Role of Serum Bile Acids

in Intrahepatic Cholestasis

of Pregnancy (ICP)

Dr. Sunita Kapoor

Director

City X-Ray & Scan Clinic

Intrahepatic Cholestasis of Pregnancy refers to

a liver condition in which the normal flow of bile

is impaired resulting in severe itching in the

mother and a risk for stillbirth and prematurity

(delivery before term) in the baby.

What is

Intrahepatic

Cholestasis of

Pregnancy?ICP usually develops during the last third of

pregnancy, when hormone levels are highest.

ICP is also referred to as obstetric cholestasis,

cholestasis of pregnancy, and pruritus/prurigo

gravidarum.

There is a defect in the excretion of bile from

the liver resulting in rising of bile acids in the

blood.What causes

Intrahepatic

Cholestasis of

Pregnancy?

The exact mechanism is still not fully

understood, but current research suggests

genetic, hormonal and environmental factors.

Recently a particular gene mutation (change in

a specific gene) has been detected in some

ICP patients.

ICP typically develops when there are high

hormone levels in late pregnancy and in

women carrying twins or triplets. It may also

occur in women on the oral contraceptive pill

Yes – mothers and sisters of patients with ICP

are at higher risk of developing ICP, because

there seems to be a change in one of your

genes, which may be present in other family

members.

Does

Intrahepatic

Cholestasis of

Pregnancy

run in

families?

ICP also tends to recur in subsequent /

following pregnancies (60-90%).

The main feature is a sudden onset of severe itch that will

typically increase in severity until you are either treated for it

or delivery takes place. It often starts on the palms and

soles, but then quickly involves the whole body.

What are the

features of

Intrahepatic

Cholestasis of

Pregnancy

and what does

it look like?

The longer the itch persists, the more skin changes due to

scratching may be present.

These vary from fine scratch marks (excoriations) to 5-10mm

raised lumps (so-called prurigo nodules) typically involving

the shins, arms and buttocks. Apart from these changes,

there is usually no rash associated with ICP.

Loss of sleep, loss of appetite, and an inability to perform

normal daily tasks can be a result of the intense itching.

Less common symptoms (<10% of patients) include dark

urine and/or pale stools (greyish in colour), jaundice (the

white of your eyes and sometimes the skin becomes

yellowish), pain in your belly, and nausea.

The best available test for ICP is the “serum bile acid test”.

A diagnosis of ICP is certain when bile acid levels are

elevated above the normal range. As bile acids are not part

of a routine liver function test (LFT), this test must be

specifically requested by your doctor.

How will

Intrahepatic

Cholestasis of

Pregnancy be

diagnosed?

However, there are only few laboratories that have the

equipment necessary to perform this test, because of this

the diagnosis may be delayed.

A routine liver function test (LFT) that measures liver

enzymes in the blood should also be done when checking

for ICP. However, this test may be normal in ICP, meaning

you may still have ICP, because “serum bile acid levels”

typically rise before liver enzymes increase. If “serum bile

acid levels” are normal but LFTs are found to be increased,

your doctor will search for other liver diseases for example

hepatitis, other tests are required to diagnose this.

How can

Intrahepatic

Cholestasis of

Pregnancy be

treated?

Two important steps may be taken

Reducing the bile acids in your bloodstream: Ursodeoxycholic acid (UDCA - a naturally occurring bile

acid) is currently the best treatment of ICP. UCDA

improves the liver function, helps to reduce the toxic (bad)

bile acid concentration in the bloodstream and improves

bile acid transport across the placenta (takes it away from

the baby). However, UDCA is not licensed for use in

pregnancy. It may be prescribed on an individual base,

with what is called ‘informed consent’.

Delivering the mother as early as possible.However, the development of the baby’s lungs is

important, and usually delivery may be after they are

fully developed at weeks 36 or 37 of your pregnancy.

01

02

Is any special

monitoring

required?Certain weekly check-ups

upon diagnosis are suggested;

they include a “biophysical

profile” (test that uses the non-

stress test and ultrasound to

examine foetal movements,

heart rate, and amniotic fluid

amounts), cardiotocography

(evaluates foetal heart rate),

Doppler flow study.

Yes.

Yes. Neither ICP nor treatment with UDCA

influences breastfeeding negatively.

Is normal

delivery

possible?

Can women

with ICP still

breastfeed?

REFERENCES

Black, Edwards, Lynch, Ambros-Rudolph. Obstetric and Gynecologic

Dermatology. 3rd edition, 2008 (UK)

Schaefer, Spielmann, Vetter. Arzneiverordnung in Schwangerschaft und

Stillzeit. 8th edition, 2012 (Germany)

Schaefer, Peters, Miller: Drugs during pregnancy and lactation. 2nd edition

2007 (English)

Briggs, Freeman, Yaffe. Drugs in pregnancy and lactation. 7th edition, 2005

(USA)

Leaflet of the EADV task force “skin disease in pregnancy”,Updated 15.06.2013

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