Intrahepatic cholestasis of pregnancy (ICP)

This leaflet contains information that you may find helpful if you have been told that you have intrahepatic cholestasis of pregnancy (ICP), formally known as obstetric cholestasis (OC).

It may also be useful if you are a partner, relative, or friend of someone in this situation.

Key Points:

• ICP is a pregnancy specific problem, when itching in pregnancy occurs along with an increased level of bile acids on a blood test.
• ICP usually starts in the third trimester, but it can start at any time in pregnancy.
• The management of ICP is mainly monitoring your blood tests and planning the time of your birth accordingly.
• ICP usually resolves when you give birth
• For those with high bile acid levels, there is a slightly higher chance of preterm birth and stillbirth

Intrahepatic cholestasis of pregnancy (ICP)

ICP is a condition that affects your liver during pregnancy. It causes a build-up of bile acids in your body. Bile acids are made in your liver and help you to digest fat and fat-soluble vitamins.

The main symptom of ICP is itching (without a rash). Sometimes this is more noticeable on the hands and feet, but having generalised itching is also common. It is typically worse at night.

Other symptoms include:

• Dark urine (wee)
• Steatorrhoea (pale, floating stools (poo))
• Jaundice (yellowing of the skin and the whites of the eyes) - this is uncommon

Symptoms usually start after 28 weeks (in the third trimester) but they can start at any time in pregnancy.

If you have been diagnosed with ICP, you are at a slightly higher chance of developing pre-eclampsia (raised blood pressure with protein in the urine) or gestational diabetes.

What causes ICP?

The development of ICP may be influenced by a complex interplay of hormones, genetic factors and the environment. It is more common in certain populations, including Indian Pakistani and South American people. In some cases, a genetic origin can be identified.

How is ICP diagnosed?

Symptoms:

• Itching is common in pregnancy, affecting 1 in 4 people.
• Whilst most people who experience itching will not have ICP, it can be the first or only symptom that people with ICP experience

Examining the skin:

• A skin examination can help to rule out other causes of itchiness (such as eczema). There is no rash associated with ICP.

Blood tests:

• Liver function tests (LFTs) - these look at how well your liver is working. Some of these can be raised in ICP (typically the ALT).
• Bile Acids (BAs) - this measures the level of bile acids in your bloodstream. This level is raised in ICP.
• Sometimes other blood tests are offered to look at other possible causes for abnormal liver tests. This is more likely if the onset of your ICP is early in pregnancy or severe. Sometimes your maternity team will also refer you to a liver specialist to help exclude other causes of the abnormal blood tests.

How does ICP affect my pregnancy?

If you have been diagnosed with ICP, we recommend follow-up care at the maternity hospital for the remainder of your pregnancy.

Once you have been diagnosed with ICP, you will be offered an appointment with an obstetrician either on the telephone or in person. This will be to gather information about you and your pregnancy, and to discuss a plan of care, taking your wishes and needs into consideration.

You will be offered blood tests to check your LFTs and BAs. This is commonly every 1-2 weeks until birth but an individual plan will be recommended.

Occasionally, there will also be a recommendation to check your blood clotting – particularly if you develop steatorrhoea or jaundice. If the clotting time is prolonged, you may be recommended medication to correct this.

You will be offered follow-ups after these blood tests which can be either in person or via telephone. However, you will also need to attend regular antenatal appointments to assess your baby’s growth, your blood pressure and to have your urine tested for protein. These checks can be done by your community midwife.

If you experience any of the following, please report it to us:

• Dark urine
• Pale stools
• Yellowing of the whites of your eyes
• Reduced fetal movements
• Any other concerns

How can my ICP be managed?

Unfortunately, there is nothing we can do to reverse your ICP or to improve it. However, there are treatment options available to help you to manage your symptoms.

Taking cool baths/showers and wearing loose-fitting cotton clothes can help to reduce itching.

Topical emollients (aqueous cream with menthol, calamine lotion or double-base creams): these are helpful for some people to relieve their itching but do not work for everyone.

The antihistamine chlorphenamine can be useful to help relieve your itching and to help you sleep as it has a mild sedating effect.

Ursodeoxycholic Acid (UCDA): This has been shown to have a beneficial effect in a small number of people to improve itching. It may also be recommended for people with high BA to reduce the chance of preterm birth.

How does ICP affect my birth plan?

The timing of birth is advised according to the level of the highest BA you have had during pregnancy.

For mild ICP (BA < 40 micromol/L), birth is usually recommended between 39-40 weeks.

For moderate ICP (BA 40-99 micromol/L), birth is usually recommended between 38-39 weeks.

For severe ICP (BA >100 micromol/L), birth is usually recommended between 35-36 weeks to prevent late stillbirth.

For pregnant people with severe ICP, as well as those with other risk factors, continuous monitoring of the baby will be recommended in labour on the delivery unit.

Unfortunately, we cannot predict the likelihood of stillbirth if you choose to proceed with your pregnancy beyond the recommended gestation.

How does ICP affect my baby?

If you have been diagnosed with ICP, there is an increased chance that your baby may pass meconium (open their bowels) before they are born. This makes the amniotic fluid that surrounds your baby a green/brown colour. Your baby can become unwell if meconium gets into their lungs during labour.

There is an increased chance of you having a pre-term birth (before 37+0 weeks). This may be because you go into labour naturally, or because you and your care team have decided that you should give birth early. Having an early birth will increase the chance of your baby needing an admission to the neonatal intensive care unit (NICU).

It is important to note that in ICP there is no known long-term health risks to your baby.

What happens after I have given birth and what does it mean for future pregnancies?

After you have given birth, it is important to ensure you have a further blood test to check your liver function returns to normal. If it is still high when you leave hospital, the follow up test can be done with your GP. It can take some weeks for the tests to go back to normal. Checking around six weeks is a sensible time to do this. It can take a couple of months for your test results to resolve fully. However, if your blood tests do not return to normal, you may be referred to a hepatologist (liver specialist) for further investigations.

Following ICP in pregnancy, there is no restriction on your choice of contraceptive method. However, for women and birthing people who have previously had cholestasis when using an oestrogen-containing hormonal contraception, such as the oral contraceptive pill (OCP), it is advised to avoid this.

There is approximately 80% chance of ICP recurring in future pregnancies.

Contacts / Further information

If you have any questions regarding the information in this leaflet or your care, please discuss this with your midwife, obstetrician or GP.

Please ring the Maternity Assessment Line on 01223 217217 with any urgent concerns or questions.

More information is also available from:

Royal College of Obstetricians and Gynaecologists - RCOG Royal College of Obstetricians and Gynaecologists (opens in a new tab)

ICP Support (opens in a new tab)

British Liver Trust (opens in a new tab)