Intrahepatic cholestasis of pregnancy (ICP)

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What is intrahepatic cholestasis of pregnancy (ICP)?

Is ICP common?

What causes ICP?

What are the symptoms of ICP?

How is ICP diagnosed?

How may ICP affect my baby?

What extra care and treatment will I have?

Will having ICP affect how, when and where I give birth?

Will having ICP affect me after I've had my baby?

What is intrahepatic cholestasis of pregnancy (ICP)?

Intrahepatic cholestasis of pregnancy (ICP), sometimes called obstetric cholestasis, is a condition affecting your liver in pregnancy. Normally, bile acids are made in the liver and flow to your gut to help you digest food. But in ICP, the bile acids build up in your body instead. The most common symptom of ICP is itching, which can be mild or very intense. 

Is ICP common?

No. ICP affects about 7 in every 1,000 pregnant people in the UK (less than 1%). It is slightly more common in people of Indian-Asian or Pakistani-Asian heritage, affecting about 15 in 1000 pregnant people (1.5%). 

What causes ICP?

The causes of ICP are not fully understood but it is possibly due to a combination of hormonal, genetic and environmental factors. It sometimes runs in families.

What are the symptoms of ICP?

Symptoms of ICP usually start from around 28 weeks of pregnancy but can start at any time. 

Itching is the main symptom of ICP

Itching without a rash is the most common symptom. It is often worse at night and more noticeable on the palms of the hands and soles of the feet, but it can be anywhere on the body. Itching from ICP affects people differently and can vary at different times.  

It can be mild or intense and affect only small areas of your body or all of it. It can be distressing and affect your sleep. ICP itching will stop soon after you’ve given birth, usually in hours or days.

If you have any itching, contact your maternity service within 24 hours. Try to be specific about where you are itchy and how severe it is. Itching is very common in pregnancy and only a small number of people who itch will have ICP.  

It is important to trust your instincts if you feel something isn’t right. If you are concerned about ICP but do not feel that your symptoms are being taken seriously, you can ask to see another midwife (or doctor).

If your mental health is being affected by ICP, do tell your midwife or doctor about it so they can arrange extra support for you. You can also read our top tips for looking after your emotional wellbeing. 

What can help ease itching from ICP?

For most of the treatments that have been tried for relieving itching in ICP, there isn’t good evidence to tell us how well they work.

You can safely experiment with changes to your clothing and environment to see if anything gives you some relief. Some people have found that wearing loose, cotton clothing and having cool baths helps. You could try using unperfumed products if those with strong perfumes seem to irritate your skin.

Ursodeoxycholic acid (UDCA) is a medicine that probably slightly improves itching for a small number of people. But the benefit is so small that most people would not think this useful.

It’s not clear how useful antihistamine medicines are for itching in ICP. The itching isn’t thought to be caused by histamine, but antihistamines with sedative effects, such as such as chlorphenamine, may help you sleep. Antihistamines are safe to use in pregnancy.

Skin creams that are safe to use in pregnancy, such as aqueous cream (with or without menthol), may help ease itching.

Other symptoms of ICP

Other less common symptoms of ICP may include:

• dark wee  
• pale poo
• yellowing of the skin and whites of the eyes (jaundice).

How is ICP diagnosed?

ICP is diagnosed by excluding other causes of the itching. Your doctor will check your skin to see if the itching could be due to a skin condition, like eczema. You might have more than one condition. Your doctor will probably advise you to have some blood tests, including tests to check your liver function and bile acids.  

Some people may have itching for days or weeks before their blood tests become abnormal. If you are still itching and a cause hasn’t been found, the blood tests should be repeated every 1–2 weeks. 

How may ICP affect my baby?

Your baby is more likely to pass meconium (poo) before they are born if you have ICP. This can make your baby unwell if it gets into their lungs during labour.

Your baby is more likely to be born early (before 37 weeks). This could happen naturally. Or you may be offered a planned birth by induction of labour or c-section. This can happen from 35 weeks, depending on the level of bile acids in your blood and any other risk factors, such as pre-eclampsia.

For some people with ICP, there is an increased risk of their baby being stillborn. This can be hard to read about. But for most people with ICP the risk will be the same as for people without ICP. Your risk depends on the level of bile acids in your blood and any other pregnancy complications you have. 

For people whose bile acid levels are 100 micromols per litre or more (severe ICP), the chance of stillbirth is higher than for someone who doesn’t have it and is around 3%. Most people with ICP will have bile acid levels lower than this.

It’s important to keep an eye on your baby’s movements. Most people first feel their baby move when they are 18 to 20 weeks pregnant. Feeling your baby move is a sign they are well. Contact your midwife or maternity unit straight away if you think your baby’s movements have slowed down, stopped or changed.

Your baby has a slightly higher chance of needing to spend time in a neonatal unit, especially if they were born early. There are no known long-term health risks to your baby from you having ICP.

What extra care and treatment will I have?

There aren’t any treatments to improve your bile acid levels. But you are likely to be under the care of an obstetrician (a specialist doctor in pregnancy and birth) and a plan of care will be made for you. You will have bile acid and liver function tests, possibly every week at first. How often you have them after that will depend on your test results and symptoms. You will not need extra scans because you have ICP.

Having ICP makes you more likely to get pre-eclampsia or gestational diabetes. Your doctor or midwife will let you know what checks you may need for these.

You might be prescribed a daily dose of vitamin K if ICP is affecting your blood’s ability to clot. Not many people need this though.

When your baby is born, your ICP will get better. You should have a bile acid test and liver function test around 6 weeks after you give birth to confirm this. If the results are not normal by then, the test will be repeated. If your results are still not normal, you may then be referred to a specialist. They can find out if something else is causing your test results.

Will having ICP affect how, when and where I give birth?

You may need to have your baby in hospital, under a doctor-led maternity team. This will depend on your bile acid levels. It may mean changing your your birth plan. 

Your team will monitor your condition and talk with you about the best time for you to give birth. They should make sure you have all you need to decide what’s right for you and your baby.  

Depending on your bile acid levels and other risk factors like pre-eclampsia, they may ask you to consider having a planned birth, either by having your labour induced or by c-section. This is to reduce the chance of your baby being stillborn.

Making decisions in pregnancy can be difficult. We have some information on making decisions in pregnancy you might find helpful.

Your pain relief options in labour will be the same as for someone without ICP.

Will having ICP affect me after I've had my baby?

ICP symptoms get better once you’ve given birth. But it can take a few weeks for your blood tests to return to normal.

Previously having ICP does not affect your choice of contraception once your liver blood tests and bile acid levels are normal again. Find out more about your sexual and reproductive health after having a baby.

Having ICP increases your chance of having it again in future pregnancies.  

There is some evidence that people with ICP may be slightly more likely to have liver problems in the future, or other conditions including psoriasis, thyroid disease, heart disease and Crohn’s disease. But extra screening or follow-up is not recommended.

More support and information

ICP Support provides information and support to people affected by ICP and funds research into the condition. 

The Tommy's Midwives' Helpline is a free-phone line open 9-5, Monday to Friday for anyone who needs advice, reassurance or support on any pregnancy or planning for pregnancy issue, including mental health.

The number is 0800 0147 800.

The midwives will also answer your questions by email on [email protected]

We have a special helpline reserved for Black and Mixed Black women and birthing people. This is because this group has a higher risk of having pregnancy problems than other ethnicities. You can book your call with our Black and Black Mixed Helpline here.