Symptoms of Intrahepatic Cholestasis of Pregnancy
I have a rash all over and I itch everywhere! Is this ICP?
ICP doesn’t usually present with a rash first. However, due to itching a rash can occur. There are other conditions in pregnancy such as something called PUPPS that causes itching and a rash. If the itching seems to cause the rash, you should ask to be tested for ICP with a bile acid test.
Itching can also be generalized and does not have to involve only the hands and feet.
Can I have ICP in my first trimester?
Yes! ICP has been diagnosed as early as 5 weeks. If your bile acids return normal after a test early in pregnancy, continue to repeat testing as it might take a few weeks for levels to rise.
Early onset ICP is associated with more of a risk of meconium passage, preterm labor, and respiratory distress after birth than cases diagnosed later. However, there is not evidence of an increased risk of stillbirth with earlier diagnosis.
Why is the itching worse at night?
The reason is not known; however, it has been suggested that it might be due to circadian fluctuations in pregnancy hormones which is (of biological processes) recurring naturally on a twenty-four-hour cycle.
Is it normal with ICP to have a pain in my right side – Right Upper Quadrant (RUQ)?
Some pregnant women with ICP have pain on the right side under the right ribs and others mention the pain in the back just below the right shoulder blade.
My healthcare provider said if I had Intrahepatic Cholestasis of Pregnancy (ICP), I would be jaundiced. Is this true?
No, only a small proportion of women with ICP will have jaundice.
Why don’t antihistamines such as Benadryl work for the itching?
Itching in ICP is caused by the deposition of bile acids and does not respond as well to antihistamines which are medications that mainly affect a response to an allergen.
Are there other ICP conditions associated with the disorder?
Compared with women who did not have ICP, women with ICP were more likely to have gestational diabetes and preeclampsia.
Testing for Intrahepatic Cholestasis of Pregnancy
Is there a file to send my healthcare provider on ICP? I need medical referenced journals & articles!
Yes, you can email your healthcare provider the Healthcare Professional Brochure. It’s a useful resource to aid in the diagnosis and management of Cholestasis of Pregnancy. Also available is the ICP Infographic PDF file with the symptoms, diagnosis, treatment etc., containing section links to medical studies & references. View all resources here.
My bile acid tests are normal. Why am I still itchy? Should I have another blood test?
Symptoms can occur weeks before bile acid levels are positive on a test. If you continue to have itching, you should be retested.
Also, different bile acids labs have different reference ranges and these ranges are often misinterpreted. If you have been told that your levels were “normal”, you can request a copy of your results. Generally, a level above 10 umol/L is considered diagnostic of Intrahepatic Cholestasis of Pregnancy.
Should you fast before your bile acid test?
SMFM (Society of Maternal Fetal Medicine specialist) guidance states that fasting is no longer needed.
Fasting before testing can show lower levels of bile acids.
Recent research has shown that testing after eating is more representative of the levels of bile acids throughout the day.
Cholestasis of Pregnancy diagnosis may be missed. You should eat prior to testing.
Why does the bile acid test results take up to 5 – 7 days to receive in the USA?
There are only a few labs in the country who process that test. It is run in batches only 2-3 times per week. The test itself takes 24 hours to run.
If my liver testing is abnormal, do I have ICP?
Liver function tests (AST/ALT) will be elevated in about 60% of women with cholestasis of pregnancy. You should also have a bile acid test for diagnosis. On the other side, if liver functions are normal, this does not rule out ICP.
My bile acid blood tests are normal with treatment of the medicine Ursodiol– Should I still be delivered early?
Delivery timing should be planned based on your highest bile acid level. Even if the levels normalize with treatment, you should still be delivered in the window that corresponds to your highest level. Delivery should occur between 36 0/7-39 0/7 weeks of gestation depending on your highest bile acid level.
What is the normal reference range for bile acid testing?
It is generally recognized that ICP is diagnosed when bile acids are greater than 10 µmol/L. Different tests have different reference ranges which might be a non-pregnancy reference range and diagnosis should occur if levels are above 10. The most common test is a test with a reference range of 0-19. This test is often misinterpreted in cholestasis patients as 10 is still a diagnostic level on this test.
There are also some fractionated bile acid tests with lower reference ranges (two examples are <6.8 or <8.3). Cholestasis of Pregnancy can be diagnosed on these tests if the level is above the reference range and does not need to reach 10 µmol/L.
Intrahepatic Cholestasis of Pregnancy Treatment
How is Intrahepatic Cholestasis of Pregnancy (ICP) treated?
The main treatment is a medication called ursodeoxycholic acid (Ursodiol). It is an FDA pregnancy category B medication and is safe in pregnancy. Dosing should start at 10-15 mg/kg and can increase up to 21 mg/kg.
For additional information, please see article: New Evidence for the Benefits of Ursodiol for Intrahepatic Cholestasis of Pregnancy
For a flowchart diagram on diagnosis and treatment protocols with printable PDF visit: ICP Diagnosis & Treatment Flowchart
Why am I still itchy after starting the medicine Urso?
Ursodiol will diminish the itching for some, however not every woman. It can take up to two weeks to notice relief when it does help with the itch.
Does delivery timing change because I have Intrahepatic Cholestasis of Pregnancy?
Prior studies have shown that stillbirth risk increases after 37 weeks of pregnancy. Recent studies have shown that this risk is related to the level of the bile acids and delivery timing will be planned based on your bile acid levels. Higher levels may need to deliver earlier in pregnancy with a recommended window for delivery of 36 0/7-39 0/7 weeks. If levels reach 100 µmol/L, delivery needs to occur right at 36 weeks of gestation.
What is at risk to the baby with Intrahepatic Cholestasis of Pregnancy?
ICP is associated with an increased risk of stillbirth (intrauterine fetal death), meconium staining in utero, spontaneous premature labor, fetal distress, and respiratory issues for the baby after birth. The risk of most of these complications increases with higher bile acid levels or earlier onset of disease.
What is the risk to the patient with Intrahepatic Cholestasis of Pregnancy?
Pregnancies complicated by cholestasis of Pregnancy are also at risk for pre-eclampsia and gestational diabetes. Prior studies had shown an increased risk of bleeding around the time of delivery but recent studies have shown this risk is very low with treatment of ICP.
I am expecting twins, is this more dangerous with ICP?
Women carrying multiples appear to have a higher risk of developing ICP. Also, women with multiple pregnancies may have a higher risk of going into early spontaneous labor. Early onset disease before 30 weeks increases the chance of preterm labor. An earlier delivery window might be considered in a pregnancy complicated by both intrahepatic cholestasis of pregnancy and a twin gestation and should be discussed with your physician. There are not a lot of studies on twins and ICP and an individual plan should be determined.
What other remedies help with the itching?
No treatment has been fully proven to relieve itching in cholestasis of pregnancy. Some remedies that may be helpful are having a healthy diet with healthy fats, drinking plenty of water, wearing cool & loose cotton clothing, and keeping temperatures low. Some women find some relief with topical lotions for itching such as Sarna and Pine Tar Soap.
What happens after the birth of my child?
Will my baby have any long term health issues due to ICP?
There is no robust research to confirm ICP babies will have any long term health issues.
We do know that infants born after ICP have a higher risk of respiratory distress immediately after birth and delivery should occur at a facility that is able to offer care. However, there are not any long term respiratory issues in these infants.
Will the itching go away after delivery?
Most patients with ICP have resolution of their itching soon after delivery. Some women will continue to have itching when on hormonal birth control or with their menstrual cycle. If itching continues after pregnancy, lab evaluation with liver function testing should be performed. Some women will be found to have an underlying liver condition and may need to see a specialist for further evaluation.
Do I need to have my liver checked by a specialist after my baby is born?
Some patients with cholestasis of pregnancy have an underlying liver condition. This is a minority of patients. It is recommended to have liver functions and possibly bile acid levels measured at your postpartum visit with referral to a specialist if still elevated.
Here’s a helpful reference regarding considerations after Intrahepatic Cholestasis of Pregnancy which you can share with your healthcare providers: Healthcare Professional Brochure: Considerations After Pregnancy
Can I breastfeed my baby after Intrahepatic Cholestasis of Pregnancy?
Absolutely! Breastfeeding is completely safe and normal after ICP. Some doctors may suggest for their patients to continue their prescription of UDCA –Ursodeoxycholic Acid to help normalize bile acids in the blood after pregnancy. The medication may pass into the breast milk, but may help the baby’s immature liver to rid their own body of residual bile acids as well as help with jaundice.
Can I get intrahepatic cholestasis of pregnancy if I do not have a gallbladder?
Cholestasis of pregnancy is a disorder of the liver and not the gallbladder. Having your gallbladder removed will not affect your development of ICP.
Patients with ICP have an increased risk of having gallstones and there is a higher chance of needing to have a cholecystectomy (gallbladder removal).
Will I get Intrahepatic Cholestasis of Pregnancy (ICP) again?
Reported recurrence rates are between 60-90%. It is known that women who have ICP in one pregnancy are very likely to develop it again in a subsequent pregnancy. Since recurrence rates are high for ICP, be aware of symptoms. You can ask your healthcare provider for a baseline bile acid and LFT blood test. It is also recommended to repeat these blood test as soon as symptoms occur.
Will Intrahepatic Cholestasis of Pregnancy be worse in my next pregnancy or can I prevent it in my next pregnancy?
There is no research to show it will be worse in subsequent pregnancies or that it can be prevented. In some subsequent pregnancies symptoms may be noticed sooner such as the itch. Every ICP case and pregnancy is quite different and symptoms may vary. Some women have mentioned milder symptoms that started later in subsequent pregnancies compared to their first pregnancy. Please also keep in mind that there is a chance to not develop ICP at all in a subsequent pregnancy!
Am I more likely to get ICP if I am expecting a boy or a girl?
There is no evidence that ICP develops based on the sex of the fetus.
Will my baby inherit Intrahepatic Cholestasis of Pregnancy (ICP)?
ICP often has a genetic cause and it is possible that this could be passed to your offspring. Female infants might develop ICP in their pregnancies and male infants could carry the gene and pass it onto their offspring.
What contraception can I use after my Intrahepatic Cholestasis of Pregnancy?
ICP is thought to be caused by excessive hormones of pregnancy so theoretically people were concerned about the hormones in birth control. However, there have been no large studies regarding the use of contraception following an ICP pregnancy. There are forms of contraception that contain minimal hormones and some other options for non-hormonal contraception. If an itch begins after using a certain method, you should consult with a healthcare provider as liver function testing may need to be performed.
Why do I get occasional itching around my menstrual cycle?
Many that have experienced ICP have noticed cyclical itching which occurs during ovulation or the start of menstruation. The itching is noticeable, however not similar to the ICP pregnancy itch that disturbs sleep. It is not known why this happens after having ICP, however it may be an effect of hormone fluctuations on the liver. You should request from a healthcare provider to have a Bile Acid and Liver Function blood test to ensure your levels are normal.
For additional information see our most recent article: Considerations After an ICP Pregnancy