Intrahepatic cholestasis of pregnancy

This condition is characterized by impaired bile flow, leading to the accumulation of bile acids in the blood. ICP is associated with significant risks for both the mother and the baby, making timely diagnosis and management crucial.

ICP is a pregnancy-specific liver condition caused by the buildup of bile acids—digestive substances produced in the liver. Normally, bile flows from the liver to the intestines to aid in digestion. In ICP, this flow is disrupted, causing bile acids to accumulate in the bloodstream, leading to symptoms like intense itching and potential complications for the baby.

The exact cause of ICP is not fully understood, but it is believed to result from a combination of genetic, hormonal, and environmental factors.

1. Hormonal Changes:

• Elevated levels of estrogen and progesterone in pregnancy can impair bile flow.

2. Genetic Predisposition:

• Women with a family history of ICP or certain genetic mutations (e.g., ABCB4 or ABCB11 genes) are at higher risk.

3. Other Risk Factors:

• Multiple pregnancies (e.g., twins).

• History of liver disease.

• Ethnicity (more common in Scandinavian, South Asian, and Chilean populations).

The hallmark symptom of ICP is intense itching (pruritus), but other symptoms may include:

• Severe itching: Often worse at night, typically on the palms of the hands and soles of the feet, though it can occur anywhere on the body.

• Dark urine: Caused by increased bile pigments in the blood.

• Pale stools: Resulting from reduced bile reaching the intestines.

• Jaundice: Yellowing of the skin and eyes, seen in some cases.

• Fatigue and nausea: Often reported but less specific to ICP.

ICP can have serious implications for both the mother and the baby:

1. Maternal Complications:

• Intense itching can disrupt sleep and quality of life.

• Increased risk of postpartum hemorrhage due to impaired bile acid metabolism affecting blood clotting.

2. Fetal Complications:

• Preterm labor: Babies are often delivered early to reduce risks.

• Stillbirth: Increased bile acid levels can be toxic to the baby.

• Meconium-stained amniotic fluid: A sign of fetal distress.

• Respiratory distress: Bile acids may affect fetal lung development.

ICP is diagnosed based on clinical symptoms, laboratory tests, and ruling out other conditions.

1. Blood Tests:

• Serum bile acids: The most definitive test; elevated levels confirm the diagnosis.

• Liver function tests (LFTs): Elevated liver enzymes, such as alanine transaminase (ALT) and aspartate transaminase (AST), are common.

2. Exclusion of Other Conditions:

• Conditions like preeclampsia, viral hepatitis, and gallbladder disease must be ruled out.

The primary goal of ICP management is to alleviate maternal symptoms and minimize risks to the baby.

1. Medications:

• Ursodeoxycholic acid (UDCA): The most commonly prescribed drug for ICP, it improves bile flow, reduces bile acid levels, and alleviates itching.

• Antihistamines: May help relieve itching but do not address the underlying bile acid buildup.

2. Monitoring:

• Regular monitoring of bile acid levels and liver function tests.

• Non-stress tests and biophysical profiles to assess fetal well-being.

3. Delivery Timing:

• Early delivery is often recommended, usually between 36–37 weeks, depending on bile acid levels and fetal condition, to reduce the risk of stillbirth.

4. Lifestyle Modifications:

• Avoiding fatty foods to reduce liver strain.

• Wearing loose, comfortable clothing to minimize skin irritation.

While ICP cannot always be prevented, early detection and management significantly reduce risks.

1. Prognosis for the Mother:

Symptoms typically resolve within a few days to weeks after delivery. However, women with ICP are at higher risk of recurrence in future pregnancies.

2. Prognosis for the Baby:

With proper management, most babies are born healthy, though they may require neonatal monitoring if delivered preterm.

• Onset: Typically occurs in the third trimester but can develop earlier in subsequent pregnancies.

• Serum bile acids: The most critical diagnostic marker.

• Fetal risks: Increase significantly if bile acid levels exceed 100 µmol/L.

• Delivery: Early induction is often necessary to reduce risks of stillbirth.

Intrahepatic cholestasis of pregnancy is a complex condition requiring a multidisciplinary approach to ensure the safety of both mother and baby. Awareness of symptoms, timely diagnosis, and appropriate management can significantly improve outcomes. Women with a history of ICP should receive close monitoring in future pregnancies and work closely with their healthcare providers to mitigate risks.

For pregnant women experiencing intense itching or other symptoms, seeking prompt medical attention is crucial for early intervention and optimal care.