During pregnancy, the body is experiencing so much change that it’s often all very new, and, understandably, symptoms will just not be noticed or worried about due to their novelty. So whilst a particular symptom could actually be itchy and caused by the condition and ICP, that specific symptom may not be thought of as actually belonging to ICP.
Intrahepatic cholestasis of pregnancy ICP is a specific disease of the liver occurring during pregnancy where bile can not pass through normally; elevated concentrations of bile acids in the blood can be found in the mother. As thecondition typicallyresolves once the pregnancy has concluded, it is of concern primarily because of its links with various problems with the fetus, as a consequence of elevated maternal bile acids.
Learning the implications of what ICP is, why identification can have an impact, and the relevance of diagnostic testing can ultimately play a part in pregnancy health care for women and their babies.
Intrahepatic cholestasis of pregnancy, or ICP, is a liver disease that may occur in pregnancy where there is impaired bile flow from the liver. This causes bile acids to build up in the blood and therefore causes symptoms of ICP, often by creating itching.
Itchiness caused by ICP is not normally like “itchy dry skin.” ICP is capable of producing itching of an extreme degree in the absence of a rash. Many ICP sufferer will experience the itch mostly on their soles and the palms of their hands, although other parts of the body may be affected.
ICP normally manifests in late pregnancy, but it is not unheard of for it to begin earlier. Once the baby is born, levels and symptoms normally return to normal.
ICP is not to be taken as a nuisance, as increased levels of maternal bile acids are thought to contribute to serious risks in the pregnancy, such as premature birth and even stillbirth.
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What Causes ICP?
ICP can occur for a variety of causes that are not fully understood. It appears that the underlying factor is likely to be the interaction of hormones, genes, and perhaps environmental factors. Hormones from pregnancy can affect the action of the liver and the way bile passes, and in some people the body seems to over-respond to their effect.
Genes can help to explain why some families, and some groups of people, seem to be more prone to the condition than others.
It is essential for any of you having the condition to tell your health professional to screen your baby if a previous pregnancy has been affected, as it may well affect you in a future pregnancy too. Also, please remember that this condition occurs without your fault; it is not brought about by eating ‘bad’ foods or failing to keep fit, nor by failing to look after yourself in general.
Common Symptoms of Intrahepatic Cholestasis
The typical presentation of ICP is skin prickling without a rash, and it can range in intensity, but for women it is often worse in the evening and disturbs sleep.
Other possible symptoms include:
- Itching on the palms and soles
- Generalized itching across the body
- Dark-colored urine
- Pale or clay-colored stools
- Nausea
- Loss of appetite
- Discomfort in the upper right area of the abdomen
- Yellowing of the skin or eyes, although this is less common
The sufferer may have only some of the symptoms listed; in fact, they may only suffer from itching.
Due to the widespread occurrence of itchy skin during pregnancy, it cannot always be regarded as a natural symptom.
ICP vs Ordinary Pregnancy Itching
One of the most useful distinctions is the difference between common pregnancy-related itching and itching associated with ICP.
| Feature | Ordinary Pregnancy Itching | Intrahepatic Cholestasis of Pregnancy |
| Main symptom | Itching or dry skin | Often intense itching |
| Visible rash | May be present depending on cause | Typically no primary rash |
| Palms and soles | Can occur | Frequently affected |
| Night-time symptoms | Variable | May become particularly severe |
| Blood tests | Usually normal | Bile acids may be elevated |
| Liver involvement | Usually absent | Present |
| Pregnancy monitoring | Depends on cause | Often requires additional monitoring |
This comparison is not enough to diagnose ICP. A healthcare professional may need to perform blood tests to determine whether bile acids are elevated.
How Is ICP Diagnosed?
Diagnosis is usually through signs and symptoms, medical history, and a blood test.
A doctor or midwife will likely perform blood tests looking at your levels of serum bile acids. Blood tests measuring your liver function may also be conducted, as ICP can be linked to liver blood markers.
The blood test that tests the levels of bile acids is relevant because the level detected does affect both the management of the ICP and ICP as a whole. Sometimes the test may be normal, but there may still be itching. If itching persists with a normal blood test, the tests may need to be repeated. This is therefore a good reason for letting your maternity team know that you are still itching or that it has increased.
Why Are Bile Acids Important?
The liver produces bile acids that aid fat digestion. Normally, these move around the digestive system and liver at defined rates. When ICP occurs, this process may be disrupted, and bile acids can accumulate in the blood.
High bile acid concentrations have been associated with high risk.
For this reason, ICP is not diagnosed or treated according to discomfort, and the concentration of bile acids in the blood becomes useful information to plan pregnancy care.
Doctors will monitor and classify according to concentration, but other factors that include maternal symptoms, gestation length, past deliveries, history of other deliveries, and fetal wellbeing must also be taken into account.
Treatment and Management of ICP
The management is patient-specific, with the general aims of relieving the mother’s symptoms, monitoring pregnancy, and minimizing the risk to the baby. Ursodeoxycholic acid (UDCA) is now routinely used for the treatment of ICP, with it showing some benefits in symptom management and normalization of the LFTs with regard to the bile acid elevations. Whether and in which dose it should be prescribed will vary with each pregnancy.
Doctors may also routinely investigate bile acids and liver enzymes by carrying out blood tests.
Pregnancy monitoring is likely to be increased depending on the severity of ICP and gestation, with the team potentially recommending early delivery at a certain stage of pregnancy as risks are increased as pregnancy progresses. This should be decided by the obstetricians caring for the pregnant woman and not by a general online resource guide.
ICP and the Baby
For the mother, ICP is usually temporary. For the baby, however, the condition requires careful attention.
ICP has been associated with complications such as:
- Preterm birth
- Meconium-stained amniotic fluid
- Fetal distress
- Increased risk of stillbirth, particularly with higher bile acid concentrations
The absolute risk varies between individuals and is strongly influenced by bile acid levels and other pregnancy factors.
This does not mean that every pregnancy affected by ICP will have complications. Many women with ICP go on to have healthy babies. The reason doctors monitor the condition carefully is to identify pregnancies in which additional intervention may be appropriate.
What Happens After Delivery?
Most commonly, ICP resolves during childbirth due to changes in hormonal state during pregnancy. Usually, itching will resolve after the delivery and bile acids will return toward normal limits. Follow-up studies may be done to make sure the diagnosis has been cleared.
Abnormalities of the liver profile or symptoms persisting past the pregnancy will need further work-up, and abnormalities should not be presumed to be ICP merely because they persist post delivery.
Women with a history of ICP should also communicate this with their physician in the next pregnancy, as ICP may recur.
When Should You Contact Your Doctor?
Itching can occur during pregnancy, although significant, unrelenting, or inexplicable itching warrants a doctor’s visit. This is particularly the case when the itching cannot be explained by a visible rash.
Contact your maternity care provider if you develop:
- Severe itching, especially on your palms or soles
- Itching that becomes worse at night
- Unexplained dark urine or pale stools
- Yellowing of the eyes or skin
- Persistent itching that is interfering with sleep
If you are pregnant and the baby seems to be moving less or another concerning pregnancy sign develops, contact medical services for an immediate appointment to be seen by medical professionals; do not wait for your regular visit.
Final Thoughts
Intrahepatic cholestasis of pregnancy can start as innocuous as an ‘itchy night’. Which is why awareness.
The crucial takeaway is easy: prolonged or intense itching (which in pregnancy can be without rash) ought to be examined by a health care professional. Blood work, including bile acid testing, can ascertain whether ICP is contributing.