When it’s More Than Just an Itch: Intrahepatic Cholestasis of Pregnancy (ICP)

By Hannah Schenker

You might not think feeling itchy when you’re pregnant is that big of a deal, but more than 5,000 women each year in the UK, and around 1% of New Zealand women, develop something called intrahepatic cholestasis of pregnancy (ICP). This itch is one you do not want to ignore: while not dangerous for the mother, it can have serious consequences for your unborn child and in severe cases, even lead to stillbirth.

What is ICP?

ICP, also known as obstetric cholestasis (OC), is the most common  liver condition specific to pregnancy. It happens when bile, which is made in the liver and stored in the gallbladder (and which helps us digest our food), slows down. This results in raised levels of bile acid (which are needed for digestion but which in large amounts are toxic) rising in the mother’s blood. ICP can be passed down through families and if you are expecting a girl, she will have around a 14% of developing the condition if she ever has babies.

Symptoms

The itch. Not a pleasant sensation – and it varies in intensity from woman to woman, but has been described as “like a tingle under the skin”, to “like an army of ants underneath my skin” (source). This itching tends to affect the palms of the hands and soles of the feet, but can be elsewhere on the body too, and  there is no rash. The itching can be worse at night and interrupt your sleep. Dark urine and pale stools can also be an indicator, as well as feeling unwell and not having much appetite. Some women develop jaundice (yellowing of the whites of the eyes and skin) but this is not common.

The symptoms tend to start after 30 weeks gestation for about 80% of woman, though some experience it much earlier.

Diagnosis

There is no routine screening for ICP, as it presents differently in each woman – some early on in pregnancy, with most later. In New Zealand about 1% of pregnant women develop ICP.

Instead, ICP is diagnosed through blood tests – investigations to exclude any other reasons for the itching or liver impairment.

“Research and anecdotal (personal reporting) evidence has shown that some women may itch for several weeks before their blood tests show any abnormalities. It is therefore important that you continue to have these tests if you continue to itch.” (source)

Risks to the mother

For the mother, ICP is less risky and should resolve after the baby is born. For her it becomes more about managing the symptoms – the scratch marks for example. There is some evidence to suggest that some women with ICP have an increased risk of post-partum haemorrhage (PPH), but this is only around 10% of women. Studies have shown an increased risk of suffering from gallstones as well – however you may have had them pre-pregnancy, or only develop them later.

The sleep disruptions combined with the anxiety around the risk to the baby may trigger depression in some mothers. (source)

Risks to the baby

“There is considerable debate about the risk to the unborn baby. ICP has been linked to an increased risk of fetal distress, premature labour (spontaneous and iatrogenic), meconium staining and, in severe cases, stillbirth (Geenes et al 2013).” (source)

With ICP, labour may spontaneously begin early (before 37 weeks) or you may be induced, depending on the bile acid levels. Where the bile acid levels are extremely high, some doctors suggest delivering before 37 weeks may be better. Severe ICP is defined by researchers as bile acid levels being greater than 40 µmol/L. (source)

There is also an increased risk of your baby passing meconium before they are born (their first poo), even if they are born prematurely.

Because of both of these risks, babies born to mothers with ICP are also more likely to visit the neonatal unit after birth, for monitoring or help with things like breathing and feeding.

But by far the scariest risk is that of stillbirth. Stillbirth is more common in ICP babies than in uncomplicated pregnancies, a risk of between 1-4%, and tends to occur after 37 weeks. The risk is thought to be higher if there are other complications, such as gestational diabetes or pre-eclampsia.

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