The Itch not to be Ignored

Posted in News on 13th January 2017

Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that can develop during pregnancy. It is uncommon, affecting approximately 1 in 140 pregnant women.

ICP is caused by a build-up of bile acids and other substances in the liver, which then ‘leak’ into the woman’s bloodstream. It is most common for ICP to develop after 28 weeks of pregnancy but it is possible for it to happen as early as week 8 of pregnancy.

Having suffered from ICP on all three of my pregnancies, I can certainly say that this itch is uncomfortable to say the least! The constant itching is not harmful thankfully, but when it is severe it can be very difficult to live with, especially if it prevents sleep. Although it can be anywhere on the body, the itch usually starts on the hands and feet and is typically worse at night. The itch can range from mild to severe; the severity of the itch does not correlate to the severity of the disorder. Upper right quadrant (the area around the liver) pain and dark urine can also be present in many cases. Other less common symptoms include pale stools, jaundice and tiredness. ICP is a serious condition but with treatment and monitoring most women go on to have a healthy baby, and the itching goes away afterwards.

ICP occurs when there is a reduced flow of bile down the bile ducts in the liver. Bile is a fluid that is made by the liver that helps with digestion; the reduced flow causes the bile acids to leak out into the bloodstream.

It is still unknown why ICP happens but it is thought to be affected by three factors:

  • Hormones: Pregnancy hormones such as oestrogen and progesterone are thought to affect how the liver works
  • Genetics: ICP is more common in families and certain ethnic groups, such as South America, India or Pakistan.
  • Environment: ICP is more common in the winter months, which is why dietary factors may be involved including lack of vitamin D and selenium (a nutrient found in certain foods) levels.

ICP often happens again in a following pregnancy but not always.

If you go to your midwife or doctor with symptoms of ICP you should have blood tests to check if you have the condition. These blood tests are called Liver Function Tests and Bile Acid Tests.

A bile acid test is believed to be the most specific test for ICP. Different hospitals have different ranges for the ‘normal’ level of bile acids in the blood. Some use 0-10 µmol/L, and some use 0-14 µmol/L. Depending on which range your hospital uses, anything above the upper number supports a diagnosis of ICP. However, if your blood results come back as normal but the itching continues then it is important to have the tests again because the itching can happen before ICP shows up in tests.

A Liver function test looks at how well the liver is working (how your body is coping) by measuring the levels of different enzymes. The key enzymes that are measured are ALT (alanine transaminase) and AST (aspartate transaminase). Research has shown that these sometimes rise before the bile acids so if these are raised but the bile acid test is normal then you should be tested again in a week or so.

Sometimes bile acids can be abnormal while the ALT or AST remains normal. If your doctors have excluded all other causes of itch then the diagnosis of ICP still remains. However, it is also possible for your ALT/AST to be raised but with normal bile acids. In this instance ICP would not be diagnosed but it is important for your bile acids to continue to be tested if you are still itching.

Every woman experiences ICP to varying degrees, even in different pregnancies ICP severity can differ. Evidence suggests ICP can be more severe if you are carrying a girl, and I certainly found this to be the case. The best creams I found to give relief were Avene Xeracalm and Aveeno with Menthol. Regular baths using Avene Xeracalm Oil Wash or Oilatum Bath Additive may also be helpful. Piriton is often suggested as a treatment, but as ICP is not a histamine reaction there is little evidence to suggest this can help. However it can cause drowsiness so perhaps it can help with sleep. Personally I never tried Piriton. A well balanced healthy diet with low amounts of saturated fat and processed fats can have a positive effect also.

Once diagnosed with ICP, your pregnancy will be under the care of a consultant led team at the maternity hospital. While, there is no cure for ICP Ursofalk, ursodeoxycholic acid, is often prescribed. This sometimes improves the itching and liver function/bile acid levels, which may benefit you and the baby. Vitamin K may also be prescribed. Vitamin K helps the blood to clot and this may be beneficial in the event of pre-term labour.

Monitoring your pregnancy carefully is of the utmost importance. During the pregnancy:

  • blood tests (LFTs and bile acid tests) should be offered weekly or more frequently, depending on the stage of pregnancy and the results of the previous test.
  • the baby’s heartbeat may be monitored using a CTG machine. This cannot predict complications, but it can provide some reassurance.

If you have intrahepatic cholestasis of pregnancy, there is a higher risk of the baby being born prematurely. About 1 in 10 women diagnosed will have their baby before full term (37 weeks). It is thought that it happens spontaneously (without being induced) in around 4-10% of ICP pregnancies. Be aware of the signs of preterm labour and if you have them seek medical attention immediately.

There is evidence that women who have been diagnosed with ICP are at higher risk of having a stillborn baby (thought to be between 1 and 4%). With active management (treatment, ongoing tests and monitoring) and early delivery though, the risk may be lessened.

Because of this your doctor might advise you to have your labour induced if your bile acids go over 40 µmol/L. Bile acids above this concentration have been shown to be associated with a higher risk of stillbirth.

There is also a higher risk that the baby may pass meconium (first poo) during the pregnancy or labour, which can cause breathing problems for them.

These factors also mean that there is also a higher likelihood that your baby may need to be admitted to the neonatal unit.

Your doctor may advise you to have your labour induced early. This will depend on:

  • your blood tests
  • how you are coping with the itching
  • how well your baby is doing.

As 37 weeks is considered full term, your doctors will do everything they can to get you to 37 weeks, and at this stage depending on your condition and previous pregnancies (if any) they will consider induction or a scheduled c-section.

Most women can stop taking Ursofalk immediately after their baby has been born. The causes of ICP usually self-correct without any extra treatment when you have had your baby. You should have a blood test 6-12 weeks after the baby has been born to be sure. If by six months your levels have not returned to normal then you should have more tests for other possible liver conditions.

 


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