Intrahepatic cholestasis of pregnancy (ICP)
What is intrahepatic cholestasis of pregnancy (ICP)?
Normally, bile acids flow from your liver to your gut to help you digest food. In ICP, the bile acids build up in your body and ‘leak’ into their bloodstream. ICP usually goes away after you’ve had your baby.
Is ICP common?
No. ICP affects less than 1% of women in the UK. It is slightly more common in women of South Asian origin, affecting about 1.24%.
What causes ICP?
Research shows that ICP is likely to be due to a combination of hormones during pregnancy and genetic factors. ICP also seems to run in families (although it can happen even if there’s no family history).
There is also some research that suggests that ICP is more common in winter pregnancies, multiple pregnancies and following in vitro fertilisation (IVF) treatment. Experts are not sure why.
Although ICP is a liver disorder, it is not caused by drinking alcohol. However, we recommend that you do not drink any alcohol during pregnancy.
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What are the symptoms of ICP?
The main symptom is itching, usually without a rash. This is often worse at night and more noticeable on the palms of the hands and soles of the feet although it can be anywhere on the body. ICP support have more information about this.
But if you are experiencing itching, it’s important to tell your midwife or doctor. Try to be specific about where you are itchy and how severe it is.
Itching is very common in pregnancy and only a small number of people will have ICP. But it is important to trust your instincts if you feel something isn’t right. If you are concerned about ICP but don’t feel that your symptoms are being taken seriously, you can ask to see another midwife (or doctor).
Other symptoms of ICP may include:
- dark wee
- pale poo
- tenderness or pain on the right-hand side, just underneath your rib cage.
Less common symptoms include jaundice (yellowing of the skin and eyes).
Symptoms of ICP typically start from around 30 weeks of pregnancy. But it is possible to develop it as early as 8 weeks.
How is ICP diagnosed?
ICP is typically diagnosed by excluding other causes of the itching. If you have unexplained itching, you may be offered liver function tests (LFTs) and bile acid tests. You do not need to fast for this test.
Some women may have itching for days or weeks before their tests become abnormal. If you are still itching and there isn’t a cause, the bile acids and LFTs should be repeated every 1–2 weeks.
It is possible that your healthcare professional may not be familiar with ICP. If you need support in getting the tests you need, contact ICP Support for more information.
If you are diagnosed with ICP, depending on your bile acid levels, you may need to have extra care, treatment and tests during your pregnancy and labour to monitor your condition.
How does ICP affect me?
ICP can be a very uncomfortable condition as the itching ranges from mild to intense. For some women, it can disturb their sleep and even make them want to scratch their skin until it bleeds. The itching does get better after birth, but some women will be at risk of long-term health issues such as gallstones and other liver diseases.
There has also been some research to suggest that women who have had ICP may be at increased risk of developing type 2 diabetes or cardiovascular (heart) problems, but this needs further research and is likely to be avoided by adopting a healthy lifestyle.
There are some things that may help relieve the itching, including:
- creams, such as aqueous cream with menthol, which are safe to use in pregnancy
- sitting directly in front of a fan, soaking in a cool bath, and applying ice packs for short periods to affected areas
- applying naturally-cooling substances, such as aloe to affected areas before rinsing off in a shower
- wearing cool, loose, cotton clothing
- using unperfumed lotion or soap.
How does ICP affect my baby?
ICP increases the risk of:
- your baby passing meconium (poo) during pregnancy or labour – this may cause breathing problems after birth
- premature birth – research shows that about 1 in 10 women diagnosed with ICP will have their baby early (most preterm deliveries are induced, rather than spontaneous/happen naturally)
This can be difficult to read. But recent research suggests that the risk of stillbirth is increased in women with intrahepatic cholestasis of pregnancy carrying 1 baby when bile acids are 100 μmol/L or more. It may be reassuring to hear that most women with ICP have bile acids below this number, so their risk of a stillbirth is similar to that of pregnant women in the general population.
Bile acids can rise and fall, so you will be tested regularly during your pregnancy to make sure your bile acid level is low.
You may also be offered an induction to reduce the risk of stillbirth. This could be any time from 35 weeks, depending on the level of bile acids in your blood.
What extra care and treatment will I have?
You may need to be looked after by a consultant-led team and will likely have more antenatal care. You will also have regular bile acid tests and liver function tests so your doctor can monitor your condition. These tests are important because they can help doctors decide when your baby should be born.
There is no agreed guideline on how often these tests should happen. But the Royal College of Obstetricians & Gynaecologists (RCOG) and ICP Support advise weekly tests (although everyone will need to be assessed individually and some may need more frequent tests than others).
Your baby will also be monitored carefully throughout your pregnancy.
You may also be offered a vitamin K supplement. This is because ICP can affect your absorption of vitamin K, which is important for healthy blood clotting.
Most experts on ICP only prescribe vitamin K if the mother-to-be reports pale stools, has a known blood clotting problem, or has very severe ICP from early in pregnancy.
Your mental health
Pregnancy can be an emotional experience. But if you are diagnosed with a complication such as ICP, this may cause some stress and anxiety. Tell your midwife or GP if you are finding it hard to cope with these feelings. You may need some extra support. ICP Support also has specialist groups to offer support during this time, as well as a dedicated support line.
Try to look after yourself and find ways to relax. Try our top tips for looking after your emotional wellbeing.
Monitoring your baby’s movements
If you have ICP, it’s important to monitor your baby’s movements. Feeling your baby move is a sign they are well. You should continue to feel your baby move right up to the time you go into labour and during labour.
Contact your midwife or maternity unit immediately if you think your baby’s movements have slowed down, stopped or changed.
Will having ICP affect how I give birth?
Depending on your bile acids levels, if you are diagnosed with ICP you may need to have your baby in hospital under a doctor-led maternity team. This may mean changing your birth plan.
You may be advised to have your labour induced from around 35-36 weeks of pregnancy if your bile acid levels are over 100. This is to reduce the risk of stillbirth. If your doctors think that you should be induced before 35-36 weeks, there is a chance that you may need a caesarean section.
Your team will monitor your condition and talk with you about when they recommend is best for you to give birth so that you can make an informed choice.
Because there is an increased risk that your baby may be born early and passing meconium (poo) during pregnancy or labour, they may have to spend some time in the neonatal unit.
Will I still have ICP after I give birth?
ICP usually goes away after you have your baby. You should have a bile acid test and liver function test around 6-12 weeks after you give birth to confirm this. If the results are still abnormal, the test will be repeated. But we know from specialist charities such as ICP Support that some develop what has been termed ‘cyclical itching’ which is an itch that they notice around the time they ovulate or just before menstruation. There is no research on this and is not thought to be a problem for women.
If the results are still abnormal after this chec, you may need to see a specialist. It’s rare for ICP to last longer than this, so your healthcare professional may look for other things that could cause liver problems.
Taking contraception after pregnancy
If you want to take contraception after pregnancy, it is better to avoid the combined pill (the pill containing estrogen) and use an alternative, such as condoms.
If you do want to start using the combined pill, you will need to have a normal liver function test before starting. If you begin to itch continuously while using it, you may need to have your liver function checked again and stop it.
Experts in ICP recommend the mini-pill (progesterone) or the progesterone implant. Talk to your midwife or GP about what contraception is best for you.
Find out more about your sexual and reproductive health after having a baby.
Will I develop ICP if I get pregnant again?
If you have had ICP in a previous pregnancy, you have a high chance (up to 90%) of developing it again. It’s a good idea to tell your midwife about your medical history as soon as you can in your next pregnancy, so they can make sure you get the care you need.
More support and information
ICP Support provides information and support to people affected by ICP and funds research into the condition.
Here’s more research on the importance of regular testing for people with ICP:
Geenes V, et al (2014) Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: a prospective population-based case-control study. Hepatology 2014; First published online 26 February 2014; DOI: 10.1002/hep.26617
Glantz, A et al (2004) Intrahepatic cholestasis of pregnancy: Relationships between bile acid levels and fetal complication rates. Hepatology, Volume 40, Issue 2, Pages 467–474. (DoI: 10.1002/hep.20336)
Abedin P, Weaver JB, Egginton E. Intrahepatic cholestasis of pregnancy: prevalence and ethnic distribution. Ethn Health. 1999 Feb-May;4(1-2):35-7. doi: 10.1080/13557859998173. PMID: 10887460.
Dixon PH, Williamson C. The pathophysiology of intrahepatic cholestasis of pregnancy. Clin Res Hepatol Gastroenterol. 2016 Apr;40(2):141-53. doi: 10.1016/j.clinre.2015.12.008. Epub 2016 Jan 25. PMID: 26823041.
Royal College of Obstetricians & Gynaecologists (2012) Obstetric cholestasis https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-obstetric-cholestasis.pdf
Geenes V, Williamson C. Intrahepatic cholestasis of pregnancy. World J Gastroenterol. 2009;15(17):2049–2066. doi:10.3748/wjg.15.2049
ICP Support www.icpsupport.org/symptoms
NHS. Itching intrahepatic cholestasis of pregnancy. https://www.nhs.uk/conditions/pregnancy-and-baby/itching-obstetric-cholestasis-pregnant/ (Page last reviewed: 2 August 2019 Next review due: 2 August 2022)
Wikström Shemer EA, Stephansson O, Thuresson M, Thorsell M, Ludvigsson JF, Marschall HU. Intrahepatic cholestasis of pregnancy and cancer, immune-mediated and cardiovascular diseases: a population-based cohort study. J Hepatol 2015; 63(2): 456–61.
Clinical Knowledge Summaries. Itch in pregnancy. https://cks.nice.org.uk/itch-in-pregnancy (Page last reviewed: July 2015 Next review due: December 2020)