Intrahepatic Cholestasis of Pregnancy (ICP)

What are the risks?

ICP poses several risks that are of great concern. It is associated with an increased risk of stillbirth (intrauterine fetal demise), premature labor, fetal distress, meconium staining and maternal hemorrhaging. The risk of stillbirth in an ICP pregnancy is believed to be the same as that of a pregnancy with no complications (1%) with active management (which usually means treatment- Medicine-Ursodeoxycholic acid and choosing to deliver early).

Fetal Distress

Compromised condition of the fetus, usually discovered during labor, characterized by a markedly abnormal rate or rhythm of myocardial contraction. Some patterns, such as decreased movements, meconium passage, high or low heart rate, late decelerations of the fetal heart rate seen on records of electronic fetal monitoring, are indicative of fetal distress.

Meconium Passage

Meconium is normally stored in the infant’s intestines until after birth; it is the baby’s first feces which is sticky, thick, and dark green. Sometimes (often in response to fetal distress) it is expelled into the amniotic fluid prior to birth, or during labor. If the baby then inhales the contaminated fluid, respiratory problems may occur.

Maternal Hemorrhaging

Cholestasis patients have a reduced ability to absorb fat-soluble vitamins (A,D and K). This may lead to Vitamin K deficiency. There is a risk of maternal intra- or postpartum hemorrhage. Therefore doctors prescribe oral Vitamin K. There have been reports of maternal hemorrhage as well as stillbirth in utero and postpartum due to ICP induced Vitamin K Deficiency.

Preterm Labor

ICP has been associated with a substantial rate of preterm birth. There is an increased risk of spontaneous preterm labor, which has been seen in as many as 60% of deliveries in some studies, however without active management most studies report rates of 30%-40%. Earlier presentations of Intrahepatic Cholestasis of Pregnancy (ICP) seem to carry an even greater risk of preterm labor, as well as twin or triplet pregnancies. Also, there are some data to suggest that neonatal respiratory distress (RDS) following ICP may be a consequence of the disease process.

Stillbirth

Still birth tends to occur in the last few weeks of pregnancy. The reason this occurs is not completely understood. Although with proper medication UDCA-Ursodeoxycholic Acid and early delivery by 37 weeks the risk is believed to be that of an uncomplicated pregnancy. Research has shown that a bile acid blood level over 40 micromol/L during pregnancy appears to be associated with an increased risk of complication to the unborn baby. ICP is associated with higher rates of intrauterine fetal demise (IUFD) also known as stillbirth. These are the ways in which bile acids may harm the baby based on research. These include abnormal heart rhythms, abnormal contraction of the veins supplying the baby with nutrients, greater sensitivity of the baby’s intestines to bile acids that may cause passage of meconium, intensified susceptibility of the uterus to hormones which may trigger labor and premature aging of the placenta due to exposure to elevated bile acids. Additional research is necessary in this area since some pregnancies appear to be at higher risk than other pregnancies with Intrahepatic Cholestasis of Pregnancy.

What Is Cholestasis of Pregnancy?

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It’s normal to experience mild itching during pregnancy as your bump grows and your skin expands and stretches—in fact, almost a quarter of all pregnant women complain of itchy skin. However, more intense, persistent itchiness could be a symptom of intrahepatic cholestasis of pregnancy (ICP), a group of liver disorders specific to pregnancy that interfere with the flow of bile.

Though there’s no long-term risk to your health, this condition can be dangerous to your baby if it goes untreated. That’s why you should always tell your doctor if you have significant itching.

What is intrahepatic cholestasis of pregnancy (ICP)?

ICP impairs the functioning of the liver, resulting in a buildup of bile—a fluid produced in the liver to digest fats—in the blood. Itching is triggered when the blood deposits these bile acids into the tissues, which can be uncomfortable but not life-threatening. For your baby, however, elevated bile levels are toxic and can cause complications if left untreated, including preterm birth, fetal distress, meconium in the amniotic fluid, and stillbirth.

  • RELATED: 6 Reasons to Always Call the Doctor During Pregnancy

What are cholestasis symptoms?

Here’s how to tell the difference between the harmless itching many women experience during pregnancy and ICP: “Itching associated with cholestasis occurs in the second and third trimesters of pregnancy, and it’s typically severe, particularly at night,” explains Christine Miller, M.D., a professor of reproductive medicine at the University of California School of Medicine. “It can be all over the body but is often worse on the palms and soles.”

Tell your doctor promptly if you experience severe itching to rule out the possibility of ICP. He or she will likely order blood tests and bile acid tests, and evaluate your liver function to determine a diagnosis. “If you are experiencing severe itching and your doctor is unfamiliar with ICP and resistant to learning more about the condition, get a second opinion,” says Dr. Miller.

In the majority of cases, itching is the only symptom reported. However, less common symptoms associated with ICP may include:

  • Dark urine and/or pale stool

  • Fatigue

  • Respiratory distress syndrome (RDS) and failure to establish breathing

  • Yellowing of the skin and whites of the eyes (aka jaundice)

  • Nausea

  • Loss of appetite

Symptoms of ICP usually resolve after delivery, but there is a high chance of recurrence with subsequent pregnancies.

Treatment for cholestasis of pregnancy

The good news for you and your baby is that ICP is treatable. In fact, with active management the risk of stillbirth is less than 1 percent, which is the same as an uncomplicated pregnancy. According to Dr. Miller, the most common active management tactics typically include:

Taking the prescription medication Ursodiol. This medication helps decrease bile acid levels in the mother’s bloodstream and relieves itchiness. Moreover, it may help protect the baby in several ways including preventing premature aging of the placenta, reducing the risk of meconium staining, protecting the baby’s heart and cells against damage due to bile acids and restoring the placenta’s ability to transport bile acids away from the baby.

Early delivery at 36 or 37 weeks, or at the time of diagnosis if later.

Additional screenings to monitor your well being and your baby’s. These tests may include blood work to monitor your bile acid levels; nonstress tests, which can detect signs of fetal distress; and biophysical profile scores to measure the volume of amniotic fluid and fetal activity.

  • RELATED: 10 Strange Pregnancy Symptoms

Treatment for general itchiness during pregnancy

It’s important to note that itchy skin during pregnancy can be very normal. “Many women get itchy for no other reason than the skin over the belly is continually being stretched and this can lead to dryness, stretch marks, and itching,” says Dr. Hakakha explains. “Most cases are harmless.”

To cut down on itching, here are a few tips from Michele M. Hakakha, M.D., a board-certified OB/GYN and co-author of Expecting 411: The Insider’s Guide to Pregnancy and Childbirth:

  • Use a moisturizer twice a day and immediately after a shower or bath.

  • Use anti-itch creams like calamine lotion, 1% hydrocortisone cream, or diphenhydramine (Benadryl) cream.

  • Avoid taking really hot showers which can dry out your skin.

  • Drink plenty of water to stay well-hydrated.

  • Try an oatmeal bath.

  • Avoid spending long periods of time in hot weather or in the sun (which can make itching worse).

For more information about ICP including managing symptoms and finding a doctor who is knowledgeable about the condition, visit ICPcare.org.

Melissa Willets is a writer/blogger and soon-to-be mom of 4. Find her on Facebook where she chronicles her life momming under the influence. Of yoga.

  • By Kim Conte and Melissa Willets

Symptoms

Itching

The most commonly reported symptom of Intrahepatic Cholestasis of Pregnancy is moderate to severe itching, and in many cases it is the only symptom reported. The itching can vary greatly from one affected woman to another, and it is important to remember that there really is no such thing as typical Intrahepatic Cholestasis of Pregnancy. Some presentations are more common than others, however.

  • Location of itching – the most commonly affected areas include the hands and feet. However, many women itch on their wrists, ankles, arms, legs, scalp, or all over. Some women itch everywhere except their hands and feet.
  • Severity of itching – the severity of the itching can vary greatly and does not correlate with the severity of the disease. Some women experience moderate itching with extremely severe Intrahepatic Cholestasis of Pregnancy, and other experience extreme itching with mild Intrahepatic Cholestasis of Pregnancy. Some women itch so frantically that they draw blood, but this does not happen to all affected women. While itching may sound like a minor symptom, in women with severe itching, quality of life can be dramatically affected. In some cases, sleep can be so severely disrupted that women get only a few hours of sleep a day. In the most troubling cases, women have had suicidal thoughts or actions.
  • Fluctuations in itching – some women find that itching follows a cyclical pattern, in which it gets much worse at night and better, or even absent, during the day. The reason for this is not completely understood but it has been suggested that it may be related to the diurnal fluctuations in other hormones, particularly cortisol. Other women find that their itching does not follow this pattern.
  • No rash – Intrahepatic Cholestasis of Pregnancy itching is not caused by a rash. In some cases, however, a rash may develop as a result of intense scratching which may damage the skin. In these cases it is important to note whether the itching caused the rash, or if the rash caused the itching. Itching that is most prominent on the abdomen and is associated with a rash may be PUPPP, another pregnancy-specific condition which does not put the baby at risk. Please keep in mind that it is possible to have both PUPPP and ICP.

Some itching in pregnancy can be normal. It is important to remember that some doctors may overlook itching due to Intrahepatic Cholestasis of Pregnancy as it is a normal side effect of pregnancy.

While most women only report itching as a symptom in their ICP pregnancy, there are other symptoms which may occur.

Right Upper Quadrant Pain (RUQ pain)

Intrahepatic Cholestasis of Pregnancy sometimes causes pain in the area of the liver. The liver itself does not have nerve endings that sense pain, but the gall bladder, bile ducts, and a capsule surrounding the liver can sense pain. This pain is most commonly felt under the ribs on the right side. Less commonly the pain can be felt radiating to a spot in the back beneath the tip of the right shoulder blade. RUQ pain is not commonly reported because it is often mistaken for pain from the baby pushing against the ribs. This pain can vary. Some women feel a dull throbbing pain, others a sharp stabbing pain. For some women the pain has been described as debilitating, however it is important to remember that most women with ICP will not feel pain in the area around their livers. RUQ pain can be caused by many things other than Intrahepatic Cholestasis of Pregnancy, and it should always be discussed with your doctor.

Dark Urine

There are many biochemical changes which take place in the body during Intrahepatic Cholestasis of Pregnancy. These sometimes cause the urine to become dark. Dark urine may range in color from apple juice-colored to dark brown. This can happen even when water intake is adequate.

Pale Stool

Under normal circumstances, bile gives the stool its distinctive color. In some ICP pregnancies, the flow of bile is so thoroughly disrupted that stool appears pale gray, or clay-colored.

Nausea/lack of appetite

Some women with Intrahepatic Cholestasis of Pregnancy find it difficult to eat due to a severe loss of appetite. It can be difficult or even impossible to force down enough food to maintain adequate weight gain. Some women even lose weight despite their best efforts. Others have nausea and/or vomiting.

Fatigue/Malaise

While it is normal to feel tired during pregnancy, fatigue related to Intrahepatic Cholestasis of Pregnancy can be extreme due to the important role the liver plays in many metabolic processes. This fatigue can be exacerbated due to stress and lack of sleep.

Jaundice

It is uncommon to develop jaundice with Intrahepatic Cholestasis of Pregnancy. It is estimated that 10% or less of women affected by ICP will become jaundiced. However, if you notice a pale yellow color to the skin and/or eyes, seek medical attention.

Mild Depression

Mild depression may develop as a result of biochemical changes in the body, hormonal changes, lack of sleep, and/or the inability to escape the itch. Please discuss any depressive thoughts or feelings with your doctor immediately.

Cholestasis Of Pregnancy

Some women experience a very severe itching in late pregnancy. The most common cause of this is cholestasis, a common liver disease that only happens in pregnancy. Intrahepatic Cholestasis of Pregnancy (ICP) is a condition in which the normal flow of bile is affected by the increased amounts of pregnancy hormones.

Cholestasis is more common in the last trimester of pregnancy when hormones are at their peak, but it usually goes away within a few days after delivery.

According to Cincinnati Children’s Hospital Medical Center, Cholestasis occurs in about 1 out of 1,000 pregnancies but is more common in Swedish and Chilean ethnic groups. Cholestasis is sometimes referred to as extrahepatic cholestasis which occurs outside the liver, intrahepatic cholestasis which occurs inside the liver, or obstetric cholestasis.

What causes cholestasis of pregnancy?

Pregnancy hormones affect liver function, resulting in slowing or stopping the flow of bile. The gallbladder holds bile that is produced in the liver, which is necessary for the breakdown of fats in digestion. When the bile flow in the liver itself is stopped or slowed down, this causes a build up of bile acids in the liver which can spill into the bloodstream.

ICP is diagnosed when the total bile acids (TBA) or serum bile acids are measured at 10 micromol/L and above. Studies initially showed that this increase in bile acids was due to estrogen only, but recent research has found that progesterone may contribute just as much to this backup.

What are the symptoms?

  • Itching, particularly on the hands and feet (often is the only symptom noticed)
  • Dark urine color
  • Pain in the right upper quadrant (RUQ), without gallstones
  • Pale/Light coloring of bowel movements
  • Fatigue or exhaustion
  • Loss of appetite
  • Depression

Less common symptoms include:

  • Jaundice (yellow coloring of skin, eyes, and mucous membranes)
  • Upper-Right Quadrant Pain
  • Nausea

Who is at risk?

1 to 2 pregnancies in 1,000 are affected by cholestasis.

The following women have a higher risk of getting cholestasis during pregnancy:

  • Women carrying multiples
  • Women who have previous liver damage
  • Women whose mother or sisters had Cholestasis or ICP

How is it diagnosed?

A diagnosis of cholestasis can be made by doing a complete medical history, physical examination, and blood tests that evaluate liver function, bile acids, and bilirubin.

The Society for Maternal-Fetal Medicine concurs that ICP should be diagnosed when the total bile acids (TBA) or serum bile acids are measured at 10 micromol/L and above.

How will the baby be affected if the mother is diagnosed with cholestasis?

Cholestasis may increase the risks for fetal distress, preterm birth, or stillbirth. A developing baby relies on the mother’s liver to remove bile acids from the blood; therefore, the elevated levels of maternal bile cause stress on the baby’s liver. Women with cholestasis should be monitored closely and serious consideration should be given to inducing labor once the baby’s lungs have reached maturity.

What is the treatment for cholestasis of pregnancy?

The treatment goals for cholestasis of pregnancy are to relieve itching. Make sure you speak with your healthcare provider before taking any medications or supplements.

Some treatment options include:

  • Topical anti-itch medications or medication with corticosteroids
  • Medication to decrease the concentration of bile acids such as ursodeoxycholic acid
  • Cold baths and ice water slow down the flow of blood in the body by decreasing the temperature
  • Dexamethasone is a steroid that increases the maturity of the baby’s lungs
  • Vitamin K supplements administered to the mother before delivery and again once the baby is born to prevent intracranial hemorrhaging
  • Dandelion Root and Milk Thistle are natural substances that are beneficial to the liver (talk to your healthcare provider before taking these)
  • Bi-weekly non-stress tests which involve fetal heart monitoring and contraction recordings
  • Regular blood tests monitoring both bile serum levels and liver function

Treatment for cholestasis of pregnancy needs to be determined by your physician, who will take the following criteria into consideration:

  • Your pregnancy, overall health, and medical history
  • The extent of the disease
  • Your tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the disease
  • Your opinion or preference

Treatments that should not be used for cholestasis include:

  • Antihistamines
  • Aveeno and Oatmeal Bath

*There are conflicting views on using the medication Cholestyramine for the treatment of cholestasis. In the past, this medication was readily used to treat this condition, but some studies have shown that Cholestyramine may not be as effective as other treatments and potentially has some adverse side effects such as blocking essential vitamins like Vitamin K (a vitamin that is already deficient in women with cholestasis).

What are the chances of the mother getting cholestasis in another pregnancy?

It is nearly impossible to know whether a woman will experience cholestasis in future pregnancies. Some sources claim that women who have had cholestasis of pregnancy have up to a 90% chance of having this repeat in future pregnancies, but the research is not conclusive.

If you plan on getting pregnant again, talk to your healthcare provider about steps you can take to promote a healthy pregnancy, or if there are any ways to prevent ICP.

Last Updated: 07/2017

Compiled using information from the following sources:

1.William’s Obstetrics Twenty-Second EdF. Gary, et al, Ch. 50.

2.ICP Care

About Itchy Feet and Pregnancy

Hormonal skin changes

Your hormones are going crazy (as you’ve probably already noticed), and all that extra action from your endocrine system can cause your skin to get irritated.

Plus, your immune system works differently while you’re pregnant — it temporarily increases or suppresses certain functions so that your baby can grow in the best way possible.

The combination of hormones and immune system changes can lead to some pregnancy-specific skin conditions that may cause itchy feet.

You may notice:

  • small, itchy bumps that resemble bug bites (prurigo)
  • rash-like, itchy hives (PUPP)
  • red, scaly, itchy patches (eczema or AEP)

The good news is that these skin conditions will not harm your baby and should go away after you deliver.

Nerve sensitivity

Again thanks to our good friends, the hormones, some pregnant women find that their nerves just seem more sensitive during pregnancy.

So seemingly “normal” things like sweating, being warm, wearing tight clothing, chafing, wearing the wrong shoes, or just lying in your bed can make your feet itchy.

Stretching

Not the kind of stretching you do in your prenatal yoga class — we’re talking about stretching of the skin. Your body goes through some amazing changes to house that rapidly growing baby, and stretching the skin, on your abdomen, thighs, buttocks, and breasts, is one of them.

Depending on your genes, hormones, and rate of weight gain you may be more or less prone to developing stretch marks (striae gravidarum). Stretch marks can be a source of itching.

While your feet are unlikely to develop stretch marks, they do bear extra weight during pregnancy and the ligaments undergo some stretching of their own that can lead to an itching sensation.

Psoriasis

If you experienced psoriasis prior to pregnancy, you might get a welcome break from symptoms while you are pregnant. But, some women continue to experience painful, itchy plaques even during pregnancy, which can occur on your feet.

Cholestasis

Now for the rare, but serious, reason for itchy feet during pregnancy: intrahepatic cholestasis of pregnancy. This is a liver condition that, if it occurs, usually shows up during the third trimester.

Normally, your liver helps send bile to your digestive tract, where it aids in breaking down dietary fat.

Hormonal and digestive changes, as well as possible genetic predisposition, can cause the liver to not work like it should, which allows bile acids to build up in your body. This buildup of bile can cause some intense itching, particularly on your hands and feet.

Cholestasis can be dangerous for your baby. It can increase the risk of premature birth, fetal distress, and even stillbirth.

Call your doctor if you experience any of the following symptoms

  • severe itching
  • increase in itching
  • itching that gets worse at night
  • yellowish tinge to your skin or eyes (jaundice)
  • dark urine
  • pale or grey bowel movements
  • right-sided upper abdominal pain
  • nausea or upset stomach

Cholestasis of Pregnancy

What is cholestasis of pregnancy?

Cholestasis of pregnancy is a common liver disease that causes severe itching late in pregnancy. It is also known as intrahepatic cholestasis of pregnancy (ICP) or obstetric cholestasis.

ICP temporarily impairs (lowers) liver function in some pregnant women. This liver impairment causes bile (a substance made by the liver that helps digestion) to build up in the liver and bloodstream. When levels of bile in the blood reach a certain point, it causes the itching.

Cholestasis of pregnancy can cause complications for both the expectant mother and baby.

How common is cholestasis of pregnancy?

Cholestasis is a common liver disease during pregnancy. About 1 to 2 in 1,000 pregnant women develop ICP. Women with Scandinavian, Indian, Pakistani or Chilean backgrounds are more likely to develop it.

Bile is a substance made by the liver. It helps break down fats during digestion. In some people, when levels of hormones such as estrogen increase during pregnancy, the flow of bile in the liver stops or slows down. This slowdown can cause bile to build up in the liver and enter the bloodstream.

Cholestasis of pregnancy typically develops in the third trimester when pregnancy hormone levels are at their highest. In some cases, it is genetic, meaning it is passed down among family members.

What are the symptoms of cholestasis of pregnancy?

The main symptom of cholestasis of pregnancy is severe itching (pruritus). This itching starts on the hands and feet and spreads to other parts of the body. Itching is usually worse at night. It does not involve a rash.

Less-common signs of obstetric cholestasis may include:

  • Nausea
  • Dark urine
  • Light-colored stool
  • Fatigue (extreme tiredness)
  • Decreased appetite
  • Pain in the upper right belly
  • Jaundice (yellowing of the skin and eyes)

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