Intrahepatic Choleostasis of Pregnancy
Intrahepatic choleostasis of pregnancy (ICP) is the most common pregnancy-related liver condition, affecting less than 1 percent of pregnancies in the United States. Though rare, it is a serious condition. Here’s everything you need to know about ICP and what to look out for during your pregnancy.
Bile usually flows directly from your liver into your gallbladder, but during ICP, bile builds up in the liver, then spills over into your tissues and blood.
What is ICP?
Intrahepatic choleostasis of pregnancy (also called choleostasis of pregnancy or ICP) refers to a decrease in bile flow within the liver during pregnancy. The liver plays many roles in the body, including filtering blood, metabolizing drugs, and producing proteins necessary for blood clotting. One of its major jobs is to produce bile, a fluid stored in the gallbladder that helps with digestion. Bile usually flows directly from your liver into your gallbladder, but during ICP, bile builds up in the liver, then spills over into your tissues and blood. As bile acid levels rise in your body, you often start to feel itchy and major complications can occur, including stillbirth and premature birth. Complications arise because the baby relies on the mother’s liver to control bile acid levels in the blood, and elevated levels can cause stress on the baby’s liver. There is no known way to prevent ICP.
Who is at risk of developing ICP?
While the cause of ICP is not entirely clear (experts suspect genetics and hormones likely play a role), there are some risk factors to be aware of:
· Personal history of ICP: About 60–75 percent of women who have ICP during pregnancy will develop it again during a future pregnancy.
· Family history of ICP: if you have a close relative, like a mother or sister, who developed ICP
· History of liver damage or liver disease like hepatitis C
· Certain gene mutations: in particular, mutations of ABCB11 or ABCB4, which are genes associated with the body’s production and use of bile
· Pregnancy with multiples (twins or more)
· Latin American or Scandinavian descent: ICP occurs in up to 15 percent of pregnancies in Latin American countries, and according to the March of Dimes, approximately 5 percent of Latina women in the United States develop ICP. Some studies indicate a prevalence of approximately 2 percent in Scandinavian countries. ICP typically affects fewer than 1 percent of pregnancies in the United States.
Signs and Symptoms
The hallmark symptom of ICP is intense itching without a rash.
The itching usually develops in the third trimester and often affects the palms of the hands and soles of the feet, but can occur anywhere on the body. Approximately 80 percent of women who develop ICP do so after 30 weeks of gestation, but it has been reported as early as eight weeks. Many women experience unrelated itching during pregnancy due to hormonal and skin changes and stretching skin, as well as increased sensitivities to things like fabrics, detergents, and fragrances, but if itching does not improve or gets worse, talk to your medical provider.
Rachel P., a 36-year-old mom of two from Pennsylvania, described her first experience with ICP: “With my first baby, I had horrible itching starting in the third trimester. It came on suddenly, and it was unbearable. I was miserable nearly all of the time—I couldn’t sleep, and I wanted to climb out of my skin. My medical provider was initially baffled, as I guess they don’t see ICP too often, but she ran some bloodwork and my bile salt levels were high. Those levels went down when I was tested again, but the itching didn’t stop until I delivered my son.”
Signs and symptoms of ICP include:
· Elevated bile salts (>10 umol/L)
· Intense itching without rash (frequently on palms of hands and soles of feet)
· Jaundice, which causes your eyes and skin to look yellow
· Loss of appetite
· Dark urine or light-colored bowel movements
· Nausea
· Upper right abdominal pain (your liver is located on the right side of your body, usually tucked up under your rib cage)
If you experience any of the above symptoms or itching during pregnancy, touch base with your medical provider. Note that itching is fairly common in pregnancy, and so some providers frequently regard itching as a natural association of pregnancy. One study showed that this association has possibly delayed proper diagnosis of ICP in up to a quarter of cases — so if something doesn’t feel right, speak up.
The baby relies on the mother’s liver to keep bile salt levels in check, and when those levels rise they may cause damage to the baby’s liver and other organs like the heart and lungs.
In Rachel’s case, her second experience with ICP was totally different. “With my second pregnancy, I never had severe itching. It didn’t start until around 35 or 36 weeks, and it was so mild that I barely noticed it all. Every once in a while, I felt a light tickling feeling in my hands and feet. I only mentioned it to my medical provider because I had ICP in my first pregnancy; if I hadn’t been through it before, I would never have known anything was wrong. They decided to do some blood tests, but I wasn’t expecting to have ICP again with such mild symptoms. Surprise!”
Complications
Complications arise with ICP due to the increased bile salt levels in the mother’s blood. The baby relies on the mother’s liver to keep bile salt levels in check, and when those levels rise they may cause damage to the baby’s liver and other organs like the heart and lungs. The complications associated with ICP can be very serious, so it’s important to discuss any concerning signs and symptoms with your medical provider.
Some complications that can occur with ICP:
· Stillbirth: death of the baby late in pregnancy before delivery
· Premature birth: birth of the baby before 37 weeks
· Fetal distress: this typically occurs when the baby is not getting enough oxygen in the womb
· Meconium aspiration: Meconium is a baby’s first bowel movement and it usually occurs after birth. A baby experiencing fetal distress may pass meconium into the amniotic fluid, which can cause complications for the baby.
· Respiratory distress syndrome: This syndrome is often experienced by premature babies whose lungs are not fully developed.
· Postpartum hemorrhage: heavy bleeding after delivering the baby, which is a serious and potentially life-threatening complication.
What to expect if you are diagnosed with ICP
If your medical provider suspects you may have ICP, they will likely order some blood tests to check your bile salt levels, as well as to see how well your liver is functioning. If your bile salt levels are high, your medical provider may suggest medication to help lower them and help reduce the itching. Always check with your medical provider before using any over-the-counter or prescription medications to treat the itching, as many are not safe for your baby during pregnancy.
Amniocentesis, ultrasounds, nonstress tests (fetal heart rate monitoring), and biophysical profiles (combination of a nonstress test and ultrasound) are all possible monitoring tools your medical provider may use to check on your baby.
Depending on your personal situation, your provider may also recommend inducing labor to help prevent severe complications like stillbirth.
Most important, from a mom who has experienced it (twice!), Rachel recommends being your own advocate and trusting your instincts. “I was never put on any medications with either pregnancy. Now that I’m more educated about ICP, I know that probably wasn’t safe at all, especially with my first pregnancy. I was 41 weeks and three days with my first son when he was born, and I realize now how lucky I am that I delivered a live, healthy baby. So lucky. With my second child, despite the milder symptoms, my bile salt levels were higher, and they scheduled me for an induction at 37 weeks, just a few days after they got the results.”
Postpartum
ICP can be scary to develop during pregnancy, but the good news is that the itching usually goes away within a few days of delivery as liver function returns to normal, and long-term liver complications are rare.
For further reading
https://ghr.nlm.nih.gov/condition/intrahepatic-cholestasis-of-pregnancy
https://www.marchofdimes.org/complications/intrahepatic-cholestasis-of-pregnancy.aspx
https://www.mayoclinic.org/diseases-conditions/cholestasis-of-pregnancy/symptoms-causes/syc-20363257
https://www.smfm.org/publications/96-understanding-intrahepatic-cholestasis-of-pregnancy
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2678574/
https://www.nature.com/articles/7211545.pdf?origin=ppub
https://www.healthline.com/health/pregnancy/itching-during-pregnancy#natural-treatments