By: Call the Midwife
No, I don’t mean
baby fever. I mean a physical itch so debilitating, relentless, and unbearable
that you’ve scratched or rubbed your skin raw ‒ all while pregnant. That’s what
can be experienced by around 1 in 1,000 pregnancies and is often an indicator of:
intrahepatic cholestasis of pregnancy (ICP) or obstetric cholestasis.
The following post will demonstrate an overview of the causes and features of
ICP, keeping in mind that more research is constantly developing and that not
all details can be explained in one post.
The term
“cholestasis” refers to any bodily condition that obstructs the flow of the
digestive fluid, bile, which is created in the liver and stored in the
gallbladder. Bile is important in the absorption and excretion of toxic substances
therefore with ICP there is a risk of
accumulating toxins and waste products in the body. The exact causes of ICP are
unknown and seem to be composed of genetic, hormonal, and environmental
factors.
ICP can be
genetically inherited as a sex-chromosome linked dominant trait meaning that it
could be passed on from generation to generation if you're either of your
parents have experienced the disease or are carries of the genetic component.
Your genetic code acts as a recipe and takes ingredients from your parents to
make up a new twist. It is also thought that the elevated hormone levels, such
as increased estrogen, experienced during reproduction may trigger an incidence
of ICP by unmasking or flipping the switch on that genetic marker that you
already possess.
What you may be
experiencing:
The most common
symptom women with ICP experience is a severe itchy feeling throughout the
body, especially in the hands and feet. Other symptoms can include darkened
urine, light stools, loss of appetite, depression, and anxiety. A rare but
possible symptom is jaundice which is yellowing of the skin.
Itching alone is not
a direct indicator of ICP, as itching during pregnancy can occur for a variety
of reasons. In order to diagnose, a physician will usually order a blood test,
a liver function test and bile acid test to identify signs and indicators of
ICP
Although the
condition does little long-term harm to the mother, there are a number of possible
fetal complications including fetal distress, fetal oxygen deprivation and
stillbirth. It’s common that the itching becomes so unbearable to the mother
that delivery as early as 36-37 weeks is common. A particular toxin to be aware
of for the sake of the baby's development is the buildup of bilirubin, which is
a byproduct of blood recycling. A buildup of bilirubin can be toxic to
developing a fetal nervous system which causes a syndrome called kernicterus
which is a form of nervous system damage caused by severe jaundice. The
general approach is to conduct twice-weekly non-stress testing to monitor the
baby and induce labor after 37 weeks if the baby’s lungs are adequately
developed. There is a low risk of hemorrhaging during delivery which is usually
addressed at birth with a vitamin K shot before and after birth to promote
blood clotting.
Why the itch?
The Great Itch ‒ itself,
is caused by the bodies lack of ability to excrete cholesterol from the body.
Cholesterol is normally converted to bile salts and excreted with them but with
the buildup of bile salts in cholestasis, cholesterol and bile salt serum
deposits can collect under the skin and cause severe irritation and itching.
Photo credit:
momjunction.com
Am I the only one
going through this horror?
Exact incidence of
ICP is difficult to identify because understanding of ICP is just recently on
the rise. Data shows that familial clustering is prominent which supports the
theory of both genetic and environmental components. The incident rate in the
United States varies between 1-5% while incidences are much higher in areas
like Chile at 16%. Advanced maternal age seems to increase risk and pregnancies
with multiples can make the mother 5 times more likely to develop ICP.
Treatment &
Prevention
There is not a cure
for ICP but rather methods to make the symptoms more comfortable. Anti-itch
creams and cold baths are generally recommended although they are mildly
effective. Diet can be a big component in both prevention and treatment.
Since bile is
important in the digestion of fatty acids, eating a diet lower in fats will
signal your body that not as much bile is needed and it will therefore make
less bile because it is not needed. Healthy fats (unsaturated and
polyunsaturated) are recommended because they are biochemically easier to break
down in comparison to less healthy fats (saturated or trans-fats) and will therefore
need less bile. Supplements such as refined fish oils, milk thistle, and
dandelion root are recommended as both prevention and treatment because of
their liver detoxifying properties.
Gallbladder removal
for the mother is also common after birth because an incidence of ICP can be a
good indicator of future complications such as gallstones.
ICP generally
resolves after birth but studies have shown that there is possibility for
increased risks of liver and immune diseases for both mother and baby.
There is still much
research to be done that could help identify more preventative actions and
develop more understanding for this challenging condition. There have been
major advances in the information available on ICP in the past decade and it
continues to grow.
As with most medical
conditions, there really is no ceiling to the amount of information available
on the topic. For more information, check out the following resources:
Dixon PH, Williamson C. The pathophysiology of intrahepatic cholestasis of pregnancy. Clin Res Hepatol Gastroenterol (2016), http://dx.doi.org/10.1016/j.clinre.
Jones, Pip. "Obstetric Cholestasis In Pregnancy: Symptoms And Treatment." The Huffington Post UK. N.p., 14 Aug. 2014. Web. 11 Feb. 2016. http://www.huffingtonpost.co.uk/2014/08/14/obstetric-cholestasis-in-pregnancy-symptoms-and-treatment_n_7359240.html.
Kim, Steven. "Obstetric Cholestasis: Is This Complication Dangerous?" Healthline. N.p., 18 Sept. 2015. Web. 11 Feb. 2016. http://www.healthline.com/health/pregnancy/obstetric-cholestasis.
Rigby, Fidelma B. "Intrahepatic Cholestasis of Pregnancy." Medscape. N.p., 23 Apr. 2014. Web. 11 Feb. 2016. http://emedicine.medscape.com/article/1562288-overview#a.
Photo credits: momjunction.com http://cdn2.momjunction.com/wp-content/uploads/2014/10/Obstetric-Cholestasis-454x255.jpg
https://upload.wikimedia.org/wikipedia/commons/thumb/3/32/Diagram_showing_the_position_of_the_distal_bile_ducts_CRUK_348.svg/2000px-Diagram_showing_the_position_of_the_distal_bile_ducts_CRUK_348.svg.png
-Prettymamma
ReplyDelete1. I like that you added additional resources at the end of your paper for easy access to keep on reading about this topic. Your paper was easy to follow and understand.
2. Overall I think you wrote a great paper, the only thing I really was interested in knowing more about was the genetic part. You mentioned it can be passed on genetically but is there a high or low risk?
3. If a mother already has her gallbladder removed before pregnancy, is she at a decreased risk of developing this?
Hello Prettymamma,
DeleteThanks for reading and sharing your feedback! In addition to hormones and environment being causes/indicators of ICP, genetics also seems to be playing a role although research on the topic is relatively new. The genetic predisposition seems to play as a recessive trait. Researchers have identified several genes which can contribute to ICP but there are likely more out there. The main genes cause problem in the coding of a protein called Bile Salt Export Protein (BSEP) which helps in the movement of bile from liver cells where it’s created and into the bile duct. Dysfunctions in these genes contribute to the blocking effect in the bile duct. Because it’s a recessive trait the likelihood of receiving the trait is lower than if it were dominant but it still plays a role.
There is no cure for ICP and they have found that gallbladder removal before or after pregnancy is not effective in preventing it. Gallbladder removal is sometimes recommended after a woman has experienced ICP once because there is an increased likelihood for gallstones but it depends if the individual has had issues with gallstones or other gallbladder issues in the past. So removal is not a direct treatment and does not offer preventative measures in prevention of ICP but it may be necessary to avoid other gallbladder issues.
Thanks for reading!
-CallTheMidwife
zombieland
ReplyDelete1. I really liked the layout of your paper. The bold topics helped lead into the next discussion well.
2. One thing that might help, is to discuss more about what possibly causes. Also I was wanting to know earlier in the paper about if this is a condition that happens during pregnancy alone.
3. Does having this condition during one pregnancy mean that they will have it with subsequent pregnancies also?
Hello Zombieland,
DeleteThank you for your feedback! Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis, is a liver/gallbladder disease that only occurs during pregnancy and although the causes are still relatively unknown, one of the biggest triggers and indicator are the increased hormone changes which happen during pregnancy.
If a mother has experienced ICP previously, there is a high likelihood that she will experience it in subsequent pregnancies. A peer reviewed, review article by J. Eileen Hay in 2008 entitled Liver disease in pregnancy, estimated that 40% - 70% of individuals will experience ICP in subsequent pregnancies if they’ve had it in previous pregnancies. Other articles note the probability to be even closer to a 90% chance. Some healthcare providers recommend testing for bile acids and liver function early in the pregnancies if they have a history.
Thanks for reading!
-CallTheMidwife
OCR-Mama
ReplyDeleteI think you picked a great topic! I appreciate you sharing this with us. I had no idea how common ICP was. I am more familiar with another pregnancy itch called PUPPs. I really like how you laid out the information. Your introduction drew me in and then got right to the point. I thought is was very effective at capturing your reader.
To improve this you might look at the end of the blog post. The final bits of information are chunked up and don’t flow as nicely as the rest of the post. A small amount of polishing could smooth out the landing of this post.
What percentage of ICP cases require a near term or early term delivery (36-37 weeks)?
Hello OCR-Mama,
DeleteThank you for reading and providing feedback! If ICP develops it is most often in the third trimester. The biggest advantage for an early term delivery around 37 weeks is to reduce the risk of stillbirth. The risk of stillbirth with ICP can be as high as 15% but with active management and monitoring the risk drops down to 1% which is the risk in uncomplicated pregnancies. It’s important to monitor bile acid levels and non-stress testing is highly recommended to watch for abnormal heart rhythms in the fetus. They have found that high levels of bile acids actually make the uterus more sensitive to oxytocin which can stimulate early contractions and early-term labor on its own in roughly 20%-40% of cases.
Thanks for reading!
-CallTheMidwife