Cholestasis of Pregnancy Awareness Day

Today is ICP Awareness day.  I am proud to be a part of this organization and be a featured story on their website  www.icpcare.org

What is Intrahepatic Cholestasis of Pregnancy (ICP)?

Intrahepatic Cholestasis of Pregnancy (ICP), or cholestasis of pregnancy, also referred to as Obstetric Cholestasis (OC), is a liver disorder which occurs during pregnancy. This condition affects the normal flow of bile. It is impaired in a woman's body resulting in itching that can vary in severity and type. The itching can be bothersome to severe itching and is often worse at night. There is rarely jaundice when suffering with ICP. Although ICP has been reported as early as a few weeks pregnant, it is more common for it to begin in the third trimester, when hormone concentrations are at their highest levels. The figure for the percentage of women for whom ICP will recur in future pregnancies is still somewhat debated, but some sources claim it to be as high as 90%. ICP is also referred to as pruritus gravidarum.

Who is at risk for ICP?

Overall, 1 to 2 pregnancies in 1000 is affected by ICP. Women carrying multiples, women who have had IVF treatment also appear to have a higher risk and those who have had previous liver damage or issues may be more likely to develop ICP. The incidence of ICP also shows a striking geographical pattern, with a higher prevalence in Scandinavia and South America specifically Chile where the reported prevalence is as high as 15.6%. Mothers and sisters of patients of ICP are also at higher risk of developing the condition, proving that there is a definite genetic predisposition.

What are the symptoms of ICP?

Symptoms of ICP can vary in severity and type, but the most common ones include:

• Itching all over, but often more severe on palms and soles.

  Many women find that it is worse at night and it disturbs their sleep.

• Dark Urine and/or Pale Stools (grayish in color)

• Preterm Labor

• Jaundice

Other symptoms may include:

• Upper-Right Quadrant Pain

• Nausea

• Fatigue or Exhaustion

• Loss of Appetite

• Mild Depression

What causes ICP?

There is still much to be learned about the exact causes of ICP and its manifestation, but researchers are currently investigating genetic, hormonal and environmental factors. The causes of ICP are likely to be due to a number of different factors, including:

Genetic predisposition – Research thus far has identified several gene mutations involved in ICP.

ICP has been shown to extend in families. Mothers and sisters are at higher risk of developing the condition, proving that there is a definite genetic predisposition although additional research is needed to explain all cases of the condition in reference to genes. Research thus far has identified several gene mutations involved in ICP.

Hormones – Pregnancy hormones estrogen and progesterone have an effect on the livers ability to transport certain chemicals, including bile acids. The flow of bile acids is significantly reduced and leads to the bile acid building up in the blood that causes the symptoms of ICP. Note: Women carrying multiples, women who have had IVF treatment also appear to have a higher risk and those who have had previous liver damage or issues may be more likely to develop ICP.

Environment

There are more women diagnosed with ICP during the winter months. Although the reason for this is not clear, it suggests that there is an environmental trigger for the condition, such as a reduced exposure to sunlight or a change in diet.

What are the risks of ICP?

ICP poses several risks that are of great concern. ICP is associated with an increased risk of stillbirth (intrauterine fetal demise), premature labor, fetal distress, maternal hemorrhaging and meconium passage in utero. Please review in more detail below to understand the risks.

What is the treatment for ICP?

Despite the possible outcomes of ICP, proper treatment for ICP provides a great degree of reduction in both fetal risk and maternal symptoms. The two most important factors in the treatment of ICP are reducing the bile acids in the bloodstream and delivering the mother as early as lung maturity will allow, often at 36 or 37 weeks gestation. In cases where bile acids do not respond to treatment, it may be necessary to deliver earlier than lung maturity to protect the child from the possibility of stillbirth. Unfortunately there is no cure for ICP, and most treatments are aimed at relieving the itch. Some may also help to protect your baby as research showing UDCA.

Ursodeoxycholic Acid (UDCA), also known as Actigall or Urso is currently the front-line medication for the treatment of ICP. UDCA is a naturally occurring bile acid that improves liver function and helps reduce total bile acid concentration in the bloodstream. Please view the Treatment page for more information about ICP treatment and management, as well as additional information about UDCA and its use.

UNDERSTAND THE RISKS INVOLVED

ICP poses several risks that are of great concern. ICP is associated with an increased risk of stillbirth (intrauterine fetal demise), premature labor, fetal distress, meconium staining and maternal hemorrhaging. The risk of stillbirth in an ICP/OC pregnancy is believed to be the same as that for a normal pregnancy (1%) with active management (which usually means treatment- Medicine-Ursodeoxycholic acid and choosing to deliver early).

Fetal Distress

Compromised condition of the fetus, usually discovered during labor, characterized by a markedly abnormal rate or rhythm of myocardial contraction. Some patterns, such as decreased movements, meconium passage, high or low heart rate, late decelerations of the fetal heart rate seen on records of electronic fetal monitoring, are indicative of fetal distress.

Meconium Passage

Meconium is normally stored in the infant's intestines until after birth; it is the baby's first feces which is sticky, thick, and dark green. Sometimes (often in response to fetal distress) it is expelled into the amniotic fluid prior to birth, or during labor. If the baby then inhales the contaminated fluid, respiratory problems may occur.

Maternal Hemorrhaging

Cholestasis patients have a reduced ability to absorb fat-soluble vitamins (A,D and K). This may lead to Vitamin K deficiency. There is a risk of maternal intra- or postpartum hemorrhage. Therefore doctors prescribe oral Vitamin K. There have been reports of maternal hemorrhage as well as stillbirth in utero and postpartum due to ICP induced Vitamin K Deficiency.

Premature Labor

ICP has been associated with a substantial rate of preterm birth. There is an increased risk of spontaneous preterm labor, which has been seen in as many as 60% of deliveries in some studies, however without active management most studies report rates of 30%-40%. Earlier presentations of ICP seem to carry an even greater risk of preterm labor, as well as twin or triplet pregnancies. Also, there are some data to suggest that neonatal respiratory distress (RDS) following ICP may be a consequence of the disease process.

Stillbirth

Still birth in ICP/OC tends to occur in the last few weeks of pregnancy. The reason this occurs is not completely understood. Although with proper medication UDCA-Ursodeoxycholic Acid and early delivery by 37 weeks the risk is reduced to that of a normal pregnancy. Research has shown that a bile acid blood level over 40 micromol/L during pregnancy appears to be associated with an increased risk of complication to the unborn baby. ICP is associated with higher rates of intrauterine fetal demise (IUFD) also known as stillbirth. These are the ways in which bile acids may harm the baby based on research. These include abnormal heart rhythms, abnormal contraction of the veins supplying the baby with nutrients, greater sensitivity of the baby's intestines to bile acids that may cause passage of meconium, intensified susceptibility of the uterus to hormones which may trigger labor. Additional research is necessary in this area since some pregnancies appear to be at higher risk than other pregnancies with ICP.