Bile is produced by the liver and stored in the gallbladder. Bile aids in digestion, excretion via bowel movements, and absorption of fats. The composition of bile includes bile salts, phospholipids, cholesterol, and bile pigments. But with intrahepatic cholestasis of pregnancy, things get complicated… Let’s jump into intrahepatic cholestasis of pregnancy symptoms, diagnosis, treatment, prevention, and more!
What’s Intrahepatic Cholestasis of Pregnancy
ICP (intrahepatic cholestasis of pregnancy) is a liver disorder in pregnancy that occurs when bile from your liver does not flow properly and builds up in the bloodstream.
Most commonly, this liver disorder is associated with itchy hands and soles of feet that is often worse at night due to the bile build-up in the bloodstream.
Is Intrahepatic Cholestasis of Pregnancy Common?
Depending on ethnicity and geographic region, ICP occurs in 0.1-15.6% of women [1]. It affects around 1 in 140 pregnant women in the UK [2].
Luckily, ICP does not always reoccur in following pregnancies. The recurrence rate is about 50-60% in subsequent pregnancies after having ICP [3].
How is Intrahepatic Cholestasis of Pregnancy Diagnosed?
ICP can be diagnosed from liver blood tests and a serum bile acid test. These are performed to gain an idea of how the liver is functioning.
Some liver function tests include:
- Alanine aminotransferase (ALT)
- Aspartate aminotransferase (AST)
- Serum bile acids
In most women with ICP, both ALT and bile salt levels will be raised.
Classification of ICP [4]:
- Gestational pruritus: Itching and peak bile acid concentrations <19 micromol/L
- Mild ICP: Itching and raised peak bile acid concentrations 19-39 micromol/L
- Moderate ICP: Itching and raised peak bile acid concentrations 40-99 micromol/L
- Severe ICP: Itching and raised peak bile acid concentrations greater or equal to 100 micromol/L
The most sensitive and specific marker for ICP is the total serum bile acid (91 and 93 percent) using a cut-off value of 10 micromol/L [5]. Most studies use an upper limit of bile acids between 10 and 14 micromoles/L for the diagnosis of ICP.
The risk for fetal complications increases in severe cholestasis with increased serum bile acid levels, usually over 40 micromol/L [5].
Another researcher found looking at a serum converting enzyme called autotaxin was markedly increased in women with ICP. This may be a highly sensitize, specific, and robust diagnostic marker of ICP with the ability to distinguish ICP from other pruritic disorders (disorders that cause itchy skin) in pregnancy and other pregnancy-related liver diseases.
Therefore, these are the tests you can look for in your lab result paperwork you receive from your midwife or OB.
What Causes ICP?
The cause of ICP is still poorly understood and thought to be caused by a combination of genetics, environmental factors, and hormones. Recent studies have shown evidence of mutations in genes (ABCB4).
Similarly, in recent studies trying to figure out the cause of hyperemesis gravidarum (extreme nausea and vomiting in pregnancy), they have also recently found further confirmation that abnormalities in the GDF15 gene are involved in the development of this condition [6].
The role of reproductive hormones in developing ICP has also appeared in multiple studies. Many studies showed an association of high levels of estrogen conditions and late second-trimester presentation of ICP [5]. High circulating estrogen levels may induce cholestasis in genetically predisposed women in ICP [5].
Environmental and seasonal factors have also correlated with ICP. ICP is noted to be more prevalent in women with a low level of selenium and vitamin D. It is also common in some countries in winters when selenium and vitamin D may be low [5].
Chronic underlying liver disease correlates with ICP; however, it is not yet clear whether chronic liver diseases contribute to developing ICP or are revealed by pregnancy [5].
Can Intrahepatic Cholestasis of Pregnancy be Prevented?
There isn’t enough information on ICP to know for sure if it can be prevented. For those who have this genetic mutation, it can not be prevented as of now.
However, if ICP can manifest based on reproductive hormones, environmental factors, and medical history regarding liver disease, there are very likely things that can be done to prevent ICP in some women!
I highly recommend working with a midwife, naturopath, physician, or nurse practitioner with a holistic health or herbalist certification who can help you identify herbs that can help you regulate your estrogen if needed. Depending on your current health and medical history some herbs might now be a good choice for you.
Check out Herbs for Hormonal Balance! (Coming soon)
Things you can do that may help prevent ICP:
- Balance your estrogen with a healthcare practitioner (midwife, naturopath, holistic physician, or nurse practitioner)
- Get 70-80 ÎŒg(microgram)/day of organic selenium while pregnant and breastfeeding
- Have 600 IU/day of vitamin D during pregnancy. Don’t forget to check out The Complete Guide to Vitamin D in Breastfeeding to save for later too!
Further, some general things that can prevent liver dysfunction/disorders include:
- Avoiding or limiting alcohol consumption
- Avoiding or limiting unnecessary medications that can be hard on the liver
- Talking to a holistic health professional about taking herbs for liver health including milk thistle, ginseng, green tea, licorice, turmeric, garlic, and ginger.
- And more!
As you can see I really love and trust Now Foods Supplements! Their supplements have always worked and proves their quality. I highly recommend them if you’re interested in any of these herbal supplements to support your liver health during pregnancy!
Intrahepatic Cholestasis of Pregnancy Symptoms
Itching without a rash is often the only symptom of ICP.
This itching is more noticeable at night and on the hands and feet. Still, the itching can be all over your body.
Other symptoms of ICP can include:
- Dark urine
- Pale stools
- Yellowing of the skin and whites of eyes (jaundice). But this is less common.
Is Intrahepatic Cholestasis of Pregnancy Dangerous?
ICP is associated with increased risks of:
- Premature birth. This may be spontaneous or caused by an induced labor
- Stillbirth
- Respiratory distress syndrome
- Meconium passage. This is when the baby passes meconium (their “first poo” before he or she is born. Sometimes this is a sign of fetal distress.
- NICU admission
- Fetal asphyxiation
Call your midwife or OB if you have itching that is mild or distressing, possibly worse at night. Anywhere on your body, but may be worse on the palms of your hands and soles of your feet. Feeling itchy like this can be a sign of ICP and needs to be checked.
ICP Treatment
ICP management should be an interprofessional team approach with your midwife, an obstetrician, gastroenterologist, and a nursing team if you are giving birth in a hospital or hospital birth center.
Truthfully, if your ICP is not in the range where it is seen to cause morbidity or mortality (100 micromol/L or more of bile acid concentrations), and it manifests soon before you will go into labor, you can go through shared-decision making on what you want your birth plan to be, and if it should change, with your midwife or OB. Check out this story of a woman who had a homebirth with ICP.
With severe ICP (100 micromol/L or more of bile acid concentrations), a weekly biophysical profile for fetal health monitoring is recommended and a medically induced labor between 36-37 weeks should be considered to avoid fetal complications in this case [5].
Some other studies now consider recommending birth to occur 25-26 weeks of pregnancy with severe ICP (bile concentrations of 100 micromol/L or more) [5]
If you are giving birth in the medical system in the U.S., and have been diagnosed with gestational pruritus or mild ICP, it’s highly unlikely that your OB or midwife will want you to go into labor spontaneously. But if your ICP can be slowed and controlled enough with or without medications, you should still have the choice to go into labor naturally if you desire!
Don’t miss this story of a woman who had a homebirth with ICP to learn more!
More on Intrahepatic Cholestasis of Pregnancy Treatment
Creams, such as aqueous cream with menthol, are considered safe to use in pregnancy and can provide some relief from itching.
Another alternative if the itching is keeping you awake at night, is antihistamine medications such as chlorphenamine. Chlorphenamine can cause drowsiness and reduce your itching. Remember to avoid driving or operating machinery on this medication!
Furthermore, consider a vitamin K supplement or adding in more foods rich in vitamin K as ICP can affect your absorption of vitamin K which is important for healthy blood clotting.
Most experts only prescribe vitamin K if you report pale stools, have a known blood clotting problem, or have severe ICP from early in pregnancy.
Foods rich in vitamin K include:
(In order from exceptionally high sources to good sources of vitamin K)
- Raw turnip greens
- Raw spinach
- Broccoli
- Romaine lettuce
- Cabbage
- Soybean oil
- Okra (check out “Everything You Need to Know About Okra Water for Labor!“)
- Blackberries
- Blueberries
- Green Peas
- Asparagus
- Green beans
- Artichokes
Additionally, because vitamin K is fat soluble (a vitamin that dissolves in fats) it is best to get your vitamin K with some fats like olive oil, avocado, nuts, seeds, and fish!
Questions or Comments on Intrahepatic Cholestasis of Pregnancy?
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Talk soon, mama!
– Katelyn Lauren
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DISCLAIMER: This post is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding you or your baby’s health. Please read my Medical Disclaimer for more info
References:
[1] Bartolone, S., & Alexis, R. (2022). Intrahepatic Cholestasis of Pregnancy: An Autobiographical Case Report. Cureus, 14(1), e21366. https://doi.org/10.7759/cureus.21366
[2] Itching and Intrahepatic Cholestasis of Pregnancy
[3] Understanding Intrahepatic Cholestasis of Pregnancy
[4] RCOG: Intrahepatic Cholestasis of Pregnancy
[5] Pillarisetty LS, Sharma A. Pregnancy Intrahepatic Cholestasis. [Updated 2022 Jun 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551503/
[6] Fejzo, M. S., MacGibbon, K. W., First, O., Quan, C., & Mullin, P. M. (2022). Wholeâexome sequencing uncovers new variants in gdf15 associated with hyperemesis gravidarum. BJOG: An International Journal of Obstetrics & Gynaecology, 129(11), 1845â1852. https://doi.org/10.1111/1471-0528.17129
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