Obstetric cholestasis/Intraheptic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis (OC), is a liver disorder that can develop during pregnancy.

Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis (OC), is a liver disorder that can develop during pregnancy. It is uncommon, affecting 1 in 140 pregnant women (0.7%). Mothers whose family birth origins are India or Pakistan have a slightly higher risk (1-2%).

ICP is caused by a build-up of bile acids and other substances in the liver, which then ‘leak’ into the woman’s bloodstream. It is diagnosed by looking for a raised level of bile acids in the blood.

It is most common for ICP/OC to develop after 28 weeks of pregnancy but it is possible for it to happen as early as week 8 of pregnancy.

Although it the itching can be very uncomfortable and it can be frightening to be diagnosed, most women who have ICP have a healthy baby.

Symptoms of intrahepatic cholestasis of pregnancy/ obstetric cholestasis

Itching during pregnancy

The main symptom of ICP/OC is itching, usually without a rash.

  • This is often more noticeable on the palms of the hands or the soles of the feet although it can be anywhere on the body.
  • Typically, the itching is worse at night.
  • It can range from mild to severe but more severe itching does not mean you have a worse case of the disorder.

Dark urine is also usually present in many cases.

If you have itching as described above tell your midwife or doctor promptly.

Other less common symptoms of ICP/OC

Other less common symptoms that not all women will have include:

  • pale stools (poo) 
  • jaundice (noticeable by yellowing of the skin or whites of the eyes) 
  • pain in the area around the liver (Right Upper Quadrant Pain). It is most commonly felt under the ribs on the right side. Less commonly it can be felt radiating to a spot in the back under the right shoulder
  • tiredness.

If you have these symptoms see your midwife or doctor.

Is intrahepatic cholestasis of pregnancy / obstetric cholestasis serious?

ICP/OC is a serious condition but with treatment and monitoring most women go on to have a healthy baby, and the itching goes away afterwards.

For you, the constant itching is not harmful but when it is severe it can be very difficult to live with (see more below), especially if it prevents sleep. Some women report feeling anxious because of the concerns of the condition, the need for extra hospital appointments and as a result of sleep disruption from the itching. If so, the information on this page may help you.

ICP/OC and premature birth

If you have intrahepatic cholestasis of pregnancy, there is a higher risk of the baby being born prematurely. About 1 in 10 women diagnosed will have their baby before full term (37 weeks). This figure, however, includes women who have their labour induced because of ICP/OC. It is thought that it happens spontaneously (without being induced) in around 4-10% of ICP/OC pregnancies. Be aware of the signs of preterm labour and if you have them seek medical attention immediately.

ICP/OC and stillbirth

There is evidence that women who have been diagnosed with ICP/OC are at higher risk of having a stillborn baby (thought to be between 1 and 4%). With active management (treatment, ongoing tests and monitoring) and early delivery though, the risk may be lessened.

Because of this your doctor might advise you to have your labour induced if your bile acids go over 40 µmol/L. Bile acids above this concentration have been shown to be associated with a higher risk of stillbirth. They will discuss the pros and cons with you if so.

ICP/OC and meconium

There is also a higher risk that the baby may pass meconium (first poo) during the pregnancy or labour, which can cause breathing problems for them.

These factors also mean that there is also a higher likelihood that your baby may need to be admitted to the neonatal unit.

Causes of intrahepatic cholestasis of pregnancy/obstetric cholestasis

ICP/OC occurs when there is a reduced flow of bile down the bile ducts in the liver.

  • Bile is a fluid that is made by the liver that helps with digestion.
  • The reduced flow causes the bile acids to leak out into the bloodstream.

We don’t know why ICP/OC happens but it is thought to be affected by three factors:

  • Hormones: Pregnancy hormones such as oestrogen and progesterone are thought to affect how the liver works

  • Genetics: ICP/OC is more common in families and certain ethnic groups, such as South America, India or Pakistan.

  • Environment: ICP/OC is more common in the winter months, which is why dietary factors may be involved including lack of vitamin D and selenium (a nutrient found in certain foods) levels.

ICP/OC often happens again in a following pregnancy but not always.

Diagnosis of intrahepatic cholestasis of pregnancy/obstetric cholestasis

If you go to your midwife or doctor with symptoms of ICP/OC you should have blood tests to check if you have the condition.

These tests will check for ICP/OC as well as other causes of itching.

Blood tests for ICP/OC

Bile acid test – In ICP bile acids leak into the bloodstream. A bile acid test is believed to be the most specific test for ICP. Different hospitals have different ranges for the 'normal' level of bile acids in the blood. Some use 0-10 µmol/L  and some use 0-14 µmol/L. Depending on which range your hospital uses, anything above the upper number supports a diagnosis of ICP.

If your blood results come back as normal but the itching continues then it is important to have the tests again because the itching can happen before ICP/OC shows up in tests.

Liver function test (LFT) – This blood test looks at how well the liver is working (how your body is coping) by measuring the levels of different enzymes. The key enzymes that are measured are ALT (alanine transaminase) and AST (aspartate transaminase). Research has shown that these sometimes rise before the bile acids so if these are raised but the bile acid test is normal then you should be tested again.

Sometimes bile acids can be abnormal while the ALT or AST remains normal. If your doctors have excluded all other causes of itch then the diagnosis of ICP still remains. However, it is also possible for your ALT/AST to be raised but with normal bile acids. In this instance ICP would not be diagnosed but it is important for your bile acids to continue to be tested if you are still itching.

Treatment of intrahepatic cholestasis of pregnancy/obstetric cholestasis

Dealing with itchy skin in pregnancy

The itching can be persistent and can affect your sense of wellbeing, especially if it prevents you from sleeping. 

Women have told us that use of aqueous creams with menthol can be soothing and give relief but they cannot help improve bile acids or liver function. Chlorpheniramine (Piriton) may be prescribed by your doctor. Although again there is little evidence on how effective this is in reducing the itching, some women have reported that it has helped. It may help you sleep as it causes drowsiness.

Other steps that are not proven to be effective against the condition but could help your sense of wellbeing are:

Counselling or talking therapies can also help if you are feeling very anxious about the condition.

Your care during pregnancy with ICP/OC

Once diagnosed specialists recommend that your pregnancy be under the care of a consultant led team.

There is no cure for ICP/OC but ursodeoxycholic acid (UDCA) is often prescribed. This sometimes improves the itching and liver function/bile acid levels (which may benefit you and the baby) but researchers are still trying to find out if it’s the best drug there is for women with the condition. Many researchers do think it helps to protect the baby but they are still working to prove this. It is not licensed for use in pregnancy but there is no evidence that it is harmful to the baby and has been given to many thousands of women in pregnancy.

The main treatment is to monitor your pregnancy carefully. During the pregnancy:

  • blood tests (LFTs and bile acid tests) should be offered weekly or more frequently, depending on the stage of pregnancy and the results of the previous test.
  • the baby’s heartbeat may be monitored using a CTG machine. This cannot predict complications, but it can provide some reassurance.

If you are not offered weekly blood tests, you can request them and use the following research to justify your request:

  • Geenes V, Chappell LC, Seed PT, Steer PJ, Knight, M, Williamson C 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
  • Anna Glantz, Hanns-Ulrich Marschall and Lars-Åke Mattsson (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)

They are both available to download from http://www.icpsupport.org/download.shtml

If you have intrahepatic cholestasis of pregnancy/obstetric cholestasis it is really important for you to monitor your baby’s movements and if there is any change or reduction in movements from the usual pattern report it promptly to your midwife or hospital.

Labour and birth with obstetric cholestasis/intrahepatic cholestasis of pregnancy

Your doctor may advise you to have your labour induced early. This will depend on:

  • your blood tests
  • how you are coping with the itching
  • how well your baby is doing.

As you have a very small extra risk (1-4%) of having a stillborn baby. your doctor might advise you to have your labour induced if bile acids go over a certain limit (40 µmol/L).

They will discuss the pros and cons with you if so.

There is also a higher risk that the baby may pass meconium (first poo) during the pregnancy or labour, which can cause breathing problems for them.

This means there is an increased likelihood that your baby may need to be admitted to the neonatal unit.

You have a small increased risk of slightly higher blood loss when giving birth.

If you are writing your birth plan keep in mind that your pregnancy complication means you may be advised not to have a water birth or home birth. 

Intrahepatic cholestasis of pregnancy/ obstetric cholestasis after the birth

Most women can stop taking UDCA immediately after their baby has been born. However, we know from speaking to specialists in ICP, that a very small number of women have had to remain on UDCA where there bile acids have been in the hundreds, and then have the dosage gradually reduced to taking nothing after a week or two. You may want to do discuss this with your doctor to see what they usually do. 

The causes of ICP/OC usually self-correct without any extra treatment when you have had your baby. You should have a blood test 6-12 weeks after the baby has been born to be sure. If by six months your levels have not returned to normal then you should have more tests for other possible liver conditions.

Researchers have now also shown that ICP may have longer term implications for women such as an increased risk of developing gallstones and Type 2 diabetes. It’s probably a good idea for you to have an annual check on your liver and your sugars (glucose) and these are very simple blood tests that your GP can help you with.

Read more: Myths about itching and ICP/OC:
Read more: Support and information for sufferers of ICP/OC

Sources

RCOG (2012) Obstetric cholestasis, Information for you. Royal College of Obstetrics and Gynaecologists, London https://www.rcog.org.uk/globalassets/documents/patients/patient-informat...

RCOG (2011) Obstetric Cholestasis, Green top guideline No 43. Royal College of Obstetrics and Gynaecologists, London https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg43/

NHS Choices (accessed Nov 2016, Next review date: 25/07/2018) Itching and intrahepatic cholestasis of pregnancy. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/itching-obstetric-...

Ovadia C, Williamson C (2016) Intrahepatic cholestasis of pregnancy: Recent advances, Clinics in Dermatology, 34, 327–334
Williamson C, Geenes V (2014) Intrahepatic cholestasis of pregnancy. Obstet Gynecol 2014; 124:120–133.

Geenes V, Chappell LC, Seed PT, Steer PJ, Knight M, Williamson C (2014) Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: A prospective population-based case-control study. Hepatology; 59: 1482–91

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