Facts About Intrahepatic Cholestasis of Pregnancy

*UPDATED 10/22

Have you or did you ever have intense itching in pregnancy?

If so, you are not alone, but there is a condition in pregnancy that causes itching that every pregnant person should be aware of. Keep reading to learn more!As the skin of the belly stretches to accommodate a growing baby, the abdominal skin is stretched and sometimes feels itchy. You might have heard about this from others or even experienced it yourself, or perhaps you’ve seen the endless number of pregnancy body butters on the market to help reduce itching and skin discomfort!

But at what point is itching actually a sign that something else is at play?

While some itching is common in pregnancy, if it becomes excessive, the itching can be a symptom of intrahepatic cholestasis of pregnancy (ICP). ICP is a liver disorder in which the bile acids that flow from your liver to your gut to help digest food are unable to properly flow, and instead cause a build-up of bile acids within your body. ICP typically presents itself in the 2nd or 3rd trimester, but sometimes it can start as early as 8 weeks of pregnancy.Excessive itching, also known as pruritus, primarily in the palms of the hands and soles of the feet, is the most common symptom. The itching can then spread to other parts of your body. Though jaundice and dark urine might also occur, they are not typically seen in ICP.

The Outcomes of ICP

Knowing the signs and symptoms of ICP is important because it can increase the risk of stillbirth. In pregnancies over 37 weeks, the risk of stillbirth increases to 1.2% versus 0.1%-0.3% of the general population. The highest risk exists if bile acids are above 100 micromol/L. ICP can also cause meconium-stained amniotic fluid, preterm birth, and preeclampsia. Preeclampsia has a 2-to-5-fold increase, usually if bile acids are above 40 micromol/L. It typically occurs 2 to 4 weeks after diagnosis of ICP.

Risk Factors & Prevention

The risk factors for ICP are:

• Preexisting hepatobiliary disease (gallstones, hepatitis)
• Prior personal or family history with ICP
• Advanced maternal age

Prevention

Antenatal testing can be done, though the efficacy to prevent stillbirth is unknown. Antenatal fetal surveillance to assess fetal well-being, typically with nonstress tests (NST), is usually started at 32 weeks. More frequent testing could be used for the following:

• Total bile acid levels of ≥100 micromol/L due to stillbirth risk
• Additional complications like high blood or diabetes

Management and Treatment Planning

Though there is no treatment for ICP, it usually ends when the baby is born and the symptoms  can be managed during pregnancy. Management for ICP includes two medications: one to help bind the bile acids [(Ursodeoxycholic acid (UDCA)] and one to help the itching (antihistamine). Timing of delivery will depend on the level of bile acids in your blood.

Recurrence of ICP

Recurrence for ICP in a subsequent pregnancy may be as high as 90%, with a higher risk if there is underlying hepatic or biliary disease. Therefore, if you had ICP previously, be sure to inform your OBGYN. If you experience excessive itching on your hands or feet, discuss it with your physician.

Learn more:

• SMFM Recommendations: Intrahepatic Cholestasis of Pregnancy
• Risk of Stillbirth with Intrahepatic Cholestasis of Pregnancy: What do bile acid concentrations tell us?
• PITCHES RCT: Ursodeoxycholic Intrahepatic Cholestasis of Pregnancy
• ICP: What you should know by Dr. Clark