Itchy skin is common in pregnancy, but, while most itches fall into the category of dry skin syndrome, there is a rare condition called intrahepatic cholestasis of pregnancy (ICP), of which itching is a symptom. Itchy skin is normal in pregnancy due to changes in hormones and skin stretching. But in about a small percentage of cases this itching can be a symptom of the high-risk condition called ICP.
What is ICP?
ICP is the most common liver disorder of pregnancy. It is a temporary condition which slows down the flow of bile acid, causing it to build up in the blood. During pregnancy there is an increased risk of preterm labour, foetal distress, meconium staining, maternal hemorrhaging and in severe cases, stillbirth.
Causes of ICP
The exact cause of ICP is not known, but research has shown that there are hormonal, genetic and environmental links.
Women pregnant with multiples or who have had IVF treatment have a higher chance of developing ICP.
ICP is more common in certain populations, and it may also run in families. Sisters and daughters of women with ICP have around a 14 percent increased chance of developing ICP in their own pregnancies. The presence of liver conditions and/or gall bladder issues in the family are also indicative of this genetic link.
More women are diagnosed with ICP during the winter months. Although the reason for this is not clear, it suggests that there is an environmental trigger for the condition.
Signs and symptoms
- The main symptom of ICP is itchy skin.
- Itching can be mild or severe, constant or intermittent, localized or general.
- Itching can start as early as 5 weeks, but is more common in the second or third trimester.
- Some women find that it affects the palms of their hands and soles of their feet.
- There is no rash associated with ICP, but red inflamed skin, scratch marks and bleeding skin can be caused by the scratching.
Other symptoms include:
- Pale stools
- Dark urine
- Reduced appetite
- Feeling tired and listless
- Sometimes depression
- Upper quadrant pain
- Only about 10 percent of women with ICP develop jaundice.
After excluding other causes of itching, doctors will need to perform two separate blood tests:
Bile acid test:
A bile acid test is believed to be the most specific test for ICP. Bile acids are harmful because they may be responsible for the complications that affect the baby. In South Africa, a bile acid test can be arranged via special request. It is a fasting test, and anything over 10 µmol/L is positive for diagnosis. A bile acid level over 40 µmol/L is considered to be “severe”, and is associated with increased risk to your baby.
Liver function test:
Not all women with ICP have raised liver function, but ALT and AST are the specific enzymes that can be used to help make a diagnosis. When these are raised it can indicate that there is something going on with your liver, and in some cases these enzymes can go up before bile acid does.
With active management the risk to the baby can drop to that of a normal low-risk pregnancy (around 1 percent). Active management includes taking the medication Ursotan, monitoring bile acid levels with weekly blood tests and delivering the baby at around 36 to 38 weeks (depending on how high the bile acid levels get). Doctors will also monitor the baby closely with more regular scans.
To help the itch
The ICP itch can range from being annoying to being debilitating.
- Ursotan: Although the main purpose of the medication Ursotan is to reduce the harmful bile acid levels, some women say that it also helps to reduce their itching.
- Antihistamines: Some doctors may prescribe an antihistamine.
- Body cream with menthol: This can provide temporary relief due to it’s cooling effect on the skin.
- Keeping cool: Some women say that keeping as cool as possible helps with the itch, and recommend trying ice-packs, fans and cool clothing on the affected areas.
- Rest, relaxation and a healthy diet: Anecdotal evidence suggests that these can help to reduce the symptoms.
What happens after the birth
Usually the condition resolves within 48 hours of delivery, but it can take several weeks for the itching to disappear completely. It’s recommended to have blood tested at around 6 to 12 weeks postpartum, just to make sure that everything goes back to normal. In some cases it may take even longer.
If blood tests are still elevated after several months, doctors may need to be refer the mother to a hepatologist (liver specialist) to make sure they don’t have an underlying liver condition.
Sometimes the liver is left sensitive to hormones, and certain hormonal contraceptives may make a woman feel itchy again. It may be a case of trial and error, as what works for some women may not work for others.
Some women experience “cyclic itching” during ovulation or at the start of menstruation. It generally only lasts for a few days and is not as intense as the itching experienced during an ICP pregnancy.
Will ICP reoccur?
There is a 60 to 90 percent chance of ICP recurring in future pregnancies. It’s advisable to get baseline blood tests done at the beginning of pregnancy, and to be tested regularly throughout.
Antenatal visits are important, particularly in the last three months of your pregnancy. Never dismiss symptoms as unimportant; they could be telltale signs of an avoidable problem. Cholestasis could be mild and easily resolved, but on the other hand, it could be acute and necessitate immediate delivery.
Have you had any experience with ICP? Let us know about your experience, email firstname.lastname@example.org.