]. I personally endured severe pruritus in my first pregnancy and was able to reverse the condition by using these recommendations, leading to a full term delivery. As a doula I have seen several women reverse their pruritus symptoms within two weeks of following these recommendations. Often these women will feel considerably better after the adjustment to a nourishing diet, even remarking that they feel better than before they became pregnant. The human body is amazing when it is given the right nutrients. When nourished properly, it will heal itself and promote the natural state of homeostasis, even when confronted with the toxic effects of ICP in pregnancy.
Works Cited
Axe, Dr. 8 Natural Treatments for Cholestasis. n.d. <https://draxe.com/cholestasis/>.
Biberoglu, E. Role of inflammation in intrahepatic cholestasis of pregnancy. March 2016. <https://www.ncbi.nlm.nih.gov/pubmed/2678678>.
Cholestasis of Pregnancy. 07 2017. <http://americanpregnancy.org/pregnancy-complications/cholestasis-of-pregnancy/>.
Clinic, Mayo. Labor Induction. n.d.
Gencosmanoglu, Turkmen G. Low Serum Vitamin D level is associated with intrahepatic cholestasis of pregnancy. 2018. <https://www.ncbi.nlm.nih.gov/pubmed/29978524>.
Ghosh, Sangita. Intrahepatic Cholestasis of Pregnancy: A Comprehensive Review. Indian Journal of Dermatology. Jul-Aug 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726904/.
Jin, W.Y. Associations between maternal lipid profile and pregnancy complications and perinatal outcomes. 21 Mar 2016. <https://www.ncbi.nlm.nih.gov/pubmed/27000102>.
Johnson, W.G. Overview of Intrahepatic Cholestasis of Pregnancy. 1979. <http://www.icpcare.org/icp0-overciew/>.
Johnston, W.G. ICP, Overview of Intrahepatic Cholestasis of Pregnancy. 1979. <http://www.icpcare.org/icp-overview/>.
Kamath. Healthy Diet for Intrahepatic Cholestasis of Pregnancy. 2015. <http://www.icpcare.org/healthy-diet/>.
Kamath, Binita M., MBB Chir, MRCP, MTR. Nutritional Issues in Cholestatic Disease. October 2015. <https://www.naspghan.org/files/ConcurrentSession3_Nutrition_Kamath.pdf>.
Kauppila, A. Low serum selenium concentrations and glutathione peroxidase activity in intrahepatic cholestasis of pregnancy. 17 January 1987. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1245162>.
Kirbas, A. Maternal circulation levels of irisin in intrahepatic cholestasis of pregnancy. Nov 2016. <https://www.ncbi.nlm.nih.gov/pubmed/26689349>.
Kuczynska-Sicinska, J. Carbohydrate metabolism in the course of intrahepatic cholestasis of pregnancy. Oct 1989. <http://www.ncbi.nlm.nih.gov/pubmed/2801844>.
Malachi, Rebecca. Intrahepatic Cholestasis of Pregnancy (ICP): Symptoms and Treatment. 23 July 2018. <https://www.momjunction.com/articles/treatments-for-obstetric-cholestasis_00100404/#gref>.
Maldanado, M. Intrahepatic Cholestasis of Pregnancy leading to severe Vitamin K Deficiency and Coagulopathy. 7 June 2017. <https://www.ncbi.nlm.nih.gov/pubmed/28680707>.
Moore, Misha M.D. Pregnancy and the Liver. 16 August 2013. British Journal of Hospital Medicine. <https://www.magonlinelibrary.com/doi/abs/10.12968/hmed.2001.72.Sup11.M1702journalcode=hmed>.
Naomi. My Cholestasis Journey. 12 Oct 2014. <https://thebirthpro.org/my-cholestasis-journey/>.
Obstetrics, William's. Cholestasis of Pregnancy. July 2017. <http://americanpregnancy.org/pregnancy-complications>.
Overview of Intrahepatic Cholestasis of Pregnancy (ICP). 2017. <http://www.icpcare.org/icp-overview/>.
Price, Maria Z. Cholestasis Pregnancy Diet. 13 June 2017. <http://www.livestrong.com/article/519413-cholestasis-pregnancy-diet/>.
Ribalta, J. Can a selenium deficiency affect the pathogenesis of cholestasis in pregnancy? Mar 1995. <https://www.ncbi.nlm.nih.gov/pubmed/7621286>.
—. Can Selenium Deficiency Affect the Pathogenesis of Cholestasis in Pregnancy? 18 March 1995. <https://www.ncbi.nlm.nih.gov/pubmed/7621286>.
Annotated Bibliography
American Pregnancy, (07/2017). Cholestasis of Pregnancy. http://americanpregnancy.org/pregnancy-complications/cholestasis-of-pregnancy/
Dandelion Root and Milk Thistle are natural substances that are beneficial to the liver (talk to your healthcare provider before taking these)
Axe, Dr., 8 Natural Treatments for Cholestasis. https://draxe.com/cholestasis/.
Here are herbs and supplements that can be used to relieve the symptoms of cholestasis, including milk thistle, guar gum, activated charcoal, SAMe, vitamin K, vitamin D and calcium. It’s also important to avoid alcohol and medications that can trigger this condition.
Biberoglu E, 2016, Role of inflammation in intrahepatic cholestasis of pregnancy. J Obstet Gynaecol Res. 2016 Mar;42(3):252-7. doi: 10.1111/jog.12902. Epub 2016 Jan 19
Intrahepatic cholestasis of pregnancy (ICP), the most common liver disease in pregnancy, is characterized by elevated serum total bile acid and/or transaminase concentration, and pruritus.
While serum IL-6 was significantly higher in the mild ICP (P = 0.01) and severe ICP (P = 0.001) groups than in the control group, hs-CRP was similar between the groups.
Interleukin-6 may have an essential role, apart from CRP, in the pathogenesis of ICP and, also, is a more sensitive marker of inflammation.
Binita M. Kamath, (October 2015) Nutritional Issues in Cholestatic Disease. MBB Chir MRCP MTR. . https://www.naspghan.org/files/ConcurrentSession3_Nutrition_Kamath.pdf
Overview of cholestatic diseases • Mechanisms of nutritional impairment in cholestasis • Impact of poor nutrition in cholestasis • Optimizing nutrition in cholestasis
Gençosmanoğlu, Türkmen G (2018). Low serum vitamin D level is associated with intrahepatic cholestasis of pregnancy. Vural Yilmaz Z., Dağlar K., Kara Ö., Sanhal CY., Yücel A., Uygur D. Zekai Tahir Burak Women's Health Care, Training and Research Hospital, Ankara, Turkey. J Obstet Gynaecol Res. US National Library of Medicine National Institutes of Health, 2018 Jul 6. doi: 10.1111/jog.13693. https://www.ncbi.nlm.nih.gov/pubmed/29978524
There is increasing evidence that vitamin D deficiency plays a role in hepatobiliary homeostasis and in various liver diseases. The study aimed to investigate the association between serum Vit D level and ICP. Study suggests that low levels of 25(OH) Vit D3 were associated with ICP disease and its severity.
Jin, W.Y. (2016). Associations between maternal lipid profile and pregnancy complications and perinatal outcomes: a population-based study from China. In Lin SL, Hou RL, Chen XY, Han T, Jin Y, Tang L, Zhu ZW, Zhao ZY. Department of Children's Health Care, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China. BMC Pregnancy Childbirth. 2016 Mar 21. doi: 10.1186/s12884-016-0852-9. https://www.ncbi.nlm.nih.gov/pubmed/27000102
Among Chinese population, maternal high TG in late pregnancy was independently associated with increased risk of GDM, preeclampsia, ICP, LGA, macrosomia and decreased risk of SGA. Relative low maternal HDL-C during pregnancy was significantly associated with increased risk of GDM and macrosomia; whereas relative high HDL-C was a protective factor for both of them.
Johnston, W.G. (1979), ICP, Overview of Intrahepatic Cholestasis of Pregnancy (ICP) 22 Johnston WG, Baskett TF: Obstetric Cholestasis. A 14 year review. Am J Obstet Gynecol. 1979;133:299-301. http://www.icpcare.org/icp-overview/
This study shows a connection to insufficient selenium intake during pregnancy in the winter months having been associated with higher rates of ICP. Improved nutrition has been accompanied by decrease of ICP, although “no causal relationship has been established.”
Kamath, B.M. Healthy Diet for Intrahepatic Cholestasis of Pregnancy (ICP), ICP Care. http://www.icpcare.org/healthy-diet/
This Clinical Practice Guideline on ICP in Argentina recommends a healthy diet as part of the treatment, while also stating there’s no way to prevent or cure ICP once you are diagnosed. A healthy diet should not replace any treatment and management plan that may have been implemented by the healthcare provider such as the medicine Ursodeoxycholic acid (UDCA or Urso) and early delivery by 37 weeks.
Kauppila, A. (1987), Low serum selenium concentration and glutathione peroxidase activity in intrahepatic cholestasis of pregnancy. In H Korpela, U M Mäkilä, and E Yrjänheikki. Low serum selenium concentration and glutathione peroxidase activity in intrahepatic cholestasis of pregnancy, Br Med J (Clin Res Ed). 1987 Jan 17; 294(6565): 150–152. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1245162/
Selenium concentrations were found to be significantly lower in women with cholestasis of pregnancy than in women with normal pregnancies during the last trimester of pregnancy and postpartum. These findings suggest that selenium deficiency is associated with the aetiopathogenesis of intrahepatic cholestasis of pregnancy.
Kirbas, A. (Jan 22, 2016). Maternal circulating levels of irisin in intrahepatic cholestasis of pregnancy. J Matern Fetal Neonatal Med. https://www.ncbi.nlm.nih.gov/pubmed/26689349
Irisin is a newly discovered myokine that is able to regulate glucose and lipid levels, thus improving insulin sensitivity. In this study, maternal serum irisin levels were analyzed in order to provide a new perspective on the pathogenesis of ICP. The results of this study indicate that serum irisin levels were significantly higher in women with ICP compared to healthy pregnant controls. However, it is difficult to infer whether high irisin level is a cause or effect of ICP.
Malachi, Rebecca (2018), Intrahepatic Cholestasis Of Pregnancy (ICP): Symptoms And Treatment. Diet For Intrahepatic Cholestasis. https://www.momjunction.com/articles/treatments-for-obstetric-cholestasis_00100404/#gref
The primary goal of the pregnancy cholestasis diet is to place less strain on the liver, and for that, you should be taking foods containing lecithin, which is an unsaturated fat that helps absorb fats in the bile. A low-fat diet makes it easy for the intestine to absorb vitamins and minerals from the food.
Maldonado M. (2017). Intrahepatic Cholestasis of Pregnancy Leading to Severe Vitamin K Deficiency and Coagulopathy. In Alhousseini, A., Awadalla, M., Idler, J., Welch, R., Puder, K., Patwardhan, M., Gonik, B. Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA, Case Rep Obstet Gynecol. Epub 2017 Jun 7. https://www.ncbi.nlm.nih.gov/pubmed/28680707
Intrahepatic cholestasis in pregnancy and nutrition issues were identified as the main risk factors for the severe coagulopathy of this patient.
Mayo Clinic. Labor Induction
Common side effects of labor induction.
Moore, Misha M.D. ( 2013). Pregnancy and the Liver. British Journal of Hospital Medicine. Published online: August 16, 2013. https://www.magonlinelibrary.com/doi/abs/10.12968/hmed.2011.72.Sup11.M170?journalCode=hmed
A study on Cholestasis, preeclampsia and postpartum eclampsia risks.
Naomi, (October 12, 2014). My Cholestasis Journey.
“Instead of automatically transferring my care, my amazing midwives recommended an herbal regimen. I started taking milk thistle and dandelion leaf religiously.
So back to waiting for the results… they came back and not only did they not increase, they went DOWN into “normal” levels!! It was a miracle!! We kept a really close eye on everything and I stayed extremely consistent with the herbal regimen that my midwives had me on and just continued with the original plan of staying pregnant until the baby decides to come.”
Price, Maria Z. (June 13, 2017), Cholestasis Pregnancy Diet. Live strong, https://www.livestrong.com/article/519413-cholestasis-pregnancy-diet/
Cholestasis is a liver condition that occurs most common during the third trimester, and that it typically goes away within a few days after the mother gives birth. Certain dietary changes may help prevent or reduce the symptoms of cholestasis. According to a study published in "Life Sciences" in June 2003, the consumption of lecithin may prevent the development of cholestasis. The study was conducted on rats and further research is needed, but the results appear to be promising.
Ribalta, J (1995). Can a selenium deficiency affect the pathogenesis of cholestasis in pregnancy?
Reyes, H., Hernández I, Fuentes O, Báez M, González M, Palma J. Gastroenterol Hepatol. 1995 Mar;18(3):114-20. Departamento de Medicina, Universidad de Chile, Santiago de Chile. https://www.ncbi.nlm.nih.gov/pubmed/7621286
In patients with cholestasis of pregnancy, plasma and erythrocytic Se and GSH-Px activity were lower than in normal pregnant women.
William’s Obstetrics (07/2017), Cholestasis of Pregnancy. Twenty-Second EdF. Gary, et al, Ch. 50. ICP Care. http://americanpregnancy.org/pregnancy-complications/cholestasis-of-pregnancy/
Dandelion Root and Milk Thistle are natural substances that are beneficial to the liver (talk to your healthcare provider before taking these)
Wójcicka-Jagodzińska J. (1989 Oct) Carbohydrate metabolism in the course of intrahepatic
cholestasis in pregnancy; In Kuczyńska-Sicińska J, Czajkowski K, Smolarczyk R. II Department of Obstetrics and Gynecology, Medical School, Warsaw, Poland. American Journal of Obstetrics & Gynecology, US National Library of Medicine National Institutes of Health, 161(4):959-64. https://www.ncbi.nlm.nih.gov/pubmed/2801844/
Glucose metabolism was evaluated in pregnant women. Serum samples collected 2 hours after breakfast demonstrated higher glucose concentrations in women with intrahepatic cholestasis when compared with healthy control subjects. The 24-hour glycemia profile showed greater glucose concentrations in serum samples collected 2 hours after breakfast and after supper. These results suggest that in the course of cholestasis in pregnancy, visible changes occur in the carbohydrate metabolism of the pregnant woman.
[1] Overview of Intrahepatic Cholestasis of Pregnancy (ICP). 2017.
[2] Johnson, W.G. Overview of Intrahepatic Cholestasis of Pregnancy
[3] Ghosh, Sangita. Intrahepatic Cholestasis of Pregnancy: A Comprehensive Review
[4] American Pregnancy, (07/2017)
[5] Mayo Clinic Staff. Labor Induction
[6] Moore, Misha M.D. ( 2013). Pregnancy and the Liver. British Journal of Hospital Medicine.
[7] Binita M. Kamath, (October 2015) Nutritional Issues in Cholestatic Disease
[8] Biberoglu E, 2016, Role of inflammation in intrahepatic cholestasis of pregnancy
[9] Maldonado M. (2017). Intrahepatic Cholestasis of Pregnancy Leading to Severe Vitamin K Deficiency
[10] Ribalta, J (1995). Can a selenium deficiency affect the pathogenesis of cholestasis in pregnancy?
[11] Wójcicka-Jagodzińska J. (1989 Oct) Carbohydrate metabolism in the course of intrahepatic cholestasis in pregnancy
[12] William’s Obstetrics (07/2017), Cholestasis of Pregnancy
[13] Gençosmanoğlu, Türkmen G (2018). Low serum vitamin D level is associated with intrahepatic cholestasis of pregnancy
[14] Jin, W.Y. (2016). Associations between maternal lipid profile and pregnancy complications and perinatal outcomes: a population-based study from China.
[15] Malachi, Rebecca (2018), Intrahepatic Cholestasis Of Pregnancy (ICP): Symptoms And Treatment. Diet For Intrahepatic Cholestasis.
[16] Malachi, Rebecca (2018), Intrahepatic Cholestasis Of Pregnancy (ICP): Symptoms And Treatment. Diet For Intrahepatic Cholestasis
[17] Price, Maria Z. (June 13, 2017), Cholestasis Pregnancy Diet. Live strong,
[18] William’s Obstetrics (07/2017), Cholestasis of Pregnancy
[19] Dr. Axe
[20] Naomi, (October 12, 2014). My Cholestasis Journey
Comments