ICP in pregnancy: symptoms, causes and treatment
Juliet Blank
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All pregnancies are full of weird niggles, so if you’re feeling itchy, it’s tempting to write it off as another bizarre symptom. But, itching in pregnancy can sometimes be a sign of something more serious called Intrahepatic Cholestasis of Pregnancy, or ICP. Here's what you need to know about it.
While many mums-to-be develop itchy, sensitive skin for many reasons, it can be a sign of a rare but serious condition that could put your baby’s life at risk.
According to the British Liver Trust, every year, one in every 140 pregnant women develops Intrahepatic Cholestasis of Pregnancy, or ICP.
The condition is still largely unheard of, and even GPs and midwives sometimes miss the signs, but it’s not something that should be overlooked: left untreated, it can lead to premature labour and stillbirth.
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The good news is that ICP can be managed successfully, but it’s vital that you know the signs to look out for – and what to do if you have them.
What is ICP?
ICP – which used to be known as obstetric cholestasis, or OC – is a pregnancy-related liver disorder.
In ICP, the levels of bile acids (which help with digestion) in your blood are raised because your liver doesn’t process them properly.
'There are very effective treatments for ICP, but if left untreated, there is a small but significant risk of preterm labour, foetal distress and stillbirth,' explains Netmums' official midwife, Leah Hazard.
Who's at risk of ICP?
No one really knows what causes ICP, which makes it hard to predict who’s going to get it.
'The Royal College of Obstetricians and Gynaecologists estimates that itchy skin can affect around 23% of pregnant women, but genuine ICP only affects about 0.7% of pregnancies,’ explains Leah.
'Some minority ethnic groups are slightly more prone to developing the condition.
'Overall, the risk to the general population of pregnant women is low, but it’s a good idea to understand the condition and be able to spot the signs.’
Signs and symptoms of ICP
‘In my experience, many women have itchy skin in pregnancy at one time or another, and it’s usually harmless,’ says midwife Leah.
‘However, genuine ICP is usually characterised by severe itching, particularly on the palms of the hands or soles of the feet, and it often gets much worse at night. There’s no visible rash, but the itch can be really distressing and some women are unable to sleep,' she says.
Along with itching, Leah also says a small minority of women with severe ICP may have symptoms including:
- jaundice (yellowing of the skin and eyes)
- dark urine and pale poo, although not all women with ICP notice these
- feeling generally tired and ill
- loss of appetite.
ICP is most common from 28 weeks onwards, but it can develop at any stage of pregnancy, so the symptoms should never be overlooked.
It can be diagnosed with two blood tests:
- A liver function test, which measures enzymes in the blood to establish how well your liver is working.
- A bile acids test – this measures the levels of bile acids in the blood. If they’re raised, it’s a sign of ICP – and the higher the levels, the greater the cause for concern.
Leah says:
'Your midwife or GP can take the initial diagnostic blood tests, and if ICP is confirmed, your care may need to be supervised by a consultant.'
Can ICP harm my unborn baby?
‘If left untreated, ICP can cause problems for both mothers and babies,’ says Leah.
‘That’s why it’s important to seek help early on if you develop any symptoms.'
However, it’s also important not to terrify yourself with worst-case scenarios, she adds:
'The vast majority of women who are diagnosed with and treated for ICP go on to have healthy pregnancies.’
What's the treatment for ICP?
There’s no cure for ICP other than giving birth, but medication may help to protect your baby from the dangerous effects of bile acids.
Until now, most hospitals have treated ICP with a drug called ursodeoxycholic acid (also called ‘urso’ or UDCA).
‘However, there’s been some new research to suggest that this may not be the most effective treatment for all women,' says Leah.
The research, conducted by King's College London, involved 605 pregnant women with ICP. Between 2015 and 2018, half the women were given urso and half a placebo.
The results found that 'urso did not have an impact on pregnancy outcomes including preterm birth, neonatal unit admission and stillbirth. They also found that it did not show any meaningful improvement in itch for most women, nor did it reduce the woman’s bile acid levels.'
Jenny Chambers, CEO of UK charity ICP Support said:
'As a charity, we witness the anxiety that many women with ICP experience because the fear of stillbirth is uppermost in their minds; effective drug treatments are therefore vital to help reduce this fear.
'The trial clearly demonstrates that for most women urso is not the drug to do this and while the outcome is likely to be hugely disappointing for women, it is also vital that they are not being falsely reassured.
'What we now urgently need is a drug treatment that can reduce both the itch and the risk of stillbirth that is associated with the condition and ICP Support will continue to work with researchers in their fight to do this.'
Professor Catherine Williamson, Department of Women & Children’s Health at King’s College London added:
'It is now clear that urso should not be used routinely to treat all women with ICP.
'Our future research focus will be to try to establish whether there is a subgroup of women who may still benefit from this drug, and also to focus on new drugs to improve outcomes for mothers and babies of ICP pregnancies.'
If you're concerned about your treatment for ICP, talk to your midwife, says Leah:
'It’s best to speak to your own medical team to review any new evidence and decide on the best path for you and your baby.
'Regardless of which medication you’re prescribed, you’ll be invited to have more frequent appointments involving monitoring of your baby’s heartbeat and a plan for earlier delivery,' she adds.
Will ICP affect my labour and birth?
Because the risks to your baby increase in the last weeks of pregnancy, women with ICP are often induced at or just before full term to minimise any possible complications caused by the condition.
There’s no evidence that giving birth by caesarean is safer, so you should be able to try for a vaginal delivery, although being induced does make a c-section more likely.
'Your midwife and consultant will be able to review your individual history and advise you on what’s safest,' says Leah.
'Your baby’s heart will be monitored as it usually would with any higher-risk condition, but as long as your condition is stable, little else (if anything) will change,’ she says.
Will ICP affect my newborn baby?
Once your baby has been delivered, they’re no longer at risk from ICP, so they won’t need any extra monitoring or tests, but may need blood tests 6 to 12 weeks after giving birth to make sure your liver function is back to normal.
ICP symptoms will go away after the birth, and it’s unlikely that you’ll have any ongoing complications linked to ICP.
Will ICP affect future pregnancies?
'There’s a slightly higher risk that if you’ve had ICP in one pregnancy, you may develop it in any subsequent pregnancy too,’ says Leah.
‘It’s important that this is noted in your medical history if you do book into maternity services again, as knowledge of your history can help your team to detect any problems earlier on next time. With the right guidance and support, ICP can have excellent outcomes.'
If you need more information about any aspect of ICP, visit ICP Support.
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