Intrahepatic Cholestasis of Pregnancy (ICP), also termed Obstetric Cholestasis in the United Kingdom, is a reversible form of cholestasis, a liver disorder that occurs in pregnant women. ICP gives rise to troublesome itching during pregnancy but may lead to possibly serious complications for the mother and very serious outcomes for the fetus. Itching has long been considered to be a common symptom of pregnancy. The vast majority of times, itching, or pruritus is a minor annoyance caused by changes to the skin, especially that of the abdomen.
Cholestasis is a condition that impairs the release of a digestive fluid called bile from liver cells. As a result, bile builds up in the liver, impairing liver function. Because the problems with bile release occur within the liver (intrahepatic), the condition is described as intrahepatic cholestasis. Intrahepatic cholestasis of pregnancy usually becomes apparent in the third trimester of pregnancy and recurs in 45 to 70% of subsequent pregnancies. Bile flow returns to normal after delivery of the baby, and the signs and symptoms of the condition disappear. However, they can return during later pregnancies.
Hallmarks of ICP include the following symptoms:
This condition causes severe itchiness (pruritus) in the expectant mother.
- The itchiness usually begins on the palms of the hands and the soles of the feet and then spreads to other parts of the body.
- Occasionally, affected women have yellowing of the skin and whites of the eyes (jaundice).
- Some studies have shown that women with ICP are more likely to develop gallstones sometime in their life than women who do not have the condition.
- Intrahepatic cholestasis of pregnancy can cause problems for the unborn baby.
- This condition is associated with an increased risk of premature delivery and stillbirth.
- Some infants born to mothers with intrahepatic cholestasis of pregnancy have a slow heart rate and a lack of oxygen during delivery (fetal distress).
- increased serum bile salts
- abnormal liver enzymes
- fetal complications, including
- placental insufficiency
- premature labor
- fetal distress
- intrauterine death
- Some women with ICP may also be susceptible to oral contraceptive-induced cholestasis (OCIC).
The cause of cholestasis of pregnancy is unknown. However, the condition may be related to pregnancy hormones. Pregnancy hormones affect gallbladder function, resulting in slowing or stopping the flow of bile. The gallbladder holds bile that is produced in the liver, which is necessary in the breakdown of fats in digestion. When the bile flow is stopped or slowed down, this causes a build up of bile acids in the liver which can spill into the bloodstream.
Mutation in the ATP8B1 gene can also cause progressive familial intrahepatic cholestasis.
In addition genetic changes in the ABCB11 or the ABCB4 gene can increase a woman's likelihood of developing intrahepatic cholestasis of pregnancy.
While most pregnant women experience some itch from time to time, itching on the palms and soles without a visible rash, or persisting severe or extensive itch symptoms should be reported to the midwife or obstetrican. To obtain a diagnosis of ICP, a blood test is arranged to check the liver function tests (LFTs). This is a simple blood test, the results of which should be available by the next day. If the ALT level is elevated, this, plus pruritus of palms and soles, should be treated as diagnostic of ICP (however LFT's are not always elevated in ICP patients). Another blood test for ICP is a quantitative measurement of bile salts. The results of this test often take longer to return, but the test is more specific for ICP.
Treatment for cholestasis of pregnancy has two goals: relieve itching and prevent complications.
Upon diagnosis, most providers will prescribe Ursodeoxycholic Acid. However, some will prescribe Cholestyramine. While there is no cure for ICP, and no way to guarantee a successful outcome, studies have shown a slightly better fetal and maternal outcome from administration of Ursodeoxycholic Acid, whereas Cholestyramine appears to only relieve itching.