The MamasteFit Podcast Episode 155 – Itchy Palms in Pregnancy? ICP Explained

Roxanne: If you’re wondering why itchiness of the palms or the soles of our feet would be concerning and what you should do, this is the video for you. 

Hi, I’m Roxanne. I’m a certified nurse midwife, and in this video we’re gonna be discussing all about Intrahepatic Cholestasis of Pregnancy, and what this means for your pregnancy, as well as what this means for your baby. 

A common symptom that people will discuss is itchiness within the palms or the soles of our feet, and it has no rash associated with it. It is not super common in pregnancy, it’s like 2% to 3% of pregnancies, but it can be concerning. But what even is this? What is going on that’s causing this? 

So this is a pregnancy specific liver condition where something is going on within the liver that is leading to an accumulation of bile acids within our bloodstream. So something is happening within the liver that the bile acids, which is responsible for a lot of things, like digestions of fat, absorption of fat soluble vitamins, as well as waste removal- very important thing for our bodies- but something’s happening within the liver, that it’s not going into the bile ducts and then either going to the gallbladder to be stored, or to our intestines to do all of those things. So when there’s this disruption within the liver, usually due to pregnancy hormones, this is leading to an accumulation of those bile acids within our bloodstreams, which can lead to the symptoms that we’re experiencing. 

During pregnancy, it doesn’t have any effect on you. It’s usually going to lead to some sort of itchiness that’s going to be very disruptive potentially to sleep and comfort. But it also, if it’s there for a while, and if this happens outside of pregnancy, could lead to a possible vitamin deficiency because bile acids are very responsible for vitamin absorption, especially the fat soluble ones. The fat soluble ones are vitamin A, D, E, and K. So vitamin K would be important because that is involved with clotting, so sometimes if it’s been there for a while, it could increase your risk for vitamin K deficient bleeding, or increasing risks for like postpartum hemorrhage. But increased risk for the mom or the birthing person is really limited to that: the itchiness and the vitamin deficiency. 

Really the risks are associated for baby when this is present in pregnancy; and those risks are associated with, one, babies have an increased risk of preterm birth, whether that is spontaneous preterm labor, or potentially recommend induction preterm labor; and this could lead to increased risk of respiratory distress for babies at birth; and, an increased risk of still birth. This is why the recommendation for ICP when you’re pregnant is moving towards an induction of labor or moving towards delivery. But these recommendations are entirely based off of our bile acid levels. 

So, if you’re having itchiness of the like palms of your hands or soles of your feet and there’s no rash present, there could also be other symptoms that you can look out for. There’s jaundice, or yellowing of this skin. You can have dark urine or very light colored stools. You can be very fatigued, and you can have some right upper quadrant pain, which is where our liver is located. So if somebody touches your right upper quadrant and it’s painful and you’re having this itchiness, that could be a sign that ICP is present. 

How do we diagnose it, is, one based off of your symptoms and then we’ll draw a bile acid level. This usually does take a few days to come back though, which is kind of where it’s hard with management, but they also might do some liver enzymes to see how your liver is functioning and there could be some changes slightly with the liver enzymes. But the biggest things are symptoms and bile acid levels. So once your bile acids come back, that is where our treatment can come into effect. Are we gonna give you some medications to potentially lower those bile acids and prolong your pregnancy; or, are they so high and you are past 36 weeks, and we would recommend induction? It’s really entirely based off those bile acids. If they’re less than 40, we can continue to monitor you and baby and prolong the pregnancy, potentially giving you some medication, this is a specific medication to lower your bile acid levels. Treatment for ICP is really entirely dependent on those bile acids. So once those come back, we can develop a treatment plan. And treatment can range from medication to help lower the bile acid levels… it can range from medication that we can give you to possibly decrease the bile acid levels and as well as increase your comfort- ’cause hopefully it’s going to also decrease your itching- as well as we can do some monitoring for baby with non-stress tests and biophysical profiles. And if you’re curious what those are, we’ll link the video for a non-stress test and biophysical profiles down below. And then we’re gonna continue monitoring those bile acid levels. 

And then, depending on where you are in your pregnancy and what those bile acids are, they may recommend induction of labor as early as 36 weeks. So severe ICP would be at like bile acids that are greater than 100. This is where we would consider the severe ICP, and all of those risk factors for baby- the stillbirth, preterm birth, respiratory distress, all of those things- are at the highest amount when it’s over 100, and this is why the recommendation for that is induce labor as early 36 weeks. If you’re diagnosed with ICP with severe levels of bile acids and 38 weeks, this is when they’re just going to recommend induction at that time, ’cause the 36 weeks has already passed. If you have mild ranging bile acids, so 40, or 40 to 99, this is where you and your provider kind of like create a plan that you both feel comfortable with because that is not as severe. So the risk factors are still there, but they’re not as severe and as high of a risk as the severe ICP. 

Many of the times someone will be diagnosed with ICP, you’ll have all of the symptoms and after 36 weeks, because the bile acids can take a few days to come back, sometimes they will recommend induction. And this is again, where you have a conversation with your provider on what are the risks associated with ICP, and do you feel comfortable waiting for the bile acids to come back before moving towards induction, or would you rather just move towards induction in that time? 

A lot of the time, the stillbirth risk is brought up, and there is an increased risk of stillbirth, but understanding the percentages and the true risk associated with it can be helpful for some people to develop a plan that they feel confident in. The general population of low risk pregnancies, the risk of stillbirth is like, 0.3 to 0.5%, so like three to five in 1000 pregnancies will have a still birth. So someone who has a bile acid less than 40, has a very similar rate for stillbirth as the general population, and someone who has a bile acid between 40 to 99 also has a very similar rate to the general population, but it is slightly increased. So if it’s the general population risk is again 0.3%, or 3 in a thousand pregnancies, this one is like 3.5 in a thousand pregnancies, or 0.35%. And then we get to the greater than 100, and this is where the true stillbirth risk actually does increase. The rate of stillbirth in people who have over 100 level of bile acid is 3.4% stillbirths, or 35 in a thousand pregnancies, or it’s 35 in 1000 pregnancies will have a stillbirth that have this severe ICP. This is like a 10 times increased risk associated with stillbirth for people with severe ICP, but it’s not always explained with those numbers, so sometimes having the different numbers can be helpful for you to truly understand the risks associated with it. 

So just to recap, the stillbirth rate for the general population is around 0.3%, or 3 in 1000 pregnancies. The rate of stillbirth for someone who has a 40 bile acid or a 40 to 99 bile acid is very similar to that general population. The 40 to 99 does have a slight increased risk, but it is not like clinically significant. Whereas when someone has a bile acid greater than 100, this does have a 10 times increased risk where it goes from 0.3 to 3.5%, so instead of 3 in a thousand pregnancies, it is 35 in a thousand pregnancies. And again, knowing those risks, one person may choose something else than another person, but having these numbers to make a confident, informed decision for your pregnancy in the birth of your baby can be helpful. 

While ICP and pregnancy is not a super common condition that develops during pregnancy, I do see it often as a reason for an induction for somebody who develops this during pregnancy because there are increased risks associated with it. 

But just to recap, what is ICP? This is a liver condition that develops in pregnancy that affects the transfer of bile acid within the liver. So something is going on within the liver that prevents the bile acids to enter the bile ducts, that leads to an accumulation of bile acids within the body. That can lead to that severe itching, specifically soles of the hands or palms of the hands, soles of the feet, and there’s no rash associated with it. Bile acids are, what do bile acids even do? Bile acids really important for fat digestion and vitamin absorption- specifically the fat soluble vitamins, as well as it’s also really important for waste removal. Other things that you might experience if you have ICP, other than the itching is you can have jaundice, which is yellowing of the skin, dark urine light stools, as well as really fatigued, just due to the bile acid buildup. And then also you might start having some right upper quadrant pain. 

If we’re noticing any of those symptoms, specifically the itching, we will usually recommend drawing a bile acid level. Again, this can take a couple days sometimes to come back, but based off of those bile acids, then we’ll develop a treatment plan, which is either moving towards an induction of labor, we can give you some medication to lower the bile acids, and then we’ll also continue monitoring baby with non-stress tests and biophysical profiles, and monitoring the bile acid levels depending on when in pregnancy does this develop. 

The risks for you pretty low, other than itching could affect your comfort potential risk of vitamin deficiencies. For baby there are increased risk of preterm birth, respiratory distress after birth and stillbirth, but those risks are associated with the bile acid levels. Severe ICP is bile acids greater than 100, and that is associated with the most risk and the highest risk of stillbirth that increases 10 times the general population- which the general population, again is 3 in a thousand, and then the risk with severe ICP is 35 in a thousand. 

With ICP, we discussed all of these things about it during pregnancy, what are the symptoms, treatment plans, but after pregnancy, once the baby is born, usually this will self resolve within a few days, doesn’t hold any increased risk. There is increased risk for future pregnancies, there is a high rate of recurrence, and then there is the potential increased risk of cholestasis that can develop outside of pregnancy affecting our gallbladder. 

Once baby is born, usually ICP will resolve within a few days and doesn’t hold any long-term complications for you for your liver or gallbladder, but there are increased risks for subsequent pregnancies because it does have a high recurrence rate. So in one pregnancy, if you had ICP, you have like a 40 to 60% chance of developing again in subsequent pregnancies. 

So if you also had ICP or you’re noticing some itchiness of your palms or soles of your feet, let us know your symptoms below, and if you have any specific questions about this, let us know down in the comments below as well. 

And if you’re looking for more support during your pregnancy, check out our online childbirth education course where we break down the science and labor of birth very similarly, like we do in these videos on YouTube. Within the course, we go over birth options, labor timeline, labor comfort techniques for you, how your partner can prepare for it, and how you can prepare mentally for birth as well. And there is even a small section on what to expect postpartum! They’re broken down into small videos, so it’s easily digestible. And our goal is after you finish that course to go in to have a confident and empowering birth experience. 

And you can check out all of our offerings at mamastefit.com and use code YOUTUBE10 for 10% off as a thank you for watching this entire video. If you enjoy this video and want more from us, be sure to like and subscribe to our channel so you can be notified whenever we release new videos. We release new fitness videos on Tuesdays and new educational videos on Wednesdays.