Month 7 More than just an itch!

Itching during pregnancy is more often than not caused by your changing hormones and stretching skin. But there is another, more alarming, condition you should know about.

The exact cause of ICP is not known, but research has shown that there are hormonal, genetic and environmental links.

One of the hardest things about being pregnant is knowing what’s normal, and knowing what’s not. Because often you think what you’re feeling (itchy, tired, nauseous, perhaps even a little down) are simply signs of your pregnancy, when in fact the symptoms point towards something more worrying. Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disorder of pregnancy. It results from a buildup of bile acids in the bloodstream that cause a persistent itch in the last trimester. It can, however, start as early as five weeks into pregnancy. According to Cape Town obstetrician and gynaecologist Dr Philip Zinn, it is only seen occasionally in South Africa’s private sector. The exact cause of ICP is not known, but research has shown that there are hormonal, genetic and environmental links. Sisters and daughters of women with ICP have around a 14 percent increased chance of developing ICP. What is known is that women who have ICP in one pregnancy are very likely to develop it again in the next one. Reported recurrence rates vary, with some researchers stating that 60 percent of cases reoccur, while others claim up to 90 percent.

THE SYMPTOMS

Because the severe itching is a common symptom, every woman who has itching in pregnancy (particularly in the third trimester and especially if there is no rash) needs to have liver enzyme tests as well as a bile acid test. These are two separate blood tests. The liver function test shows how the mother’s liver is coping with the pregnancy, and the bile acid test gauges the risk to the baby, and is used to diagnose ICP, guide treatment and time delivery. Dark urine, pale stools, jaundice (yellowing of the skin and whites of the eyes), nausea, fatigue, anxiety, depression and loss of appetite are other signs to look out for. You will need to visit your doctor immediately should you experience any of these symptoms.

SHOULD I WORRY?

ICP is associated with spontaneous preterm labour, foetal distress, meconium staining and – in severe cases – stillbirth. There is also an association of postpartum haemorrhage (loss of blood following delivery), but this is thought to affect less than 20 percent of women with the condition. Recent research has suggested that with active management (monitoring bile acid levels and liver function regularly), the risk of foetal complication in an ICP pregnancy can be the same as that of a normal pregnancy; ditto for the risk of stillbirth (about 1 percent).

TREATMENT

“A high index of suspicion is needed to pick up ICP and manage it properly,” Dr Zinn says. “While treatment to relieve the itch – which can be mild or severe, constant or intermittent, localised or general – can help you, it doesn’t necessarily help the risk to your baby.

“Your baby will need early delivery, but usually this is still around term (from 37 weeks) and not prematurely. If early delivery is a possibility, then steroids may be required to help mature the baby’s lungs.”

While liver function tests are indicative of how well your liver is working, bile acid levels are most important in gauging the risk to baby. “Depending on the results, ursodeoxycholic acid is given to reduce the buildup of bile salts,” Dr Zinn says.

AFTER BIRTH

Usually the condition resolves itself within 48 hours after delivery, but it can take several weeks for the itching to disappear. You can breastfeed your baby, even if your doctor suggests that you continue on medication.

Around six to 12 weeks after giving birth, your liver function and bile acid levels should be checked.

There may be an underlying liver condition that has caused the itching during pregnancy. If this is the case you will be referred to a hepatologist (liver specialist) or gastroenterologist who has a special interest in the liver. If you want to try for another baby, talk to your doctor so your pregnancy can be managed. ●