Intrahepatic Cholestasis of Pregnancy is a condition in which the normal flow of bile is affected by the increased amounts of pregnancy hormones.
Cholestasis is more common in the last trimester of pregnancy when hormones are at their peak.
Cholestasis occurs in about 1 out of 1,000 pregnancies but is more common in Swedish and Chilean ethnic groups.
Intrahepatic Cholestasis of Pregnancy (ICP) is a liver disorder which occurs during pregnancy. This condition affects the normal flow of bile. Bile acids are chemicals in the bile of the liver that help with digestion. With ICP the bile flow begins to slow down in tern the bile acids build up in the blood. This results in the woman itching that can vary in severity and type. The itching can be bothersome to severe itching and is often worse at night. There is rarely jaundice when experiencing this condition. Although it has been reported as early as a few 8 weeks pregnant, it is more common for it to begin in the third trimester, when hormone concentrations are at their highest levels. The figure for the percentage of women for whom Intrahepatic Cholestasis of Pregnancy will recur in future pregnancies is 60% or as high as 90% for severe ICP.
Who is at risk for ICP?
Overall, 1 to 2 pregnancies in 1000 is affected by ICP in the USA with Latina populations at 5.6%. Women carrying multiples, women who have had IVF treatment also appear to have a higher risk and those who have had previous liver damage or issues may be more likely to develop. The incidence of ICP also shows a striking geographical pattern, with a higher prevalence in Scandinavia and South America specifically Chile where the reported prevalence is as high as 15.6%. Mothers and sisters of patients are also at higher risk of developing the condition, proving that there is a definite genetic predisposition.
What are the risks?
ICP poses several risks that are of great concern. It is associated with an increased risk of stillbirth (intrauterine fetal demise), premature labor, fetal distress, meconium staining and maternal hemorrhaging. The risk of stillbirth in an ICP pregnancy is believed to be the same as that of a pregnancy with no complications (1%) with active management (which usually means treatment- Medicine-Ursodeoxycholic acid and choosing to deliver early).
Compromised condition of the fetus, usually discovered during labor, characterized by a markedly abnormal rate or rhythm of myocardial contraction. Some patterns, such as decreased movements, meconium passage, high or low heart rate, late decelerations of the fetal heart rate seen on records of electronic fetal monitoring, are indicative of fetal distress.
Meconium is normally stored in the infant’s intestines until after birth; it is the baby’s first feces which is sticky, thick, and dark green. Sometimes (often in response to fetal distress) it is expelled into the amniotic fluid prior to birth, or during labor. If the baby then inhales the contaminated fluid, respiratory problems may occur.
Cholestasis patients have a reduced ability to absorb fat-soluble vitamins (A,D and K). This may lead to Vitamin K deficiency. There is a risk of maternal intra- or postpartum hemorrhage. Therefore doctors prescribe oral Vitamin K. There have been reports of maternal hemorrhage as well as stillbirth in utero and postpartum due to ICP induced Vitamin K Deficiency.
ICP has been associated with a substantial rate of preterm birth. There is an increased risk of spontaneous preterm labor, which has been seen in as many as 60% of deliveries in some studies, however without active management most studies report rates of 30%-40%. Earlier presentations of Intrahepatic Cholestasis of Pregnancy (ICP) seem to carry an even greater risk of preterm labor, as well as twin or triplet pregnancies. Also, there are some data to suggest that neonatal respiratory distress (RDS) following ICP may be a consequence of the disease process.
Still birth tends to occur in the last few weeks of pregnancy. The reason this occurs is not completely understood. Although with proper medication UDCA-Ursodeoxycholic Acid and early delivery by 37 weeks the risk is believed to be that of an uncomplicated pregnancy. Research has shown that a bile acid blood level over 40 micromol/L during pregnancy appears to be associated with an increased risk of complication to the unborn baby. ICP is associated with higher rates of intrauterine fetal demise (IUFD) also known as stillbirth. These are the ways in which bile acids may harm the baby based on research. These include abnormal heart rhythms, abnormal contraction of the veins supplying the baby with nutrients, greater sensitivity of the baby’s intestines to bile acids that may cause passage of meconium, intensified susceptibility of the uterus to hormones which may trigger labor and premature aging of the placenta due to exposure to elevated bile acids. Additional research is necessary in this area since some pregnancies appear to be at higher risk than other pregnancies with Intrahepatic Cholestasis of Pregnancy.
What are the symptoms?
Symptoms can vary in severity and type, but the most common ones include:
- Itching all over, but often more severe on palms and soles of the feet. The itching can be recurrent or constant. Many women find that it is worse at night and it disturbs their sleep.
- Dark Urine and/or Pale Stools (grayish in color)
- Preterm Labor
Other symptoms may include:
- Right Upper Quadrant Pain
- Fatigue or Exhaustion
- Loss of Appetite
- Mild Depression
What causes ICP?
There is still much to be learned about the exact causes of ICP and its manifestation, but researchers are currently investigating genetic, hormonal and environmental factors. The causes are likely to be due to a number of different factors, including:
Genetic predisposition – Research thus far has identified several gene mutations involved.
ICP has been shown to extend in families. Mothers and sisters are at higher risk of developing the condition, proving that there is a definite genetic predisposition although additional research is needed to explain all cases of the condition in reference to genes.
Pregnancy hormones estrogen and progesterone have an effect on the livers ability to transport certain chemicals, including bile acids. The flow of bile acids is significantly reduced and leads to the bile acid building up in the blood that causes the symptoms. Note: Women carrying multiples, women who have had IVF treatment also appear to have a higher risk and those who have had previous liver damage or issues may be more likely to develop.
There are more women diagnosed with Intrahepatic Cholestasis of Pregnancy (ICP) during the winter months. Although the reason for this is not clear, it suggests that there is an environmental trigger for the condition, such as a reduced exposure to sunlight or a change in diet.
What is the treatment for ICP?
Despite the possible outcomes of ICP, proper treatment provides a great degree of reduction in both fetal risk and maternal symptoms. With active management that include the two most important factors in the treatment are reducing the bile acids in the bloodstream with the medicine Ursodeoxycholic Acid and delivering the mother as early as lung maturity will allow, often by 37 weeks gestation. In cases where bile acids do not respond to treatment, it may be necessary to deliver earlier than lung maturity to protect the child from the possibility of stillbirth. Unfortunately there is no cure for ICP, and most treatments are aimed at relieving the itch. Some may also help to protect your baby as research has shown with UDCA.
Ursodeoxycholic Acid (UDCA), also known as Actigall or Ursodiol or Urso is currently the front-line medication for the treatment of ICP. UDCA is a naturally occurring bile acid that improves liver function and helps reduce total bile acid concentration in the bloodstream.
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