What Is Intrahepatic Cholestasis of Pregnancy?
Intrahepatic cholestasis of pregnancy (ICP), also called cholestasis of pregnancy, is the most common liver condition that occurs during pregnancy. The liver is the largest organ in the body. It helps the body store energy, digest (break down and use) food, and remove harmful substances. In addition, the liver generates a fluid called bile that helps break down fats and helps the liver eliminate poisonous substances and waste. Intrahepatic cholestasis of pregnancy (ICP) slows the normal flow of bile, leading to the build-up of bile in the liver. Bile buildup can cause chemicals called bile acids to enter the blood and tissues, leading to severe itching.
ICP happens most commonly during the third trimester, but some women may have severe itching earlier in pregnancy.
What Problems Does ICP Cause During Pregnancy and After Birth?
ICP can cause the following complications in the mother and the baby-
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Premature Birth- This is a condition in which the birth happens too soon, before 37 weeks of pregnancy. Premature-born babies have more health complications or need to stay in the hospital for a more extended period than babies born later.
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Stillbirth- This condition refers to the death of the baby in the womb after 20 weeks of pregnancy.
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Fetal Distress- This is the condition of lack of oxygen supply to the baby in the womb. Signs of fetal distress include lesser fetal movement (movement of the baby less often than usual), changes in the heart rate of the baby, and the passing of meconium by the baby. Meconium is the first bowel movement of the baby. Meconium is usually passed after birth, but in fetal distress, the baby may pass meconium into the amniotic fluid that surrounds him in the womb before or during labor and delivery.
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Meconium Aspiration- This is when a baby develops breathing problems after breathing in amniotic fluid with meconium. This can lead to blockage of the airways.
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Respiratory Distress Syndrome (RDS)- RDS is a breathing problem in newborns whose lungs have not yet fully developed. Babies with RDS lack enough surfactant that helps the lungs fill the air and prevents the tiny air sacs in the lungs from collapsing. RDS is commonly seen in premature babies.
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Postpartum Hemorrhage (PPH)- This is a serious but rare condition that causes heavy bleeding post-delivery.
What Causes ICP?
The exact cause of ICP is unknown, but genes and pregnancy hormones may have a role to play. Genes are present in the cells of the body that carries hereditary information and instructions for how the body grows, looks, and works. Genes get passed on from parents to children. During the last trimester of pregnancy, there is more production of the pregnancy hormones estrogen and progesterone. This increase in the hormone level may slow the bile flow out of the liver.
What Are the Risk Factors of ICP?
Some women may be at a higher risk of developing ICP if they-
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Previously had ICP during the first pregnancy. More than half of women with ICP tend to develop it again in another pregnancy.
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Have a family history of ICP. It is more common in some families, so it is best to inform the healthcare provider if there is a history of ICP in the family.
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Previously had liver disease, like hepatitis C. It is caused by the hepatitis C virus that causes swelling of the liver. Hepatitis C usually spreads through infected blood. However, it can also spread through unprotected sex with an infected person or from mother to baby during delivery.
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Have genetic changes (mutations) in the ABCB11 or ABCB4 gene. These genes help the body with the production and use of bile. This gene mutation can occur on its own or be passed from parents to children.
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When pregnant with multiples, the estrogen levels may be higher than if pregnant with just one baby.
What Are the Signs and Symptoms of ICP?
Signs and symptoms of ICP range from mild to severe and may start in the second or third trimester of pregnancy. ICP signs and symptoms include the following:
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The most common symptom of ICP has severe itchy skin. The itching may occur all over the body, but it may be most severe on the palms of the hands and the bottom of your feet. The itching may worsen at night, interrupting and making it hard to sleep.
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Dark-colored urine or light-colored bowel movements.
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Jaundice is a condition that causes the eyes and skin to appear yellow. It occurs when the liver is not working well and leads to the excess of a substance called bilirubin in the blood.
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Loss of appetite (not feeling hungry enough).
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The feeling of nausea or pain in the upper right side of the belly.
To check for ICP, the healthcare provider may perform a physical exam and order a blood test. The blood test detects the number of bile acids and other chemicals in the blood, showing how well the liver works.
How Is ICP Treated?
For the treatment of ICP, the healthcare provider may prescribe medicines such as Ursodiol. Ursodiol helps relieve itchy skin, lowers the number of bile acids in the blood, and may help reduce the risk of the baby having complications caused by ICP. Doctors usually ask to avoid using over-the-counter medicines like antihistamines, corticosteroid creams, or lotions to help relieve the symptom of severe itching. Antihistamines treat symptoms of allergy, like itchy eyes or skin rashes. However, these antihistamines, corticosteroid creams, and lotions may harm the baby during pregnancy. Soaking in a lukewarm water bath may also help relieve itching symptoms.
Once diagnosed with ICP, the healthcare provider may order the following tests to monitor the baby-
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Amniocentesis- This test checks congenital disabilities and genetic conditions that may be present in the baby. The provider may use ultrasound to check the amniotic fluid for meconium (early stool passed by a newborn soon after birth) or to detect whether the baby's lungs are developed for birth.
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Fetal Heartrate Monitoring- This test checks the baby's heart rate in the womb and looks for any changes in the heart rate when the baby moves. This test is done to ensure that the baby is getting enough oxygen.
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Biophysical profile (BPP)- This test combines fetal heart rate monitoring with an ultrasound. The provider can use BPP to measure amniotic fluid in the womb and check the muscle tone and movements of the baby.
The healthcare provider may also recommend inducing labor to help prevent complications like stillbirth. This is done with the help of medicines or breaking the water (amniotic sac) to begin the labor.
Conclusion
Intrahepatic cholestasis of pregnancy is a liver condition most commonly seen during the third trimester of pregnancy. It can lead to premature birth, stillbirth, and a few other pregnancy complications which may affect both the mother and the baby. Treatment includes prescription medications to relieve the symptoms and monitoring the baby throughout pregnancy. In addition, to prevent stillbirth, doctors may recommend inducing the labor earlier.
