Intrahepatic cholestasis of pregnancy (ICP)

Symptoms Of Intrahepatic cholestasis of pregnancy (ICP) 

The most common and characteristic symptom of ICP is severe itching (pruritus), often affecting the palms and soles and is typically worse at night.

Other symptoms and signs that can occur with ICP include:

• Nausea

• Dark urine

• Pale stool

• Fatigue

• Loss of appetite

• Right upper abdominal pain

• Jaundice (yellowing of the skin and whites of the eyes), but this is less common

• Mild itch with a rash

Note: Pregnancy-related ICP might not begin with a rash, but itching can cause one. There's also a similar condition called PUPPS that causes itching and rashes. If you itch and develop a rash, ask for a bile acid test to rule out ICP and get the right care for you and your baby.

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Causes Of Intrahepatic cholestasis of pregnancy (ICP)

The exact cause of intrahepatic cholestasis of pregnancy (ICP) remains complex and not fully understood. However, several factors, including genetics, hormones, and environmental influences, may contribute to its development.

The liver produces bile, which aids in the digestion of fats, which is stored in the gallbladder. Cholestasis occurs when there is a slowdown or blockage of bile movement, leading to its accumulation in the liver. This buildup of bile eventually causes bile acids to enter the bloodstream, which is thought to trigger the symptoms and complications associated with ICP.

Several factors likely play a role in the development of ICP:

1. Genetic predisposition: In some cases, intrahepatic cholestasis of pregnancy (ICP) seems to have a hereditary component. Certain gene mutations linked to pregnancy-related cholestasis have been identified.

2. Hormonal influence: Pregnancy hormones like estrogen and progesterone impact gallbladder function, potentially slowing or halting bile flow. Bile, accumulating in the liver, can enter the bloodstream. Notably, higher-risk groups include women with multiples, those who underwent IVF, and those with prior liver conditions.

Risk Factors For Intrahepatic cholestasis of pregnancy (ICP)

Several factors can potentially trigger or exacerbate ICP, including:

1. Previous history of ICP:  Women who have experienced intrahepatic cholestasis of pregnancy (ICP) in a previous pregnancy have a high recurrence risk, with over an 80% likelihood of developing it in subsequent pregnancies.

2. History of hepatitis C infection: Hepatitis C infection has been linked to an increased risk of developing ICP. Both conditions affect the liver, and underlying inflammation and liver function changes may contribute to ICP.

3. Cholelithiasis (gallstones): The presence of gallstones can interfere with the normal flow of bile, potentially leading to cholestasis and increasing the risk of ICP.

4. Multiple Pregnancies (twins or More): Women carrying multiple fetuses (twins, triplets, etc.) are at an increased risk of developing ICP compared to those with a singleton pregnancy.
   
   

5. Environmental component: Winter months see more ICP diagnoses. This hints at an environmental factor, possibly reduced sunlight exposure or dietary changes, triggering the condition.

6. Assisted reproduction: Women who conceive with assisted reproduction techniques have a higher risk of developing ICP compared to those who conceive spontaneously.
   
   

7. Maternal age: Some studies suggest that older maternal age might be a risk factor for developing ICP.

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Diagnosis Of Intrahepatic cholestasis of pregnancy (ICP)

Diagnosing ICP involves a combination of clinical assessment, laboratory tests, and sometimes imaging studies. Here are the diagnostic measures commonly used for intrahepatic cholestasis of pregnancy:

1. Clinical assessment
A doctor will evaluate the patient's medical history and symptoms, which may include intense itching (pruritus), often on the palms of the hands and soles of the feet. The itching can be severe and usually worsens during the evening and night.

2. Blood Tests

• Liver Function Tests (LFTs): Such as Alanine transaminase (ALT), Aspartate transaminase (AST)

• Bile Acid Levels

• Serum Bilirubin Levels

• Complete blood count (CBS)

• Autotaxin and diagnostic marker test

3. Coagulation profile

Tests such as

• Prothrombin time (PT)

• International normalized ratio (INR) 

4. Imaging studies

Ultrasound: To assess the liver and gallbladder and rule out other potential causes of liver dysfunction.

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Prevention Of Intrahepatic cholestasis of pregnancy (ICP)

Although there is no guaranteed way to completely prevent ICP, however early intervention can help manage its effects.

1. Consulting a doctor
Before pregnancy, consult with an ob-gyn if you have a family history of ICP or liver conditions. This will enable them to assess your risk and provide tailored advice.
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2. Early prenatal care
Initiate prenatal care as soon as you suspect pregnancy. Early monitoring and regular check-ups can help detect and manage any issues promptly.

3. Avoid alcohol or drug substances
 It is vital to completely avoid alcohol or any other substances that could harm your liver or overall health during pregnancy.

4. Monitor Symptoms
Be vigilant about any symptoms of ICP, such as intense itching, dark urine, pale stools, or jaundice. If you notice these symptoms, contact your doctor promptly.

6. Monitoring baby's movement
Pay attention to your baby's movements. If you notice reduced activity, contact your healthcare provider for further assessment. They may recommend more frequent fetal monitoring through ultrasounds and non-stress tests.

7. Avoid triggers
Identify and avoid triggers such as heat, stress, and certain fabrics that may worsen itching, to help alleviate discomfort.

Doctor To Visit

If you experience symptoms such as intense and persistent itching, particularly on the hands and feet, dark urine, pale stools, or jaundice (yellowing of the skin and eyes), you must contact your gynecologist immediately.

The doctors who can help in the prevention and management of cholestasis during pregnancy are:

• General Physician
• Obstetrician & Gynecologist
• Gastroenterologist
• Hepatologist

An obstetrician & gynecologist oversees the pregnancy, monitors the health of the mother and baby, and manages the delivery process. They assess risks, recommend treatments, and ensure a safe delivery.

A gastroenterologist provides expertise in digestive health. In cases of cholestasis, they can help diagnose and manage liver-related issues, provide dietary guidance, and collaborate with the obstetric team.

A hepatologist specializes in liver disorders. They contribute to cases of cholestasis by diagnosing and treating liver problems, prescribing medications, and advising on overall liver health during pregnancy.

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Treatment Of Intrahepatic cholestasis of pregnancy (ICP)

Managing Intrahepatic Cholestasis of Pregnancy (ICP) requires a combination of approaches to ease symptoms, manage complications, and protect both mother and baby. Key aspects include:

1. Medications

• Antihistamines: Ex- Hydroxyzine or diphenhydramine can help reduce itching.

• Bile acid sequestrants: ursodeoxycholic acid (UDCA) is commonly used to lower bile acid levels and improve liver function.

• Other medications: Rifampin, cholestyramine, and S-adenosyl-L-methionine

2. Vitamin K supplement

ICP can impair vitamin K absorption, which is crucial for blood clotting. Supplementation may be recommended if blood clotting tests show abnormalities. The dosage and form (oral or intravenous) depend on the severity.

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3. Topical relief

Topical treatments, including sorbolene lotion, Pinetarsol solution, aqueous cream with 2% menthol, or bicarbonate of soda baths, can provide relief from itching and discomfort associated with ICP.

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Post-delivery Management

Managing ICP (Intrahepatic Cholestasis of Pregnancy) after childbirth is crucial and includes:

1. Symptom resolution: Itching (pruritus) and jaundice in ICP often vanish after childbirth due to placental removal, relieving symptoms. Jaundice fades within a week, and itching improves within days.

2. 6-week follow-up: Bile acid and liver function tests are recommended to ensure a return to normal levels. If you had gestational diabetes, a glucose tolerance test should also be done.

3. Persistent liver disease: If liver abnormalities persist after 6 weeks, further testing is necessary to rule out other liver conditions.

4. Breastfeeding: Most women with ICP can breastfeed safely, but it’s essential to discuss this with your doctor, especially if you are on medications.

5. Long-term monitoring: Periodic liver function tests may be advised to ensure ongoing liver health.

Is hormonal contraception safe for women who have experienced ICP? 

Yes, hormonal contraception is generally safe for women with a history of ICP. However, if itching reoccurs while using hormonal contraception, further investigation is needed. If liver function is abnormal, considering alternative contraception methods may be recommended.

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Home care For Intrahepatic cholestasis of pregnancy (ICP)

Managing ICP involves various strategies to alleviate symptoms and support liver function. Here are some natural remedies and home care tips:

Natural remedies

1. Milk thistle
Milk thistle is known for supporting liver health and detoxification due to its active compound, silymarin, which offers antioxidant and anti-inflammatory benefits. It can be taken in tablet, capsule, or powder form.

2. Dandelion 
Dandelion may support liver and gallbladder function, and aid digestion. It’s often used for its diuretic properties to promote liver detoxification.

3. Apple cider vinegar
Apple cider vinegar is sometimes recommended for its potential health benefits. Ensure it’s diluted properly to avoid discomfort from its acidity.

4. Water-soluble prenatal vitamins
Prenatal vitamins are essential during pregnancy for adequate nutrient intake. Opt for a reputable brand and consult your doctor before using any supplements. 

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5. Fresh raw fruits, sun-dried fruits, and berries
A diet rich in fresh and sun-dried fruits, as well as berries, provides essential nutrients and fiber. Ensure fruits are well-washed to reduce contamination risk.

6. Guar gum
Guar gum can help alleviate itching associated with ICP, though it may only partially reduce cholestasis indicators.

Home tips for managing ICP symptoms

1. Anti-Itch medications

• Consult your doctor about medications for itching, such as antihistamines or bile acid-binding resins. 

• Always seek medical advice before taking any new medication during pregnancy.

2. Diet

• Maintain a balanced diet rich in fiber and nutrients. 

• Avoid fatty or fried foods that could worsen liver symptoms. 

• Stay hydrated.

3. Clothing
Wearing soft, loose-fitting clothing can help reduce irritation and discomfort caused by itching.

4. Rest
Adequate rest can help manage stress and discomfort, possibly easing symptoms.

5. Warm baths
A warm bath can temporarily relieve itching, but avoid hot water as it can aggravate itching for some.

6. Monitoring bile levels
Regular blood tests to monitor bile acid levels and liver function are crucial for assessing the severity of ICP and guiding treatment decisions.

7. Early birth
If other management strategies are ineffective, early delivery around weeks 37 to 38 might be recommended to reduce risks, including stillbirth. In some cases, a cesarean section may be considered if labor induction isn't feasible.

Complications Of Intrahepatic cholestasis of pregnancy (ICP)

Intrahepatic cholestasis of pregnancy primarily affects the mother but can also pose risks to the fetus. Here are some potential complications:

Maternal Complications

• Increased risk of preterm labor: ICP may be linked to a higher risk of preterm labor (labor that begins early, before 37 weeks of pregnancy), particularly in women with previous ICP episodes or multiple pregnancies.

• Postpartum hemorrhage (PPH): This rare but serious condition involves heavy bleeding after delivery. Women with ICP may have a slightly increased risk of PPH.

Fetal Complications

• Preterm Birth: ICP is associated with a higher risk of preterm birth, which can lead to respiratory distress syndrome and developmental issues for the newborn.

• Stillbirth: ICP increases the risk of stillbirth, potentially due to bile acid accumulation affecting placental function and causing fetal distress.

• Fetal distress: Elevated bile acids in the mother can affect fetal heart rate patterns, potentially leading to fetal distress.

• Meconium passage: Stress from ICP may cause the fetus to pass meconium (a newborn's first poop) into the amniotic fluid. This can lead to meconium aspiration syndrome, where the baby inhales meconium-stained fluid, resulting in respiratory problems.

• Neonatal breathing issues: Elevated bile acids can hinder surfactant production, leading to Respiratory Distress Syndrome (RDS) in the newborn, who may require respiratory support.

Note: Recent research suggests that very high bile acid levels may alter the baby’s heart rhythm (arrhythmia) and, in extreme cases, cause it to stop.

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Alternative Therapies For Intrahepatic cholestasis of pregnancy (ICP)

Managing stress is crucial for pregnant women with Intrahepatic Cholestasis of Pregnancy (ICP), as stress can exacerbate symptoms. Complementary approaches to stress reduction include:

1. Meditation and positive affirmations
Regular meditation helps maintain calm and focus. Positive affirmations boost confidence and positivity, alleviating stress and promoting a sense of control.

2. Distraction and relaxation techniques
Engage in activities like reading, watching movies, or practising relaxation techniques such as deep breathing and prenatal yoga to divert attention from itching and discomfort.

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3. Exercise
Activities like walking, or swimming enhance mood through endorphin release, improve circulation, support muscle health, and aid sleep. Always consult your doctor before starting any new exercise routine, particularly with ICP.

4. Essential oils
Aromatherapy with essential oils can create a calming environment. Use oils by diffusing them or applying them topically. Ensure safety by consulting your doctor before use.

Note:  Individual responses to stress management techniques vary. Consult your doctor to ensure these methods are appropriate for your health and pregnancy.