Cholestasis of Pregnancy

A. What is it 

Intrahepatic cholestasis of pregnancy (also called ICP or cholestasis of pregnancy) is the most common liver condition that happens during pregnancy. The liver is the largest organ in your body. It helps your body digest (break down and use) food, store energy and remove poisons. The liver makes a fluid called bile that helps your body break down fats and helps the liver get rid of toxins (poisonous substances) and waste. ICP slows the normal flow of bile, causing bile to build up in your liver. This buildup can cause chemicals called bile acids to spill into your blood and tissues, leading to severe itching. 

ICP is most common during the third trimester, but some women with ICP have severe itching earlier in pregnancy. ICP affects about 1 to 2 in 1,000 pregnant women (less than 1 percent), and it’s more common in Latina women. About 5 in 100 Latina women (5 percent) have ICP. 

This causes itching and yellowing of your skin, eyes, and mucous membranes (jaundice). Cholestasis sometimes starts in early pregnancy. But it is more common in the second and third trimesters. It most often goes away within a few days after delivery. The high levels of bile may cause serious problems for your developing little one  

Intrahepatic cholestasis of pregnancy, commonly known as cholestasis of pregnancy, is a liver condition that can occur in late pregnancy. The condition triggers intense itching, but without a rash. Itching is usually on the hands and feet but also can occur on other parts of the body. 

Cholestasis of pregnancy can make you very uncomfortable. But more worrisome are the potential complications, especially for your little one. Because of the risk of complications, your pregnancy care provider may recommend early term delivery around 37 weeks. Cholestasis of pregnancy is a liver condition. 

This condition happens when the flow of bile slows down or is blocked and doesn’t leave the liver as it normally would. Bile acids can then build up in the liver and enter the bloodstream. It may happen when hormone levels increase during pregnancy. 

Cholestasis of pregnancy most often starts in the last 3 months of pregnancy. This condition may make your skin become very itchy, often on your hands and feet.  Cholestasis of pregnancy is not very common. But there are things that increase the chances of this condition, such as if: 

• You or someone in your family has had cholestasis of pregnancy before. 

• You’re carrying twins or triplets. 

• You’ve had In vitro fertilization (IVF). 

• You’ve had liver damage or hepatitis in the past. 

B. What are the physical symptoms 

Signs and symptoms of ICP can range from mild to severe and may begin in your second or third trimester. Call your provider if you have signs and symptoms of ICP, including: 

• Severe itching. Itchy skin is the most common symptom of ICP. You may itch all over your body, but it may be most severe on the palms of your hands and the bottom of your feet. Itching may be the worst at night, and it may wake you up or make it hard to sleep. 

• Dark urine or light-colored bowel movements 

• Jaundice.  

• Loss of appetite  

• Nausea or pain in the upper right belly 

C. How is it diagnosed 

Your pregnancy care provider diagnoses cholestasis of pregnancy during a physical examination and blood test. These tests tell your provider how your liver is functioning. They’ll also measure the level of bile acids in your bloodstream using a serum bile acid test. 

Tests confirm the diagnosis when total bile acids are at 10 micromoles per liter or above. A micromole is a unit of measurement used in some medical tests. You may have blood tests regularly for the remainder of your pregnancy to monitor bile levels in your blood. 

Your provider may also order a prothrombin time test to see how well your blood clots or an ultrasound to look at your bile ducts and liver. 

Serum bile acid testing is the most accurate way to diagnose intrahepatic cholestasis of pregnancy.  This testing can be performed at any point in the day and based on recent recommendations, does not require fasting. 

There are several different bile acid tests, depending on the laboratory, and these can all be used for diagnosis. Bile acids over 10 µmol/L indicate ICP.  Prior studies have shown that levels of bile acids above 10 µmol/L are consistent with a diagnosis of ICP, even on tests which show this to be within normal range. Fractionated bile acid tests can be used to diagnose at a lower level, as these tests measure only select bile acids. 

Bile acid results can take anywhere between 36 hours-10 days for results to return, as these are specialized tests that are only performed in a few laboratories. 

Normal bile acids do not rule out an eventual diagnosis of Intrahepatic Cholestasis of Pregnancy.  Itching is often related to a chemical known as lysophosphatidic acid and not directly to the elevation of the bile acids. Studies have shown that itching can occur even a few weeks prior to an elevation in blood bile acid levels. If you continue to have itching, you should be retested as long as your symptoms persist. 

Bile acid levels should also be followed in pregnancy even after diagnosis. Prior studies have shown a greater risk for pregnancy complications with higher bile acid levels. Mild cases of ICP have bile acids below 40 µmol/L. Severe cases of ICP have bile acids above 40 µmol/L. Complications such as preterm labor, respiratory issues after birth, and meconium staining of the amniotic fluid occur at greater rates with bile acids over 40.  A recent analysis of many ICP pregnancies also found that most pregnancy complications occur with bile acids over 100, and bile acids over this level require a more aggressive management plan. There is no consensus for how often bile acids should be measured, but it is recommended that they be followed, especially near the end of pregnancy, so that delivery timing can be planned. 

When bile acid testing is not available, diagnosis should be based on symptoms. Liver function testing can be performed but does not need to be elevated for diagnosis. Proper delivery timing is more difficult to determine when bile acid levels are not available. A recent presentation with leaders in the field suggested that delivery where bile acid levels are not available should occur between 36-37 weeks gestation as the full risk to the baby is not known without knowing the bile acid level. 

Approximately 60% of people with Intrahepatic Cholestasis of Pregnancy will have elevated liver functions during their pregnancies. A normal liver function panel does not rule out the disorder as bile acid testing still needs to be performed. However, liver function results return within hours instead of days, which can provide your doctor with information more promptly. 

D. How is it treated 

Your doctor may prescribe medicine. Medicine can help reduce bile acid levels and relieve itching. Your doctor also will want to watch you and your baby closely. To keep you both as healthy as possible, your doctor may recommend an early delivery. 

How can you care for yourself ? 

• Be safe with medicines. Take your medicines exactly as prescribed. Call your doctor, midwife, or nurse advice line if you think you are having a problem with your medicine. 

• If your doctor prescribes them, use creams or pills to help with itching. 

• Use calamine lotion on itchy areas. 

• Do not take hot showers or baths. Hot water can make itching worse. 

• After bathing, pat excess water off your skin. Then apply moisturizer before your skin dries completely. 

• Try keeping your moisturizer in the refrigerator. It may feel better on your skin. 

E. How might it impact birth 

If you have ICP, you and your baby are at increased risk of having of complications, including: 

• Preterm Birth. This is birth that happens too soon, before 37 weeks of pregnancy. Babies born this early may have more health problems or need to stay in the hospital longer than babies born later. 

• Fetal distress. This is when a baby isn’t getting enough oxygen in the womb. Signs of fetal distress include reduced fetal movement (when your baby moves less often than usual), changes in your baby’s heart rate and your baby passing meconium. Meconium is your baby’s first bowel movement. A baby usually passes meconium after birth, but a baby in fetal distress may pass meconium into the amniotic fluid that surrounds him in the womb before or during labor and birth. 

• Stillbirth This is when a baby dies in the womb after 20 weeks of pregnancy. 

• Meconium aspiration. This is when a baby has breathing problems after he breathes in amniotic fluid with meconium. If your baby breathes in meconium during birth, it can block his airways. 

• Respiratory distress syndrome (also called RDS). RDS is a breathing problem that happens in newborns whose lungs have not yet fully developed. Babies with RDS have don’t have enough surfactant, a slippery substance that helps the lungs fill with air and keeps the small air sacs in the lungs from collapsing. RDS is common in preterm babies. 

• Postpartum hemorrhage (also called PPH). This is heavy bleeding after giving birth. It's a serious but rare condition.