Intrahepatic cholestasis of pregnancy (ICP)

Several factors may increase the likelihood of developing ICP or worsen the condition, including:

• Previous history of ICP: Women who have had intrahepatic cholestasis of pregnancy in a prior pregnancy are more likely to experience it again, with a recurrence rate exceeding 80% in subsequent pregnancies.
• History of Hepatitis C: Hepatitis C infection can raise the risk of ICP, as both conditions impact liver function, and the inflammation and changes in liver activity may contribute to cholestasis.
• Gallstones (Cholelithiasis): Gallstones can disrupt the normal flow of bile, which can contribute to the development of cholestasis and heighten the risk of ICP.
• Multiple Pregnancies: Women carrying multiples, such as twins or triplets, face a greater risk of developing ICP compared to those pregnant with a single fetus.
• Environmental factors: ICP diagnoses are more common during the winter months, suggesting that factors like reduced sunlight exposure or dietary changes may trigger the condition.
• Assisted Reproduction: Women who conceive using assisted reproductive techniques are at a higher risk of developing ICP compared to those who conceive naturally.
• Maternal age: Some research suggests that advanced maternal age may be a risk factor for developing ICP.

Diagnosing ICP typically involves a thorough evaluation that combines clinical assessment, lab tests, and sometimes imaging studies:

Clinical Assessment:

A healthcare provider will assess the patient’s medical history and symptoms, which often include intense itching (pruritus), particularly on the palms and soles of the feet. The itching is typically severe and may worsen during the night.

Blood Tests:

• Liver Function Tests (LFTs): Such as Alanine transaminase (ALT) and Aspartate transaminase (AST)
• Bile Acid Levels
• Serum Bilirubin Levels
• Complete Blood Count (CBC)
• Autotaxin and diagnostic markers

Coagulation Profile:

Tests like Prothrombin Time (PT) and International Normalized Ratio (INR) are used to assess blood clotting.

Imaging Studies:

An ultrasound may be conducted to evaluate the liver and gallbladder and to rule out other liver dysfunction causes.

While there is no guaranteed way to prevent ICP, early intervention can help manage the condition and its effects. Here are a few preventive strategies:

Consulting a Doctor:

If you have a family history of ICP or liver conditions, consulting an OB-GYN before pregnancy allows for a risk assessment and tailored guidance.

Early Prenatal Care:

Begin prenatal care as soon as pregnancy is suspected. Early and regular check-ups are crucial for detecting and addressing any potential issues promptly.

Avoid Alcohol and Harmful Substances:

Avoid alcohol and substances that could harm the liver or overall health during pregnancy.

Monitor Symptoms:

Be mindful of symptoms such as intense itching, dark urine, pale stools, or jaundice. If any of these arise, seek medical attention immediately.

Monitor Baby’s Movement:

Pay attention to your baby's movements. A reduction in fetal activity warrants consultation with a healthcare provider, who may recommend more frequent fetal monitoring via ultrasounds or non-stress tests.

Avoiding Triggers:

Identify and steer clear of triggers like heat, stress, or certain fabrics that might exacerbate itching, helping to alleviate discomfort.

Doctor to Visit

If you experience symptoms like severe and persistent itching, especially on the palms and soles, dark urine, pale stools, or jaundice (yellowing of the skin and eyes), consult your gynecologist without delay.

Specialists who can assist in the prevention and management of ICP during pregnancy include:

• General Physician
• Obstetrician & Gynecologist
• Gastroenterologist
• Hepatologist

An obstetrician & gynecologist manages the pregnancy, monitors the health of both mother and baby, and oversees the delivery. They assess risks, recommend treatments, and ensure a safe delivery.

A gastroenterologist specializes in digestive health and plays a key role in diagnosing and managing liver-related issues, offering dietary advice, and working alongside the obstetric team.

A hepatologist focuses on liver diseases. They assist in diagnosing and treating liver problems related to cholestasis, prescribing necessary medications, and guiding liver health during pregnancy.

Managing ICP involves a combination of treatments aimed at relieving symptoms, preventing complications, and safeguarding the health of both mother and baby. Key management strategies include:

Medications:

• Antihistamines: Drugs like Hydroxyzine or diphenhydramine can help reduce itching.
• Bile Acid Sequestrants: Ursodeoxycholic acid (UDCA) is commonly prescribed to lower bile acid levels and improve liver function.
• Other Medications: Rifampin, cholestyramine, and S-adenosyl-L-methionine can also be used.

Vitamin K Supplementation:

Since ICP can impair vitamin K absorption, supplementation may be advised to support proper blood clotting. The dosage and form (oral or intravenous) depend on individual needs.

Topical Treatments:

Topical options like sorbolene lotion, Pinetarsol solution, aqueous cream with 2% menthol, or bicarbonate of soda baths may provide relief from itching and other skin-related discomforts.

Post-Delivery Management

After childbirth, managing ICP continues to be important:

Resolution of Symptoms:

• After delivery, itching and jaundice typically subside as the placenta is removed. Jaundice usually resolves within a week, and itching improves in a few days.

Six-Week Follow-Up:

• Follow-up appointments should include bile acid and liver function tests to ensure normal liver function. Women who had gestational diabetes should also undergo a glucose tolerance test.

Persistent Liver Issues:

• If liver abnormalities persist six weeks postpartum, further testing may be necessary to exclude other liver diseases.

Breastfeeding:

• Most women with ICP can breastfeed safely, though it’s essential to consult a doctor if medications are being used to ensure it’s safe.

Long-Term Monitoring:

• Periodic liver function tests may be recommended to monitor ongoing liver health.

Is Hormonal Contraception Safe for Women with ICP?

Yes, hormonal contraception is generally considered safe for women with a history of ICP. However, if itching reoccurs while using hormonal contraception, further evaluation is needed. If liver function is abnormal, alternative contraception methods may be suggested.

ICP can have serious implications for both the mother and the fetus. Here are some potential complications:

Maternal Complications:

• Increased Risk of Preterm Labor: ICP is associated with a higher risk of preterm labor, particularly in women who have had previous episodes of ICP or multiple pregnancies.
• Postpartum Hemorrhage (PPH): Although rare, postpartum hemorrhage, which involves excessive bleeding after delivery, may occur more frequently in women with ICP.

Fetal Complications:

• Preterm Birth: ICP increases the likelihood of preterm birth, which can result in respiratory distress syndrome and developmental challenges for the baby.
• Stillbirth: The risk of stillbirth is higher in women with ICP, possibly due to bile acid accumulation affecting placental function and causing fetal distress.
• Fetal Distress: High levels of bile acids in the mother’s bloodstream can interfere with fetal heart rate patterns, potentially leading to fetal distress.
• Meconium Passage: Stress caused by ICP may lead to the fetus passing meconium into the amniotic fluid. This can lead to meconium aspiration syndrome, where the baby inhales meconium-stained fluid, potentially causing respiratory issues.
• Neonatal Breathing Problems: Elevated bile acid levels in the mother can impair surfactant production in the fetus, leading to respiratory distress syndrome (RDS) in the newborn. This may necessitate respiratory support after birth.

Note: Recent studies suggest that extremely high bile acid levels can alter the baby’s heart rhythm, potentially leading to arrhythmias or, in extreme cases, causing the heart to stop.

Managing stress is essential for pregnant women with Intrahepatic Cholestasis of Pregnancy (ICP), as stress can worsen symptoms. Here are some complementary approaches to reduce stress:

Meditation and Positive Affirmations

• Regular meditation helps to maintain calm and focus, while positive affirmations can improve confidence and positivity, reducing stress and fostering a sense of control.

Distraction and Relaxation Techniques

• Engage in activities like reading, watching movies, or practicing relaxation methods such as deep breathing and prenatal yoga to shift attention away from itching and discomfort.

Exercise

• Gentle activities like walking or swimming can elevate mood by releasing endorphins, improve circulation, support muscle health, and enhance sleep quality. Always consult your doctor before starting any exercise routine, especially if you have ICP.

Essential Oils

• Aromatherapy with essential oils can help create a soothing environment. You can diffuse the oils or apply them topically, but it is important to consult your healthcare provider before using them to ensure safety.

Note: Different individuals respond to stress management techniques in various ways. Always consult your doctor to confirm that these methods are suitable for your health and pregnancy.

Managing ICP effectively at home involves various strategies aimed at alleviating symptoms and supporting liver function. Here are some natural remedies and practical home care tips:

Natural Remedies:

Milk Thistle

• Milk thistle, rich in the antioxidant compound silymarin, is known for its liver-supportive and detoxifying properties. It is commonly available in tablet, capsule, or powder forms.

Dandelion

• Dandelion is often used to promote liver and gallbladder health and improve digestion. Its diuretic effects may aid liver detoxification.

Apple Cider Vinegar

• Apple cider vinegar is sometimes recommended for its potential health benefits. Be sure to dilute it properly to avoid irritation from its acidity.

Water-Soluble Prenatal Vitamins

• Prenatal vitamins are essential during pregnancy to ensure adequate nutrient intake. Choose a trusted brand and consult your healthcare provider before using any supplements.

Fresh Raw Fruits, Sun-Dried Fruits, and Berries

• A diet rich in fresh and sun-dried fruits, along with berries, provides valuable nutrients and fiber. Be sure to wash fruits thoroughly to reduce the risk of contamination.

Guar Gum

• Guar gum may help reduce itching associated with ICP, although it may only offer partial relief from cholestasis symptoms.

Home Tips for Managing ICP Symptoms:

Anti-Itch Medications

• Consult with your doctor about potential treatments for itching, such as antihistamines or bile acid-binding resins. Always seek professional advice before introducing any new medication during pregnancy.

Diet

• Maintaining a balanced diet that is rich in fiber and nutrients is important. Avoid fatty and fried foods, as they can worsen liver symptoms. Staying hydrated is also crucial.

Clothing

• Wearing loose, soft clothing can help minimize irritation and discomfort caused by itching.

Rest

• Ensure adequate rest to help reduce stress and discomfort, which may ease ICP symptoms.

Warm Baths

• A warm bath can offer temporary relief from itching, but avoid hot water, as it may aggravate the itching for some women.

Monitoring Bile Levels

• Regular blood tests to track bile acid levels and liver function are essential for assessing the severity of ICP and guiding treatment options.

Early Birth

• If other treatment options are ineffective, early delivery around 37 to 38 weeks may be considered to reduce risks, such as stillbirth. In some cases, a cesarean section may be recommended if labor induction is not possible.