Summary
- There is an increased risk of hypothyroidism, gallstones and other liver disorders after a pregnancy with Intrahepatic Cholestasis of Pregnancy. Patients with ICP are more likely to need to have their gallbladder removed but removal will not prevent another Cholestasis of Pregnancy.
- Some of this may be due to the fact that the genes that cause this condition also are responsible for causing some of these other disorders. Over 15% of cases have been linked to the ABCB4 gene.
- Some patients with ICP may have an underlying liver disorder and the extra hormones of pregnancy causing it to occur is the first sign. An underlying disorder is more common in patients with a strong family history, early onset of Intrahepatic Cholestasis of Pregnancy (ICP) or a severe case.
- Liver function tests and possibly bile acids should be measured postpartum with follow-up with a gastroenterologist (GI) doctor or hepatologist if elevated.
- Studies on children of ICP pregnancies have shown no significant health problems when followed out to 30 years of age
Background
The exact cause of Intrahepatic Cholestasis of Pregnancy is unknown but it is thought to be caused by a combination of genetic, environmental and hormonal factors. Certain genes that cause it can also cause other disorders of the gallbladder and liver.
It is often thought to be a pregnancy disorder that resolves. While the Cholestasis of Pregnancy does resolve, there are some implications for life-long health that should be considered in these patients.
Future Medical Risks
Studies following patients after Intrahepatic Cholestasis of Pregnancy have shown increased risks for mainly:
- Gallstones and other gallbladder diseases
- Liver diseases including non-alcoholic pancreatitis, Hepatitis C, Non-alcoholic fatty liver disease (NAFLD), and elevation of liver function tests
- Hypothyroidism (low thyroid function)
The good news is that life expectancy is not decreased.
Overall risk of cancer also is not increased. One study showed a small increase in biliary tree cancer that is most often correlated with patients who also have other issues with their gallbladder. This cancer is very rare.
It is thought that the risk factors that caused the ICP might also be the reason for the development of these disorders and not that the ICP itself caused these issues.
Underlying Liver Disorders
The other question is whether a patient might have an underlying liver condition that leads them to have an increased risk of developing Intrahepatic Cholestasis of Pregnancy (ICP).
Hepatitis C has been linked to the development of ICP. There is also a higher risk of Cholestasis of Pregnancy in patients with Primary Biliary Sclerosis (PBC), autoimmune hepatitis, alpha-1 antitrypsin deficiency and PFIC. Some of these conditions may be unknown to the patient and the pregnancy with ICP might be the first “sign” that there is an underlying liver disorder.
Given these risks of liver disorders, the current recommendations are for repeat liver function testing 6-12 weeks after a pregnancy. Should the testing continue to be elevated, referral should be made to a liver specialist (hepatologist) for further evaluation. This evaluation usually includes a full history, a family history, liver ultrasound and a panel of blood testing to look for any underlying conditions.
Risk for Future Intrahepatic Cholestasis of Pregnancy (ICP)
The recurrence risk for ICP in a future pregnancy has been noted to be up to 90%. There are some other risk factors linked with the development of ICP including hormonal treatment such as in IVF pregnancies or elevated hormones in twin pregnancies that might not occur in the next pregnancy and might lessen these chances of ICP. Patients should be aware however that ICP is likely to recur and should monitor for symptoms.
Risks to Children of Intrahepatic Cholestasis of Pregnancy (ICP)
There have been a few different studies that look at the long-term risks to the children that are born from a pregnancy that is complicated by ICP.
These studies have shown only minor differences and it is thought to have no significant impact on the babies and their overall health.
One study did show an increase in obesity and a metabolic syndrome (pre-diabetes) in children from pregnancies with Cholestasis of Pregnancy. A follow-up study showed that the use of ursodeoxycholic acid was able to stop these changes.
Cyclic Itching
Patients with Intrahepatic Cholestasis of Pregnancy will sometimes report itching at the time of their menstrual cycle or with birth control. This has not been well studied. However, if itching does recur, an evaluation of liver function testing should occur. Some patients may be unable to tolerate hormonal birth control after pregnancy. As above, there could be a separate disorder that is causing these symptoms and evaluation with a liver specialist could be considered. Some conditions such as Benign Recurrent Intrahepatic Cholestasis (BRIC) will present with episodes throughout life of itching.
For more detailed information: Please visit the segment of this webpage for Providers that discusses the above subjects in more detail and links to research studies for your review.