My journey with ICP began in January 2023 during my first pregnancy. Overall, I felt great during this pregnancy until I was diagnosed with COVID-19 at 38 weeks and 6 days. I can vividly recall how terrible I felt during that time, with common symptoms on top of being heavily pregnant. A few days after my diagnosis, I can remember feeling an intense itching on my chest, hands, and feet. At the time, I thought it was a weird COVID-19 symptom and didn’t stress about it. This went on for a few days, and I almost did not tell my OB at my 40-week appointment as I thought it was benign and not a concern.
Thankfully, I decided to tell her what was going on and I was so glad I did! Aside from my COVID-19 symptoms and the unusual itching in my hands/feet I was also experiencing blurred vision and headaches that were not going away. Given all my symptoms at the time and gestational age (at this point, 39 weeks 6 days), my OB recommended I go to the hospital and be further evaluated.
Upon further evaluation at the hospital, my liver enzymes were significantly elevated, so they decided to induce me at 39 weeks 6 days. At the time, they were unsure if my liver enzymes were elevated due to active COVID-19 infection or a new onset of cholestasis of pregnancy (ICP), which was a medical diagnosis I had never heard of. The attending OB did inform me that if it were ICP, there is an increased risk for stillbirth if delivery is delayed. At the time the weight of those words shook me, however, I felt comfortable that I was in the right place and in good hands.
As my labor progressed, my condition worsened. I was then diagnosed with severe pre-eclampsia and placed on a magnesium sulfate drip. Miraculously, after several hours in labor and 3 excruciating hours of pushing with little progression, I gave birth to my first son, Liam. During delivery, he experienced shoulder dystocia, but thankfully, he was ok and did not require NICU given all my complications. A few days after delivery, it was confirmed by my bile acids (25) that I did have ICP in addition to severe pre-eclampsia. After delivery, it took approximately 6 weeks for my liver enzymes to return to normal.
Fast forward to February 2024, and I found out I was pregnant with my second child. Given my history with pre-eclampsia and ICP, I was referred to a maternal-fetal medicine specialist right away. I can recall being anxious about this pregnancy as I was fearful of developing either of those conditions again. For most of this pregnancy, I felt off despite normal examinations and labs. At around 14 weeks, I developed a strange rash on my upper and lower extremities. MFM did not believe it was ICP or even PUPPs rash. However, they did check bile acids and liver enzymes to be sure and all was within normal limits, thankfully. Unfortunately, the rash continued for several weeks without any definitive cause being identified. I was referred to a dermatologist and they felt it was possibly a contact dermatitis with an unknown cause. I was prescribed a cream and hydroxyzine by MFM for the itching. The rash would resolve after a few days of applying the cream, then would continue to return off and on. The rash resolved on its own around 23-24 weeks pregnant. I was thrilled!
A few weeks later, around 27 weeks, I began with dull headaches, mild blurry vision, and occasional nausea and vomiting. I followed up with my OB office, and they did extensive lab work yet again, ruling out ICP or pre-eclampsia, given my blood pressure was normal. All serial growth scans of the baby were normal, with the possibility of macrosomia, but overall, not concerning at the time. Around 32 weeks and 6 days pregnant I was diagnosed with COVID-19. Concurrently, this is when the intense ICP symptoms began. I can recall it being 4 am one morning, and I woke up out of a dead sleep with intense itching of my ankles and wrists. I knew immediately before being officially diagnosed that it was ICP yet again. I was scheduled for a same-day visit with my provider to review symptoms. My OB ordered STAT bile acids and liver enzyme labs. Given my history, she diagnosed me with ICP and started me on Ursodiol right away without confirmed lab results. My bile acids resulted in 3 days and were elevated at 52. My liver enzymes were also elevated at this time. After my official ICP diagnosis, my time was consumed with routine OB visits, MFM visits, 2x weekly NSTs, and ultrasounds on top of being a mom, wife, and still actively working. Around 34 weeks pregnant, my dull headaches continued unresolved with Tylenol, blurred vision, itching of my palms and soles, and now an intense RUQ pain. My OB recommended that I go to the hospital for further evaluation.
When I was evaluated at the hospital, my liver enzymes increased from 53/103 to 181/438 and was also diagnosed with gestational proteinuria. I was kept overnight for monitoring, additional labs, and was also provided with betamethasone to mature the baby’s lungs in the event of early delivery. At the time they felt my liver functions were exacerbated by the combination of ICP and COVID-19. I was discharged the following evening in stable condition and continued my weekly NSTs and ultrasounds. Thankfully, the ursodiol therapy returned my bile acids to the normal range and decreased my liver functions substantially as well as decreased the severity of my itching to be tolerable.
At 36 weeks 4 days, I went in for my planned induction, which almost did not occur as the attending OB felt comfortable with me postponing due to improved labs and continued fetal growth would benefit the baby. My husband and I advocated to continue with the induction as my symptoms have improved, but yet did not resolve, and I simply did not want to take the risk of waiting due to the spontaneity of ICP. At 36 weeks 5 days, I gave birth to my second son, Eli. Shortly after birth, Eli had difficulty maintaining his sugar levels and also developed jaundice. We stayed in the hospital for an additional few days for phototherapy treatment before being discharged, and he is as healthy as can be today!
My journey with ICP was an unplanned one yet the diagnosis continued to intrigue me to want to learn more about this rare pregnancy disorder and, more importantly, inform others of the harsh reality a simple itch could cause in pregnancy.
I am honored to have been a part of the ICP Care community and am committed to continued advocacy and support of expecting mothers and their babies.