What Is Cholestasis of Pregnancy?

Intrahepatic cholestasis of pregnancy (ICP), commonly referred to simply as cholestasis of pregnancy, is a liver condition that most often occurs in late pregnancy.

Bile is made by the liver cells. It is stored and secreted by the gallbladder. When a person has ICP, the normal flow of bile in the gallbladder is slowed or stopped.

Symptoms may include itchy hands and feet and yellow eyes. ICP poses risks to the fetus, so early diagnosis and monitoring are important.

Signs / Symptoms of Cholestasis of Pregnancy

The most prominent symptom of ICP is extreme itching. Itching may occur all over the body, but it most commonly affects the palms of the hands and soles of the feet.

Other symptoms include:

• Pain in the upper right abdomen
• Light-colored stool
• Dark urine
• Jaundice (yellow-colored skin and eyes)
• Fatigue
• Nausea
• Loss of appetite

While cholestasis is a liver condition that affects all genders and can occur at any age, ICP is a temporary complication of pregnancy. Symptoms usually resolve soon after giving birth.

Causes

ICP may be caused by a combination of genetic, hormonal, and environmental factors. Researchers have found that a mutation in some genes can lead to bile transport dysfunction. ICP has been known to run in families.

Estrogen and progesterone also play a known role in the development of ICP. These hormones can affect the liver’s ability to move bile acids. Estrogen and progesterone naturally rise late in pregnancy, which may be why ICP most commonly develops in the third trimester.

People carrying multiples and who have undergone IVF treatment are at higher risk of developing ICP. In addition, ICP occurs more commonly in colder months in some countries, although researchers have not identified why.

Diagnosis

People with ICP most often present with pruritis (itchy skin). Healthcare providers usually begin with a skin examination to determine whether the itching could be related to a skin condition, like dermatitis or eczema. A rash does not accompany ICP-related itching.

It is possible to have more than one condition at a time, so even if your healthcare provider suspects that your itching is caused by something more superficial, they may still order labs to confirm or rule out ICP. Bloodwork is done to check liver function and the level of bile acids in the blood. 

When bile acids total 10 micromoles per liter and above, a diagnosis of ICP is confirmed. Increased transaminases and direct bilirubin are also present in up to 60% of cases. Your healthcare provider may also screen for hepatitis C since ICP is higher among people with this liver condition.

Treatment

Ursodeoxycholic acid (UDCA) is a medication that is used to treat pruritis. Though the Food and Drug Administration (FDA) does not list ICP as an indication for using UDCA, it is considered an effective treatment for the pruritis and liver function.

A meta-analysis of randomized controlled trials found that UDCA is safe and effective at reducing pruritis symptoms, improving liver function, and improving maternal and fetal outcomes.

In addition to treatment with medication, it is important to deliver the baby as early as safely possible. Generally, this is around the 37-week mark because that is when fetal lung maturity occurs. If bile acids do not respond to medication, your healthcare provider may discuss delivery before 37 weeks with you.

Vitamin K deficiency often accompanies ICP. That’s because the underproduction of bile can interfere with the body’s ability to absorb fat-soluble vitamins, like vitamin K. If a deficiency is present, it should be treated before delivery to prevent postpartum hemorrhage. 

Risk Factors

ICP is the most common liver condition that affects pregnancy. It occurs at a rate of 0.2% to 2% of pregnancies. The rate is as high as 15% in Latin American countries.

Risk factors for developing ICP include:

• Hepatitis C infection
• Multiple gestation
• Prior ICP complication of pregnancy
• Family history of ICP

Complications

ICP is a serious condition of pregnancy that can impact maternal and fetal health. As the maternal bile acids reach the placenta, they accumulate in the amniotic fluid, leading to complications in the fetus. The higher the serum bile acid levels, the greater the risk for fetal complications.

Possible complications of ICP include:

• Stillbirth
• Meconium-stained amniotic fluid
• Preterm birth
• Neonatal Intensive Care Unit (NICU) admission

Maternal symptoms usually resolve shortly after giving birth. The long-term maternal prognosis is good, although a study did find an increased risk for a later diagnosis of gallstones, liver cirrhosis, and hepatitis C.

Coping

Being diagnosed with ICP can be unnerving. If you have been diagnosed with ICP, be sure to follow your healthcare provider’s instructions. If you have been given medication, take it regularly. Be sure to ask lots of questions about your options and what to expect.

Most people recover fully, shortly after giving birth. You may find support groups for people with pregnancy complications or those who have given birth early to be helpful.

Search online for groups or ask your healthcare provider or nurse if they can suggest any. If you have a friend or family member who has experienced a pregnancy complication or premature birth, they may be able to provide valuable support as well.

A Word From Verywell

Cholestasis of pregnancy is a rare but serious complication of pregnancy. If you have been diagnosed with ICP, you will want to work closely with your healthcare provider to manage your condition. You will likely need to take medication to reduce bile acids. You may also need to give birth earlier than expected. 

If you experience any symptoms of ICP—especially the most common symptom of itching skin—tell your healthcare provider. Diagnosing and managing ICP is the only way to reduce the risk of complications. Remember, most of the time ICP resolves after giving birth, and people do not usually go on to have long-term complications from it.