Intrahepatic Cholestasis of Pregnancy (ICP)

What happens in cholestasis of pregnancy

Bile is made in the liver and flows through small ducts into the gut, where it helps digest fat. In ICP, pregnancy hormones, mainly estrogen and progesterone breakdown products, slow the pumps that move bile acids out of liver cells. Bile acids spill into the bloodstream. They are thought to cause the itching and can cross the placenta to the baby.

Hormone levels peak in the third trimester, which is why ICP usually appears then and why it is more common in twin pregnancies. Once the placenta is delivered, hormone levels fall and ICP resolves.

Symptoms

• Itching, often intense, typically starting on the palms of the hands and soles of the feet and spreading to the arms, legs and body
• Itching that is worse at night, causing poor sleep and exhaustion
• No rash, although scratching can cause marks and broken skin
• Less commonly, dark urine, pale stools, mild jaundice and a dull ache under the right ribs

Mild itching is common in pregnancy, often from stretching skin or dry skin. Itching of the palms and soles, or itching that is severe or keeps you awake, should always be checked with a blood test.

Causes and risk factors

ICP results from a combination of hormones and inherited susceptibility. Risk is higher with:

• ICP in a previous pregnancy (recurrence is 60% to 90%)
• a mother or sister who had ICP
• twins or more
• IVF pregnancy
• South Asian, Chilean or Bolivian ancestry
• hepatitis C or other pre-existing liver disease
• gallstones
• age over 35

Risks to the baby

The main concern in ICP is the baby. Risks rise with higher bile acid levels:

Other risks include preterm birth, either spontaneous or because doctors recommend early delivery, meconium (the baby's first stool) in the amniotic fluid, and breathing problems in the newborn. Why stillbirth happens is not fully understood; it may relate to bile acids affecting the baby's heart rhythm. It often happens suddenly, so routine fetal monitoring cannot reliably predict it.

Risks to the mother

ICP is uncomfortable rather than dangerous for the mother in most cases. Possible issues include sleep deprivation and distress from itching, a slightly higher chance of preeclampsia and gestational diabetes, and, rarely, reduced vitamin K absorption. Women who have had ICP have a higher later risk of gallstones and some liver and bile conditions.

How ICP is diagnosed

1. Serum bile acid test: the key test. A level of 19 micromol/L or above, with itching and no other explanation, confirms ICP. Bile acids rise after eating, so a non-fasting result may be compared with a fasting one.
2. Liver function tests: liver enzymes (ALT, AST) are often raised.
3. Other checks: tests for viral hepatitis, an ultrasound for gallstones, and blood pressure and urine protein checks to exclude preeclampsia and HELLP syndrome.

Bile acids may be normal at first in someone who is itching, so the test is often repeated every 1 to 2 weeks while symptoms continue.

Treatment

For the itching

• Ursodeoxycholic acid (UDCA, ursodiol): the most widely used medicine. It improves itching and liver tests for many women, though large trials found it does not clearly reduce risks to the baby.
• Skin care: cool baths, loose cotton clothes and emollient creams with menthol (such as aqueous cream with menthol) can soothe skin.
• Antihistamines: sedating ones may help sleep but do not reduce itching itself.
• Rifampicin or other options under specialist care for severe, resistant itching.

Monitoring the pregnancy

• Bile acids and liver tests repeated regularly, often weekly.
• Fetal growth and well-being checks, and knowing to report any reduction in baby movements.
• Vitamin K supplements if blood clotting is affected or stools are pale.

Timing of birth

Recommendations depend on the peak bile acid level:

• Below 100 micromol/L: birth is typically recommended between about 37 and 39 weeks, with exact timing set by the level and the local guideline.
• 100 micromol/L or above: birth at about 35 to 36 weeks is usually recommended.

Your care team will discuss the balance between the risks of stillbirth and of early birth for your situation.

After birth

Itching usually stops within days of delivery. Liver tests should be rechecked about 4 to 6 weeks later to confirm they are normal. If they are not, you will be checked for an underlying liver disease. Contraception containing estrogen can trigger itching again in some women, so discuss options; progestogen-only or non-hormonal methods are often preferred.

ICP is likely to recur in future pregnancies, so tell your care team early next time.

Frequently asked questions

What does cholestasis itching feel like?

It is often an intense, deep itch without a rash, most commonly on the palms of the hands and soles of the feet, and frequently worse at night. Some women describe it as unbearable or say it feels like it is under the skin. Scratching does not relieve it.

Is cholestasis of pregnancy dangerous for the baby?

It can be when bile acid levels are high. The main risks are stillbirth and preterm birth, and they are greatest when bile acids reach 100 micromol/L or more. With mild ICP, the risk is close to that of other pregnancies. Monitoring and planned delivery reduce the risk.

When does cholestasis of pregnancy start?

Usually in the third trimester, after about 28 weeks, when pregnancy hormone levels are highest. It can start earlier, occasionally in the second trimester, particularly in twin pregnancies or in women who had ICP before.

Does cholestasis go away after birth?

Yes. Itching usually stops within a few days of delivery, and liver blood tests return to normal within weeks. A follow-up blood test 4 to 6 weeks after birth confirms this. The condition often returns in later pregnancies.

Can diet help cholestasis of pregnancy?

No diet has been shown to lower bile acids or reduce risks to the baby. A balanced diet, staying hydrated and avoiding alcohol are sensible, but medical monitoring and treatment are what matter. Do not take herbal liver remedies without checking with your doctor.