Intrahepatic Cholestasis of Pregnancy

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A Layperson's guide to Intrehepatic Cholestasis of Pregnancy, or Obstetric Cholestasis

Itching has long been considered to be a common symptom of pregnancy. The vast majority of times, itching, or pruritis is a minor annoyance caused by changes to the skin, especially that of the abdomen. However, there are instances when itching is a symptom of a condition called Intrehepatic Cholestasis of Pregnancy (ICP), or Obstetric Cholestasis.

Hallmarks of ICP include the following symptoms:

• Itching of the palms of the hands and soles of the feet without presence of a rash
• Itching that increases in the evening
• Darker urine
• Lighter stools
• Increased clotting time
• Fatigue
• Increased Nausea
• Decrease in appetite
• Jaundice
• Premature labor

It is important to note that not all ICP sufferers have all of the above symptoms. For example, Jaundice only occurs in relatively small subset of cases.

Consequences of ICP

Maternal consequences include:

• Itching, which can become intense and debilitating
• Premature labor
• Deranged clotting, which requires Vitamin K

Fetal consequences include:

• Stillbirth
• Meconium ingestion
• Meconium Aspiration Syndrome

Delivery before the beginning of the 38th week is considered to be crucial for the best fetal outcome.

Do I have ICP?

If you are pregnant and read about this condition, you may wonder how to determine if you have it. Everyone does itch from time to time, and the question becomes how to tell when an itch is a serious one. If you feel that you are experiencing any of the following scenarios, you should contact your OB/GYN or doctor with the information given below.

Case One

31 year old female, experiences itching in her hands and feet which is worse at night. It becomes noticable to her because she finds she is taking off her shoes at work to rub her feet on the floor, and is "scrubbing" her feet together at night due to the itching. She finds she is digging into her hands with her fingernails. She is 26 weeks pregnant, and presents to her OB/GYN with these symptoms. Having read a magazine article that describes ICP, she asks for a Liver Function Test to see if her LFT values are normal or abnormal. The LFT comes back with both ALT and AST numbers elevated. Bilirubin is normal, patient is not jaundiced. Initially, she is prescribed an antiparasitic cream, often used for scabies infection to deal with the itching.

Upon further research, patient reads that Ursodeoxycholic Acid is the recommended treatment for ICP and requests that instead of topical cream. Through the remainder of her pregnancy, she goes for regular non stress tests and then is delivered of a healthy female at 37 weeks. Unfortunately, what was not noticed in blood tests was that as a consequence of the ICP, the patient has deranged clotting, or an impaired ability to clot. Upon delivery, she has a post partum hemorrhage of approximately 2.5 liters, which is resolved using hemabate, erometrine, uterine massage and compression, and a transfusion. In this instance, clotting tests should have been performed and Vitamin K supplements given. Mother's condition resolves within one week of delivery.

Case Two

33 year old female with previous history of ICP experiences itching similar to that in Case One. Itching is worse at night, and patient resorts to biting hands and scratching with sharp objects, including forks and knives. Patient reports some relief obtained when she scratches her feet on a fake grass welcome mat or on gravel. It is observed that she has bruised herself while scratching. Itching begins at 16 weeks, and her LFT returns abnormal ALT and AST levels, normal bilirubin low blood sodium, raised creatinine, and deranged clotting is noted at 24 weeks. Patient is given Ursodeoxycholic Acid and Vitamin K. Initial Serum Bile Acid tests are normal, further Serum Bile Acid tests return as elevated. Patient is given Dexamethasone at 33 weeks to mature the infant's lungs, and is delivered at 34 weeks via induction using prostin only as a cervical ripening agent. The infant male suffers briefly from grunting and recessed breathing, but is otherwise healthy and is able to leave NICU within four days and go home. Patient experiences a slightly increased post partum bleed of 300ml, but no other consequences, and condition resolves fully within one week.

Case Three

36 year old female with previous history of ICP reports itching of the palms and soles, dark urine, and lighter stools in the 8th week of pregnancy. LFT returns with elevated ALT and AST. After discussion with the Perinatologist, Ursodeoxycholic Acid is prescribed. Follow up LFT one week later shows a large improvement in LFT, with ALT values dropping from 114 to 27, and AST dropping from 60 to 17. Serum Bile Acid test returns well within the laboratory's normal range at 4.7. Patient reports a cessation of pruritis that week, but states that itching has returned the week after. A potential contributing factor to the early onset in this case may be progesterone supplements, prescribed in week 6, 200mg twice daily. This case is still ongoing.

I itch, what do I do?

If you are pregnant, regardless of the trimester, and experiencing itching on your palms and soles without a visible rash, you will need to contact your health care provider and inform them that you believe you may have ICP (or in the UK, Obstetric Cholestasis). To obtain a diagnosis of ICP, you will need to have a Liver Function Test, or LFT performed. This is a simple blood test, the results of which should be available by the next day. If your ALT level is elevated, this, plus pruritis of palms and soles, should be treated as diagnostic of ICP.

ICP occurs most commonly in the third trimester, but can begin at any time during the pregnancy. Upon diagnosis, most providers will prescribe Ursodeoxycholic Acid. However, some will prescribe Cholestyramine. While there is no cure for ICP, and no way to guarantee a successful outcome, studies have shown a slightly better fetal and maternal outcome from administration of Ursodeoxycholic Acid, whereas Cholestyramine appears to only relieve itching.

Additional issues to consider include checking clotting function on a regular basis to avoid risk of hemorrhage at delivery, and the necessity of early delivery. Delivery before the beginning of the 38th week is considered crucial to fetal outcome.

Summary

If you experience itching of the palms and soles, especially at night:

• Get an LFT performed.

If your ALT level is elevated:

• Ask your doctor to discuss prescribing Ursodeoxycholic Acid
• Ask your doctor to watch your clotting, and prescribe Vitamin K if necessary
• Ask your doctor to consider delivering before 38 weeks
• Ask your doctor to have you return for repeated bloodwork on a regular basis, and for non stress tests
• Ask your doctor to consider ordering a Serum Bile Acid test

Other Resources

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