Intrahepatic Cholestasis of Pregnancy (ICP), also known as obstetric cholestasis (OC) is the most common pregnancy-specific liver disease in the UK, affecting around 5,500 women a year. Its main symptom is itching, and the condition is associated with spontaneous premature birth, fetal distress and, in severe cases, stillbirth.

ICP is more common in certain populations, including Scandinavians, South Americans and women from South Asia (namely India and Pakistan), or whose family origins are India or Pakistan.

Because of the link with stillbirth, you may be offered induction of labour. This could be any time from 35 weeks, depending on the level of bile acids in your blood.

Causes of ICP

Hormones

Both pregnancy hormones, estrogen and progesterone, have been cited in ICP, and research has shown that the breakdown products of the pregnancy hormone, progesterone, (called sulphated progesterone sulphated metabolites) are known to be higher in women who have ICP. The result of these high levels have an effect on the ability of the liver to transport some chemicals, including bile acids. The flow of bile is reduced leading to the bile acids building up in the blood, which in turn leads to the symptoms women experience in ICP.

Environment

ICP is more common in the winter months in some countries. There has been very little research conducted into the possible reasons for this variation, and at present it can’t be fully explained. Some theories include that the cause of ICP could be linked to:

• sunlight and vitamin D levels - research studies have shown that supplementation with vitamin D can improve cholestasis in animals
• diet - people often have a tendency to eat fattier foods in the winter.

Why do we worry about ICP?

Although ICP is not generally harmful for the mother-to-be, it's associated with fetal distress in labour, premature labour (both spontaneous and induced) and, in severe cases, stillbirth.

How do I know if I have ICP?

The most common symptom of ICP is itching. Itching in pregnancy is common (around 20% of women will itch during pregnancy), but the itch in ICP is typically noticeable on the hands, feet, arms and legs, although it can occur anywhere on the body. It usually begins in the third trimester of pregnancy (28 weeks onwards), but some women can itch earlier than this and ICP has been diagnosed as early as 8 weeks. Women often report that their itching is more noticeable at night, and it can range from mild itching to being so severe that it can cause loss of sleep. Until recently the direct cause of this itch was thought to be raised bile acids but recent research links it to two substances in the maternal blood called lysophosphatidic acid (LPA) and sulfated progesterone metabolites.

Other symptoms of the condition can include:

• Dark urine
• Pale or ‘floaty’ stools (steatorrhea)
• Jaundice (although this is not common)
• Right upper quadrant pain (RUQ) – increasing reports of this symptom have emerged recently as potentially being associated with ICP and needs further research

How is the condition diagnosed?

The diagnosis of ICP is typically made by excluding other causes of the itch, so screening is likely to include blood tests to check for auto-immune hepatitis, hepatitis C and other conditions such as primary biliary cholangitis (PBC). Other blood tests will also check how well your liver is coping with the condition (liver function test and clotting studies) and how elevated your bile acid levels are. Bile acids are important to test because they are associated with the risk of stillbirth. It is also important that you do not fast for this test, even if you are told to do so. This is because risk is assessed on peak bile acid levels and if you fast, your bile acids will be their lowest.

What treatment might I receive?

If you are diagnosed with ICP, you'll have regular liver blood tests (LFTs) and bile acid measurement tests so your doctor can monitor you. Initially, you may be given these tests every week. 

Creams, such as aqueous cream with menthol, are safe to use in pregnancy and can provide some relief from itching.

A medicine called ursodeoxycholic acid (UDCA) can be prescribed to try to relive itching. But recent evidence suggests it may not be effective in reducing bile acids and easing itching.

UDCA is considered safe to take in pregnancy, although it is prescribed on what is known as an "informed consent" basis as it has not been properly tested in pregnancy. It is usually only prescribed by a hospital doctor.

A possible alternative, which can be helpful if itchiness is keeping you awake at night, is antihistamine medicine, such as chlorphenamine. Chlorphenamine tends to cause drowsiness so it can also help with sleep problems as well as itchiness. If you do feel drowsy do not drive or operate machinery.

Vitamin K

If one of your clotting tests is abnormal, you should be advised to have water soluble Vitamin K which helps to correct the clotting problem. Specialists in the condition will also prescribe vitamin K if the mother-to-be has pale or ‘floaty’ stools (steatorrhea). It is however, the policy of some hospitals to give Vitamin K to all women with ICP regardless of their clotting results even though there is no research to endorse this practice. It’s worth discussing this with your own doctor if you have any concerns.

How do I cope with the itch?

As well as the treatments that your doctor may offer, you can help the itch if you:

• Keep as cool as you can – use a fan in the evenings if the weather is hot
• Turn the temperature down in the house a little if it’s winter
• Freeze a plastic bottle of water, wrap in a thin cloth to avoid ice burns and place this on affected areas of your skin to cool down
• Don’t wear clothes that have fibres which will make you itch
• Don’t lay in bed and scratch, it can just make you feel worse. Get up, make a drink, turn the television on or listen to music to try and distract yourself

Baby Movements

Monitoring your baby’s movements is an important part of keeping track of their wellbeing, especially if you have ICP or other pregnancy condition. If you think your baby’s movements have slowed down or stopped, contact your maternity unit immediately. Midwives and doctors are there to help you - 24 hours a day, 7 days a week.

Do I need tests after birth?

Yes, your GP will want to make sure that all your blood tests have come back to normal, so they should repeat the liver function test and check your bile acid levels around 6–12 weeks after you've had your baby. Sometimes blood results can take a little longer to go back to normal, but if they don’t resolve you may need to be referred to a liver specialist.

More Resources

ICP Support

NHS Website

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