Obstetric Cholestasis or Intrahepatic Cholestasis of Pregnancy (ICP)

Until very recently, little was known about obstetric cholestasis or intrahepatic cholestasis of pregnancy (ICP). For this reason, women who suffered from symptoms of this condition were often misdiagnosed or simply dismissed altogether. Thankfully, however, the medical community has been paying increasing attention to this potentially serious pregnancy-related liver disorder, which is estimated to affect around 7 in every 1 000 pregnant women in the United States each year. Although it is considered rare, health experts estimate that the disorder affects many more women who remain undiagnosed.

What is ICP?
ICP is defined as a pregnancy-related liver condition that affects the flow of bile (a liver-produced substance that aids in the digestion and absorption of fats) to a woman’s body. This condition results in a build-up of bile acids in the blood, which in turn can lead to severe itching, and in more rare cases, jaundice.

The onset of ICP during pregnancy usually begins during the third trimester – as this is when hormone concentrations are highest – although some reports indicate it can begin as early as the first few weeks of pregnancy.

Unfortunately, the exact cause of ICP has not been determined. However, there does appear to be a genetic component to this disease; about half of all women with ICP reported having liver-related disorders in the family.

What are Intrahepatic Cholestasis of Pregnancy Symptoms?
The primary symptom of ICP is severe itching. The itching generally progresses in severity, and may develop to the point that it interferes with a woman’s daily activities, including sleep. Although the itching sensation can be present on any part of the woman’s body, it is most commonly felt on the palms of the hands or the soles of the feet.

In addition, women may experience yellowing of their skin or whites of the eyes – also known as jaundice. This is estimated to occur in about 20% of women with ICP.

Other symptoms may include:

• Dark urine and/or pale stools
• Fatigue
• Loss of appetite
• Mild depression

Less common symptoms include:

• Severe depression
• Upper-Right Quadrant Pain
• Nausea

What Risks Does ICP Pose for Pregnant Women?
Fortunately, ICP does not normally present any dangerous risks for the mother. However, it can present potentially serious risks for the baby, including:

• Premature birth (up to 44% of women with ICP deliver before 37 weeks gestation)
• Hemorrhaging
• Fetal Distress
• Stillbirth

Getting Diagnosed for ICP
The good news is that early diagnosis can significantly reduce the risk of any ICP-related pregnancy complications. However, since itching is often the only symptom pregnant women will experience, it is often overlooked as a common sign of pregnancy. However, there are tests that can be performed in order to determine whether or not a woman does in fact have ICP:

Serum Bile Acid Test: Perhaps the most accurate determinant of ICP, the bile acid test measures whether or not bile acid levels are elevated beyond the normal range. Normally, women are required to fast prior to the test to ensure the most accurate results, however, this is not always a requirement. Note: The problem with the bile acid test is that only a small number of labs around the world have the equipment necessary to perform it , which can result in a considerable delay for women experiencing symptoms of the condition. Women who are more than 34 weeks pregnant and experiencing ICP symptoms should receive treatment immediately rather than wait to be tested.

Liver Function Test: Although a liver test is an important component of any ICP diagnosis, health experts warn that it should not be the sole method used. This is because it is possible for women to have normal liver enzymes and elevated bile acids. In addition, patients with ICP often have elevated bile acids before their liver enzymes begin to increase. That being said, a liver function test should be performed so that results can be corroborated with those of the bile acid test as a precautionary measure to ensure the safety of the baby.

How is ICP Treated?
In previous years, the primary form of medicinal treatment for ICP was a cholesterol-lowering drug called cholestyramine. However, this drug has recently been proven to be largely ineffective in lowering bile acids. In addition, a number of potentially dangerous side-effects (including vitamin K deficiency) have caused doctors to revoke this form of ICP treatment. Currently, there are several components that generally comprise treatment for ICP:

• Ursodeoxycholic Acid (Actigall): One of the most important treatments for ICP, ursodeoxycholic acid works to improve liver function by replacing toxic bile acids in the bloodstream. It has also been shown to reduce the risk of stillbirth.

• Vitamin K: Although not an essential part of ICP treatment, vitamin K therapy is sometimes recommended to combat the reduced absorption of fat-soluble vitamins that often results from having ICP. Vitamin K deficiencies are associated with increased risk for hemorrhaging in the mother and child.

• Steroids: Because pregnant women with ICP run an increased risk of pre-term labor, steroids may be administered before 32 weeks gestation to ensure the baby’s lungs are mature at birth. The drug may also reduce the itching sensation so commonly associated with ICP.

Mother and baby will also be monitored closely during the pregnancy to ensure normal fetal development is taking place. If any abnormalities are detected, early delivery may be suggested. In addition, the doctor may perform an amniocentesis test at 36 weeks gestation in order to ensure the baby’s lungs are mature enough to survive should early delivery be necessary. If this is so, labor may be induced at 36 or 37 weeks to prevent any ICP-related complications at birth.

Finally, although ICP tends to clear up on its own shortly after delivery, women whose ICP symptoms continue or intensify after delivery should be monitored to ensure their liver is functioning normally. In addition, pregnant women who have experienced ICP in previous pregnancies should be closely monitored, as 60 to 70% of them will develop symptoms in their later pregnancies.

For more information about ICP, including additional information, resources, and support groups, visit www.itchymoms.com.