Intrahepatic cholestasis of pregnancy or ICP is a pregnancy specific condition affecting the liver. It is most commonly seen in the last trimester. 

Patients classically present with distressing itching and raised Bile acids in the blood. The liver enzymes maybe high but bilirubin is usually normal. The patient has severe itching all over the body especially palms of the hands and soles of feet. The itching presents at any time of the day but is especially distressing at night. 

Except the scratch marks caused by itching there are no other rashes or lesions associated with ICP. Itching is associated with increased liver enzymes and Bile acids without increase in bilirubin. 

If the patient has Jaundice or skin lesions or any other lab abnormalities. , alternate diagnosis should be suspected. The itching and liver tests resolve soon after delivery. If the itching or liver test abnormalities persist 4-6 weeks after delivery, patient should be investigated for other conditions.

CAUSES

 The exact cause is not known. It is considered a multifactorial disorder. The most proposed mechanism is the rising female hormones ( ie estrogen & progesterone) in women who have a genetic predisposition causing blockage in the flow of bile and rise in Bile acids 

AFFECT ON THE MOTHER & BABY

 For the pregnant Woman with ICP there is an increased risk of developing Diabetes and hypertension in pregnancy. This shows the correlation of the condition with the metabolic changes in the woman due to pregnancy. 

For the fetus, ICP doesn’t increase the risk of congenital anomalies or growth retardation compared to the general population. There is an increased risk of pregnancy complications such as Meconium stained liquor, fetal distress, preterm delivery and stillbirth. 

The increase in risk is directly proportional to the level of bile acids in the blood. It starts to increase if levels are more than 40 umol/L and is very high with levels beyond 100 umol/l. The risk of adverse pregnancy events is also high if ICP appears in the first or second trimester, with twin pregnancy or with associated Diabetes or hypertension in pregnancy. 

TREATMENT

Many Treatment protocols have been studied world over. Most commonly used drug is Ursodeoxycholic acid. It may provide relief with itching and resolution of liver enzymes, but it doesn’t decrease the risk to the baby caused by the condition.

Other treatments for itching like Anti-allergic medication, Calamine lotion, coconut oil maybe used.

Regular fetal monitoring with ultrasound also doesn’t decrease the risk. 

Depending on the level of bile acids, progression of disease and other conditions the delivery may be planned earlier. This is done to decrease the risk to the fetus.

Having a vaginal or caesarean delivery is not related to the fetal outcome. 

Thus Intrahepatic Cholestasis of pregnancy is a unique condition presenting in later half of pregnancy with only presenting symptoms of itching and rising bile acids. The risks to the baby can be controlled by early delivery especially in severe cases.