Signs and Symptoms of Intrahepatic Cholestasis of Pregnancy (ICP)
Intrahepatic cholestasis of pregnancy (ICP) is primarily characterized by pruritus (itching) without a rash that typically occurs in the second and third trimesters of pregnancy, accompanied by elevated serum bile acid levels. 1
Primary Clinical Manifestations
Pruritus (Key Diagnostic Feature)
- Generalized itching but predominantly affects the palms and soles of the feet 1
- Typically worse at night 1
- Usually not associated with a primary rash, though excoriations from scratching may be present 1
- Often the first and most troublesome symptom 2
Laboratory Abnormalities
- Elevated serum bile acid levels (≥10 μmol/L) 2
- Elevated liver transaminases (ALT, AST) may be present but not necessary for diagnosis 1
- Bile acid levels are the most sensitive indicator and may precede other abnormal liver tests 1
Risk Stratification Based on Bile Acid Levels
10 μmol/L: Diagnostic threshold for ICP 2
40 μmol/L: Increased risk of adverse pregnancy outcomes 2
- ≥100 μmol/L: Significantly increased risk of stillbirth after 35 weeks gestation 2
Less Common Symptoms and Signs
- Excoriations or prurigo nodularis from intense scratching (may be mistaken for a rash) 1
- Steatorrhea (infrequent) 1
- Jaundice is uncommon and suggests other hepatic diseases 1
- Dark urine is uncommon and suggests other hepatic diseases 1
Important Negative Findings
- Absence of primary rash (distinguishes ICP from other pruritic conditions of pregnancy) 1
- Excessive fatigue, insomnia, malaise, and abdominal pain/colic are not common with ICP 1
- If these symptoms are present, evaluation for other causes of pruritus and hepatic disease may be warranted 1
Timing and Course
- Typically occurs in the second and third trimesters 1, 2
- Early-onset ICP (before 33 weeks) may be associated with increased fetal complications 1
- Symptoms spontaneously resolve within 4-6 weeks after delivery 1
Clinical Pearls
- ICP has a recurrence rate of 45-90% in subsequent pregnancies 3
- Patients with genetic variants in hepatobiliary transport proteins (particularly ABCB4 and ABCB11) may present with earlier onset or more severe disease 4
- ICP is more common in multiple pregnancies due to higher hormonal levels 1
Differential Diagnosis Considerations
When evaluating a pregnant woman with pruritus, consider:
- Atopic eruption of pregnancy (AEP) - associated with eczematous rash 1
- Polymorphic eruption of pregnancy (PEP) - associated with urticarial papules and plaques 1
- Pemphigoid gestationis (PG) - associated with vesicles and bullae 1
- Other causes of pruritus without rash (renal failure, thyroid disorders, other liver diseases) 1
Remember that while maternal outcomes are generally benign, ICP is associated with increased risk of adverse fetal outcomes including preterm delivery, meconium staining, and stillbirth, making prompt diagnosis and management essential 1, 2.