Intrahepatic Cholestasis of Pregnancy (ICP)

A complication during pregnancy is a random event and can happen to any pregnant woman at any time during pregnancy. One such highly unpredictable pregnancy complication is intrahepatic cholestatis of pregnancy, abbreviated as ICP.

What is Intrahepatic Cholestatis of Pregnancy?

Under normal conditions, liver secretes an important fluid called the bile. Bile produced in the liver is transported to the gall bladder where it is stored until digestion of food in the stomach begins. From gall bladder, bile is released into the digestive tract where it digests fats in the food and aids in the absorption of fat breakdowns in the small intestine.

In intrahepatic cholestatis of pregnancy, bile produced in the liver, for some unknown reason, doesn’t leave the liver. It gets accumulated in the liver and excess bile is spilt into the bloodstream. As a result, the normal functioning of liver is disturbed, leading to high levels of bile acids in the blood and pruritus-like itching all over the body.

This condition is referred to as intrahepatic cholestatis because the flow of bile is obstructed within the liver. Another condition where bile gets released from the liver but its flow gets blocked from reaching the gall bladder is called extrahepatic cholestatis. It must be noted that ICP happens only during pregnancy and usually the flow of bile returns back to normal soon after delivery.

What are the symptoms of ICP?

The most common symptom of intrahepatic cholestatis of pregnancy is itching sensation, initially on the insides of the palms and feet, and may later spread to other areas including the belly.

Occasionally, there could be mild pain in the right abdomen just below the ribs – the area around the liver and gallbladder.

Other symptoms include:

·         Light-colored stool

·         Darker urine

·         Tiredness

What Causes ICP?

·         The exact cause of ICP is still under research. Some studies show that pregnancy hormones, estrogen and progesterone slow down the flow of bile out of the liver.

·         A genetic link has been found to be associated with ICP. Two genes have been found to be responsible for the synthesis of a protein which helps in releasing bile out of the liver. Changes in these genes may lead to impaired bile flow. Thus, women of common ancestry or closely related to another woman who developed ICP carries higher chances of getting ICP.

·         The risk of ICP is higher in certain genetic groups than others, such as Northern European and Indian women.

·         Women with previous history of liver problems carry higher risk of getting ICP during pregnancy.

·         If ICP had occurred in first pregnancy, there is up to 90% chances to get it again in the subsequent pregnancy.

How is ICP diagnosed?

When a pregnant woman consults a doctor for sudden onset of itching in late pregnancy, she will be advised to undergo a blood test. Blood tests testing positive for the following indicate ICP:

·         Bile acid above 10µmol/L

·         Higher levels of liver enzymes (from a liver function test), namely, ALP and ASP

How does intrahepatic cholestatis of pregnancy affect the mother and baby?

·         In the mother, ICP causes mild to severe itching. In worst cases, itching can lead to lack of sleep and depression.

·         The pregnant mother may develop a deficiency in Vitamin K, causing loss of blood during childbirth.

·         In the baby, ICP can induce premature labor, and in worst cases, may lead to stillbirth.

·         ICP may cause premature water breaking, release of meconium (the first poo) inside the womb, which can lead to serious breathing difficulty in the baby.

How is intrahepatic cholestatis of pregnancy treated?

·         The most common treatment of itching due to intrahepatic cholestatis of pregnancy is the application of topical ointments which contain corticosteroids.

 

·         Ursodeoxycholic acid is a common medicine prescribed for pregnant women with ICP. Most often, the medicine needs to be continued until delivery.