Crazy Itch; Cholestasis of Pregnancy

If you've been pregnant before you know that you get itchy. It's not uncommon to feel itchy, especially around your growing belly and breasts as your skin stretches to accommodate the baby. Hormonal changes may also be partly to blame. However, if you find yourself itching considerably more than normal and all over your body, it is important to bring it to your health care providers attention. You may have Cholestasis of Pregnancy (also known as OC (obstetric cholestasis), pruritus gravidarum., and ICP (intraheptic cholestasis of pregnancy).

What in the World is ICP?

ICP is a specific liver condition of pregnancy. The normal flow of bile 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. The itch is often worse at night. There is rarely jaundice when suffering with ICP (less than 5% of ICP patients present with jaundice, so if your doctor tells you that you cannot have ICP because your skin is not yellow,I suggest getting a new doctor). 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 as high as 90%.

What Causes ICP?

Researchers are currently investigating genetic, hormonal and environmental factors. There has been some research that indicate a particular gene mutation in some ICP patients, but much is yet to be defined. In some cases ICP is suspected to be caused by a sensitivity to the hormone estrogen.
 
What are the Symptoms of Cholestasis of Pregnancy? 

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 Dark Urine and/or Pale Stools (grayish in color) Fatigue or Exhaustion Sleep Deprivation from Itching Loss of Appetite Mild Depression

Less common symptoms include:

• Jaundice 
• Nausea
• Severe Depression 
• Upper-Right Quadrant Pain  (gall-bladder area)
  

ICP carries an increased risk of premature labor, fetal and maternal hemorrhaging, fetal distress, and most importantly, stillbirth (intrauterine death of baby).   

Who Gets ICP?

1 pregnancy in 1000 is affected by ICP. Women carrying multiples and those who have had previous liver damage 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. The highest rates of ICP are noted in Chile, specifically in the Araucanian Indians, where as many as 28% women are affected. 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 Risks to Me and My Baby?

ICP poses several serious risks. ICP is associated with an increased risk for infant stillbirth, premature labor, fetal distress, and hemorrhaging in both mother and child. If the SBA (serum bile acids) rise above 40, the risk to baby greatly increases. Basically, in a nutshell the bile acids that are building up in the body will pass into the brain of the baby and slowly poison them.

How is ICP Diagnosed?

Due to the fact that itching is considered a normal part of pregnancy, testing for ICP is often overlooked. Some doctors will even dismiss the complaint of itching altogether. This can be a dangerous mistake. Any complaint of itching during pregnancy should be taken seriously and be evaluated.

Two tests should be administered to women who are experiencing itching which include the following:

• Serum Bile Acids (SBA): The serum bile acid test is the most sensitive indicator of ICP. This is a specialized test that should be administered after a period of fasting, as eating certain foods may increase bile production. 
• Liver Function Tests (LFT):
  
  A liver function test that measures the liver enzymes in the blood should also be administered when determining ICP, but should not be the sole criteria for a diagnosis! This is due to the fact that it is possible for a patient to have normalized liver enzymes and elevated bile serum results. In ICP, bile serum levels typically rise before liver enzymes increase. Receiving results of elevated LFTs before receiving the results of a SBA test should be considered protocol to administer URSO as a precaution to ensure the safety of the unborn baby.Standard liver enzymes include Alanine Transaminase (ALT), Aspartate Trasaminase (AST), and Alkaline Phosphotase (ALK) and are often referred to as the transaminases.
  • ALT is the enzyme produced within the cells of the liver. The level of ALT abnormality is increased in conditions where cells of the liver have been inflamed or undergone cell death. As the cells are damaged, the ALT leaks into the bloodstream leading to a rise in the serum levels. Any form of liver cell damage can result in an elevation in the ALT. The ALT level may or may not correlate with the degree of cell death or inflammation. ALT is the most sensitive marker for liver cell damage.
  • AST also reflects damage to the liver. It may be elevated and other conditions such as a heart attack. Although AST is not a specific for liver as the ALT, ratios between ALT and AST are useful to physicians in assessing the reason for liver enzyme abnormalities.
  • Alkaline Phosphatase (ALK) is another liver enzyme that is evaluated during a routine LFT, but because this value is normally elevated in pregnancy, it's contribution to the diagnosis of ICP is typically disregarded by specialists.

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. 

Ursodeoxycholic Acid (UDCA), also known as Actigall or Urso is currently the front-line medication for the treatment of ICP. It is a naturally occurring bile acid that improves liver function and helps reduce total bile acid concentration in the bloodstream. 

It is also wise to eat well. A "liver cleanse" type of diet has been known to help ease the discomfort associated with ICP. Use this Diet

Check this out for more info on ICP

IMPORTANT
Remember: this is a VERY serious disease, with very serious risks. If you suspect you have ICP, please realize the uncommon nature of the disease and take into consideration the fact that your doctor may not be fully educated about the possible risks of ICP. In the past, ICP was considered to be a benign condition, and some doctors may still regard it as such. It has not been until more recent years that studies have revealed the serious risks ICP poses. A few tips for discussing testing, treatment and care with your doctor:

• When first mentioning ICP, it may be best not to mention you found the information on the internet, rather, print off a few medical journals from this site and take them with you.
• Give your doctor a chance. If they are not familiar with ICP, help to educate them. If things don't go well after at least some effort on your part to inform them, or they are still unwilling to test or treat you for ICP, then it may be time to change doctors. Society for Maternal Fetal Medicine - The Society for Maternal-Fetal Medicine has a physician locator. 
• Bring this letter with you
  Click here to print an important medical journal to take to your doctor with the above letter

My Background With ICP
I have had 4 pregnancies. All of which I had ICP with, though only 2 were diagnosed. ICP tends to get worse with each pregnancy, increasing in intensity and earlier onset. With my first pregnancy I was told by friends and family that itching was normal, so I shrugged it off and suffered. Thank goodness my child and I were fine.

With my second pregnancy, I started itching at 36 weeks, mainly on my legs, feet, and hands. I scratched so hard that my legs had terrible sores all over them. After telling my OB that I did not think it was normal, he told me to "stop complaining". At which point I did just that. And I suffered immensely for the remaining 4 weeks. I bled a LOT after the labor, and later realized that is a maternal risk of ICP.

With my third pregnancy, I started itching and had a massive gall-bladder attack at 32 weeks, at which point I went into premature labor. My LFT results came back quite abnormal, and after much testing I was diagnosed with ICP at 34 weeks. I had a wonderful OB who thankfully knew all about ICP. I was prescribed URSO, and was induced at 36 weeks. Thankfully all was perfect! Due to their awareness of ICP, steps were taken to prevent hemorrhaging.

With my fourth pregnancy, I had a complicated issue to begin with, in which case ICP was intensified. I started itching at 28 weeks. I was induced at 32 weeks.