Intrahepatic cholestasis of pregnancy (ICP)

Date: June 2020, Version 3

What is it?

Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis, is a liver condition that causes the build-up of bile acids in the blood and only occurs in pregnancy. ICP affects about one in every 100 pregnant women in the UK, usually in the third trimester. The main symptom of ICP is itching, which might be severe, can particularly affect the palms of the hands and soles of the feet, and is often worse at night. If your doctor or midwife suspects that you have ICP they will arrange for blood tests that check your bile acid levels and also your liver function. Women with ICP have raised blood bile acid levels and often (but not always) have other abnormalities in their liver function tests.

Are there any risks to me or my baby from ICP?

ICP is not life-threatening for pregnant women and goes away on its own after delivery. However, ICP can severely affect quality of life as the itching can be very unpleasant and may interrupt sleep. ICP can occasionally cause serious problems in pregnancy (see below) and women with ICP are often anxious about their baby’s wellbeing.

Historically, ICP has been thought to increase the risk of stillbirth, but research published in 2019 suggests that this is only true for a small proportion of women with ICP. In the background population in the UK, around one in every 200 pregnancies ends in stillbirth. The latest research suggests that most women with ICP have a similar chance of having a stillbirth as women in the background population, while only the small number of women with blood bile acid levels over 100 µmol/L have a much higher chance of stillbirth.

Women with ICP will be offered at least weekly monitoring of their bile acid levels and may be offered early delivery of their baby depending on the results. Induction of labour in women with ICP may be offered at around 37 weeks of pregnancy after discussion of the risks and benefits of earlier delivery.

ICP is linked to preterm birth, both because some women with ICP have their deliveries induced, and because ICP increases the chance of spontaneous preterm labour. ICP is also linked to the baby passing meconium (the first poo) while still in the womb, and as this can cause breathing problems in the newborn baby, increases the chance that they will need to be looked after in a neonatal intensive care unit.

It is recommended that pregnant women with ICP receive consultant-led care and deliver in a hospital unit.

What are the treatments for ICP?

Moisturising skin creams
Moisturising skin creams, particularly those containing menthol, may reduce the feeling of itching in some women and are considered safe to use in pregnancy.

Antihistamines
Antihistamines that cause drowsiness are sometimes prescribed for women who are experiencing severe itching, to help them sleep at night. The antihistamines for which there is the most information on use in human pregnancy are chlorphenamine and promethazine. Use in later pregnancy does not appear to cause problems in the baby before or after birth. If you are prescribed an antihistamine, please check to see if we have a bump leaflet summarising the known effects in pregnancy.

Ursodeoxycholic acid
Ursodeoxycholic acid (UDCA), or ‘urso’ is sometimes used in women with ICP. UDCA can reduce bile acid concentrations and relieve itching, although it does not work for everyone. There is no evidence to suggest that UCDA is harmful in pregnancy, and while some women benefit from reduced itching, there is no proof that its use reduces the chance of other ICP related problems.

Rifampicin
Rifampicin is occasionally prescribed alongside UCDA if a woman’s bile acid levels are high. Taking rifampicin is not known to be harmful in pregnancy, however, only a small number of studies have investigated its use in pregnant women. Ongoing research is therefore required. Rifampicin can reduce vitamin K levels, so when it is used, it is recommended that vitamin K is given to the baby after delivery.

For more detailed information on the medicines used to treat ICP please read the bump leaflets on: chlorphenamine, promethazine, ursodeoxycholic acid, and rifampicin.

Will I or my baby need extra monitoring during pregnancy?

As part of their routine antenatal care most women will be offered a scan at around 20 weeks of pregnancy to look for birth defects and to check the baby’s growth.

Women with ICP will be offered extra blood tests to check their bile acid levels and liver function. They may also be offered extra monitoring of the baby, particularly if they are anxious about the baby’s wellbeing. It is recommended that pregnant women with ICP receive consultant-led care and that they give birth in a hospital unit.

If you received treatment with rifampicin it is important that your baby receives vitamin K after birth.

Who can I talk to if I have questions?

If you have any questions regarding the information in this leaflet please discuss them with your midwife, obstetrician or GP. They can access more detailed medical and scientific information from www.uktis.org.

How can I help to improve drug safety information for pregnant women in the future?

Our online reporting system (MyBump Portal) allows women who are currently pregnant to create a secure record of their pregnancy, collected through a series of questionnaires. You will be asked to enter information about your health, whether or not you take any medicines, your pregnancy outcome and your child's development. You can update your details at any time during pregnancy or afterwards. This information will help us better understand how medicines affect the health of pregnant women and their babies. Please visit the MyBump Portal to register.

General information
Sadly, miscarriage and birth defects can occur in any pregnancy.

Miscarriage occurs in about 1 in every 5 pregnancies, and 1 in every 40 babies are born with a birth defect. This is called the ‘background risk’ and happens whether medication is taken or not.

Most medicines cross the placenta and reach the baby. For many medications this is not a problem. However, some medicines can affect a baby’s growth and development.

If you take regular medication and are planning to conceive, you should discuss whether your medicine is safe to continue with your doctor/health care team before becoming pregnant. If you have an unplanned pregnancy while taking a medicine, you should tell your doctor as soon as possible.

If a new medicine is suggested for you during pregnancy, please make sure that the person prescribing it knows that you are pregnant. If you have any concerns about a medicine, you can check with your doctor, midwife or pharmacist.

Our Bumps information leaflets provide information about the effects of medicines in pregnancy so that you can decide, together with your healthcare provider, what is best for you and your baby.