Intrahepatic cholestasis of pregnancy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: cholestatic jaundice of pregnancy

Intrahepatic Cholestasis of Pregnancy (ICP), also termed Obstetric Cholestasis in the United Kingdom, gives rise to troublesome itching during pregnancy but may lead to possibly serious complications for the mother and very serious outcomes for the fetus.

Itching has long been considered to be a common symptom of pregnancy. The vast majority of times, itching, or pruritus 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 ICP.

ICP occurs most commonly in the third trimester, but can begin at any time during the pregnancy.

Maternal consequences include the following:

• 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.

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.

Whilst most pregnant women experience some itch from time to time, itching on the palms and soles without a visible rash, or persisting severe or extenive itch symptoms should be reported to the midwife or obstetrican.

To obtain a diagnosis of ICP, a blood test is arranged to check the liver function tests (LFTs). This is a simple blood test, the results of which should be available by the next day. If the ALT level is elevated, this, plus pruritus of palms and soles, should be treated as diagnostic of ICP. Another blood test for ICP is a quantitative measurement of bile salts. The results of this test often take longer to return, but the test is more specific for ICP.

Other problems with the liver that occur in pregnancy should be considered by the treating clinician. These include preeclampsia, the HELLP syndrome, and acute fatty liver of pregnancy. Furthermore, other causes of hepatitis, like hepatitis viruses and certain medications, should also be considered.

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.

If additional blood tests to check clotting function identify a problem, giving Vitamin K may help avoid the 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. ^[1]

Intrahepatic cholestasis of pregnancy is considered an absolute contraindication to the use of the following medications:

• Hydroxyprogesterone caproate

• Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) an itchy condition of pregnancy that is associated with a rash.

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