Stop the Itch! Intrahepatic Cholestasis of Pregnancy

Stop the itch - Intrahepatic Cholestasis of Pregnancy - Image

Updated on July 11th, 2021 // by Katie Griffin

Intrahepatic cholestasis of pregnancy. What is this complicated word, and what does it mean in pregnancy? Let’s take a look at this condition — what it is, what it means for mom and baby, and how it’s treated.

Estimated reading time: 7 minutes

What is Intrahepatic Cholestasis of Pregnancy?

In short, intrahepatic cholestasis of pregnancy is a potentially-serious liver condition that occurs during pregnancy. It is also called ICP, obstetric cholestasis, or just cholestasis of pregnancy.

Intrahepatic refers to something that occurs inside the liver. This organ helps you break down and use food, store energy, and remove toxins from the body (1). To do this, it produces a fluid called bile, which is key to the break-down and absorption of fats.

Cholestasis is when bile doesn’t flow normally and is slowed or blocked inside the liver (2).

Pregnancy… well, you know this term.

Causes

Intrahepatic cholestasis of pregnancy usually emerges in the third trimester. Although rare, it can rarely develop in the second trimester or even earlier. It’s a relatively uncommon condition, occurring in fewer than 1 of every 1,000 pregnancies in the United States (3). Doctors don’t fully understand why this condition happens, but as with many other pregnancy-related ailments, they believe that hormones play a role. There also appears to be a genetic link. Women with a specific altered gene have an increased risk of developing the disorder. However, this gene alone isn’t enough to predict it (2).

Symptoms of Cholestasis of Pregnancy

Itching Without a Rash

As bile builds up in the liver, bile salts enter the bloodstream. This leads to the main symptom of ICP — itching without a rash. It usually starts on the palms of your hands and soles of your feet, and over time it may progress to other areas of your body as well. It is often worst at night. For some women, the itching is a mild annoyance. For others, it is severe and can affect their ability to sleep or concentrate on other things.

Though itching is the main symptom that women experience, there are some less common symptoms that are also possible, including:

  • Jaundice, which is where the whites of your eyes and your skin may have a yellow appearance
  • Dark urine
  • Pale or grayish stool
  • Loss of appetite
  • Nausea or upper-right abdominal pain (1)

Diagnosis

As mentioned above, itching is usually the first clue that something may be going on. Your doctor or midwife will order blood tests to check your liver function and the level of bile in your blood. Itching paired with a high level of bile acid in your blood likely means a diagnosis of ICP (3).

Treatment

Medication

The goals of treatment are to relieve symptoms in the mother and reduce the bile acids in the bloodstream to minimize risks to the baby. A prescription medication, such as ursodiol, can help reduce the level of bile in your blood (1, 3). This can decrease both the itch and the chances that your baby will have complications. Don’t use other over-the-counter meds that you might normally use to treat an itch, like antihistamines or corticosteroid creams. They aren’t effective for this type of itching and may not be safe to use in pregnancy.

Labor Induction

Since the elevated bile acid in your blood can cause complications for baby, your provider may encourage an early delivery. It is often recommended that labor be induced in the 37th or 38th week (3). This allows baby to remain inside the womb long enough for lungs to mature, but not any longer than is necessary.

Complications of Cholestasis of Pregnancy

For Mom

ICP resolves after delivery, typically within days, so there are no expected long-term complications. During pregnancy, it is possible for a woman to develop a vitamin K deficiency because of a reduced ability to absorb fat-soluble vitamins (4). For this reason, your doctor may prescribe a vitamin K supplement. Vitamin K is necessary for normal blood clotting. Thus, a lack of vitamin K can lead to postpartum hemorrhage — excessive bleeding after delivery. Though this complication is rare, your doctor or midwife will monitor your levels and treat a deficiency if necessary.

For Baby

Possible complications for baby if mom has ICP include:

Premature birth

This may be due to spontaneous early labor which can be as high as 20-40% if mom is not being treated (5). Why? Some research suggests that increased bile salts make mom more sensitive to oxytocin, and thus more likely to contract early (6). Premature birth can also result from needing to deliver a distressed baby early through induction. Premature babies can have various health complications, including respiratory distress syndrome due to immature lungs.

Fetal distress

This can be a result of baby not getting enough oxygen. It may be shown in high or low heart rate, decreased movement, and meconium passage.

Meconium aspiration

A distressed baby is more likely to poop out meconium — baby’s first stool — while in the womb instead of after delivery. Baby may breathe this meconium into his lungs, which can lead to respiratory problems at birth.

Stillbirth

Increased bile salts have been shown to alter baby’s heart rhythm. It can also constrict veins in the placenta and umbilical cord, and cause premature aging of the placenta (7,8). These factors are thought to contribute to the higher rate of stillbirth in moms with ICP. While this is obviously serious, let us ease your mind a bit! With active management (medication and early delivery) the risk of stillbirth is only 1%, which is the same as in an uncomplicated pregnancy (4).

One Mom’s Experience With Intrahepatic Cholestasis of Pregnancy

Not an “immediate” issue, but I was increasingly itchy without a rash. Not all the time, and initially just on my thighs and then arms. (Palms and soles are the places that start to concern some doctors.) My first blood test for intrahepatic cholestasis of pregnancy came back negative, but several weeks later I was still itching, and I insisted on another blood test, which was positive. My liver was leaking bile acids into my bloodstream, causing itchiness and prematurely aging my placenta. Without treatment and early induction, this leads to a 15% stillbirth rate. 😢 Fortunately it was caught on time, I started taking liver medication, I had lots of biophysical profiles and nonstress tests, and I was induced at 37 weeks. My baby (now 1) is happy and healthy — he didn’t even need to go to the NICU!

Lan B. as quoted in the Kopa Birth® Members FaceBook Group

The Takeaway

Intrahepatic cholestasis of pregnancy is a potentially serious complication, but doctors have found ways to manage it well. The diagnosis does not mean you can’t have a perfectly healthy baby! While the condition isn’t common, it’s good for all pregnant women to be aware of the signs. A person with no knowledge of the condition may not think to mention something seemingly unrelated to pregnancy, like itchy hands and feet. Now that you know, though, you should call your doctor right away.

If you’d like to learn more about ICP, you can find great information from the American Liver Foundation or from ICP Care, a nonprofit dedicated to helping mothers with this diagnosis .

Kopa Birth’s online birthing classes allow you to prepare for a natural hospital birth from the comfort of your own home, 24/7. Enroll today in our free online childbirth class and start preparing for your natural birth!

References:
  1. Intrahepatic cholestasis of pregnancy. (2020, July). Retrieved December 06, 2020, from https://www.marchofdimes.org/complications/intrahepatic-cholestasis-of-pregnancy.aspx
  2. Intrahepatic cholestasis of pregnancy: MedlinePlus Genetics. (2020, August 18). Retrieved December 06, 2020, from https://medlineplus.gov/genetics/condition/intrahepatic-cholestasis-of-pregnancy/
  3. Pusl, T., & Beuers, U. (2007). Intrahepatic cholestasis of pregnancy. Orphanet Journal of Rare Diseases, 2(1). doi:10.1186/1750-1172-2-26
  4. Cholestasis of Pregnancy (ICP) – Symptoms, Causes, and Treatment. (2020, March 10). Retrieved December 06, 2020, from https://liverfoundation.org/for-patients/about-the-liver/diseases-of-the-liver/intrahepatic-cholestasis-of-pregnancy/
  5. Reid R, Ivey KJ, Rencoret RH, Storey B: Fetal complications of obstetric cholestasis. Br Medical J 1976;1:870-872.
  6. Germain AM, Kato S, Carvajal JA, et al: Bile acids increase response and expression of human myometrial oxytocin receptor. Am J of Obstet Gynecol 2003;189:577-582.
  7. Williamson C, Miragoli M, Kadir SSA et al: Bile acid signaling in fetal tissues: implications for intrahepatic cholestasis of pregnancy. Digestive Diseases 2011;29:58-61.
  8. Sepulveda WH, Gonzalez C, Cruz MA, Rudolph MI et al: Vasoconstrictive effect of bile acids on isolated human placental chorionic veins. Eur J Obstet Gynec Reprod Biol 1991;42(3):211-215.

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Meet Katie Griffin

I’m a registered nurse, Lamaze certified childbirth educator, and the mother of 7. I help women realize their dream of a natural, intimate, and empowering hospital birth.

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Updated on July 11th, 2021 // by Katie Griffin Intrahepatic cholestasis of pregnancy. What is this complicated word, and what does it mean in pregnancy? Let’s take a look at