Post-Birth
After the birth of your baby
The longer-term effects of ICP
You will need to have follow-up checks on your liver. This is because sometimes there may be an underlying liver condition which is not ICP that has caused the itching and abnormal liver readings during your pregnancy. The check-up should include a liver blood test and bile acid test. Although the current RCOG Guideline on ICP recommends that these tests should be done four weeks after birth, our experience, together with the experience of experts in ICP shows that 6–12 weeks is fine. This is because although bile acid concentrations will drop rapidly once your baby is born, the liver enzyme alanine aminotransferase can take a little longer to return to normal. Alkaline phosphatase (another enzyme in the liver blood test) can also take longer to return to normal if you are breastfeeding.
If the results still show elevated ALT/AST or bile acid levels you will need to have the tests repeated. If, after six months, your levels are still not improving it may be advisable to be referred to a hepatologist (liver specialist) or, if there not one in your area, a gastroenterologist with a special interest in the liver. You may have another liver condition (although this is quite rare) or your liver is just taking a little while to settle down. This has been known to happen with women who have had ICP. Whatever the underlying reason you will need to see a specialist who will advise you on what to do next.
We already know that women and birthing people who have ICP have a greater risk of developing gallstones, but there is some suggestion that women who have had ICP may also have an increased risk of developing other forms of liver disease, such as biliary tree cancer, in later life. We must stress that this risk is very, very small (your risk of developing something like breast cancer is much higher), but we have received advice from a hepatologist that it makes sense for women who have had ICP to have annual liver blood tests and bile acid tests. This is very new thinking and your doctor is unlikely to be aware of this advice.
Recent research suggests that women with ICP have an increased risk of developing Type 2 diabetes and/or cardiovascular disease in later life. This is because ICP is a metabolic disease and it’s thought that the metabolic changes that take place during an ICP pregnancy have an effect not only on the woman but also on her children. For example, there may also be an increased risk of Type 2 diabetes for children in later life. It’s all very early research, so much more work is needed to fully understand the implications.
Antibiotics taken after an ICP pregnancy may cause a return of the itching (and sometimes cholestasis), but it is important to take the antibiotics if you need them. Any itch should resolve once you stop taking the antibiotics, although it may take a few days to settle. Always let your doctor know if you do experience itch on antibiotics.
Why am I still itching?
If you have only recently had your baby the itching should have at least decreased in severity and will go away in due course. However, if you are still itching several weeks after the birth you should see your GP for further investigation. Very occasionally women are discovered not to have had ICP but some other form of liver disease. You may need a referral to a hepatologist (liver specialist) or a gastroenterologist who has a special interest in the liver.
If it is some time since you have had your baby, it may be that your itching is what has been termed ‘cyclical itching’. Although this is not addressed in the current RCOG Guideline on ICP, years of feedback from women who have the condition confirms that it does exist. It can usually be linked to ovulation or the start of menstruation. It generally only lasts for a few days and is not as intense as the itching experienced during an ICP pregnancy. There has been no research to explain why this happens, but current thinking suggests that it happens because your liver has been left ‘sensitive’ to hormone fluctuations – hence the link to ovulation and menstruation.
Some women have reported that they experience itching again in times of extreme tiredness and stress, but the reasons for this are not yet known.
Contraception is also a possible cause of itching.
Contraception
The only methods of contraception that may possibly cause problems for women who have had ICP are those containing hormones. However, there have been no large studies regarding the use of contraception following an ICP pregnancy, so you may be given conflicting advice about what you can or can’t use. Given that it has yet to be established whether it is progesterone or estrogen that ‘triggers’ the condition, it may be prudent to use only those hormonal forms of contraception that bypass the liver, such as the Mirena® coil (but see the comments about this below).
However, anecdotal (not medically proven) evidence is showing that many women can tolerate the mini pill or progesterone implant and some women are also able to use a low dose combined oral contraceptive pill.
The current RCOG Guideline supports the use of the combined oral contraceptive pill, but advises against its use if you have previously suffered cholestasis whilst taking it.
If you do decide to take the pill (the decision should be made in consultation with a doctor) it is important to make sure make sure that your liver blood test is normal before you begin. It should also be checked again approximately six weeks later. This is easily checked by requesting a liver blood test. If you start to itch after you begin to take the pill you should stop. However, this itching shouldn’t be confused with cyclical itching, which is something that some women experience after having ICP and can be linked to ovulation or the start of menstruation. This itching normally only lasts for a few days and disappears once ovulation has taken place or the woman’s period starts.
It is worth noting that some women who have contacted us report being unable to tolerate any form of contraception that contains hormones, including the Mirena® coil. Of course there are other forms of contraception that you can use, and you may want to discuss these options with your GP, nurse, midwife or local family planning clinic.
There are of course other methods of contraception that do not contain hormones. These can be found here.
Can I take HRT?
There has been no research regarding HRT and ICP. As with hormonal contraception, it’s a question of trying it to see what happens. Anecdotally (not scientifically proven) some women have reported successful use of HRT. It is recommended that to bypass the liver estrogen is used transdermally, and for those women who still have a uterus progesterone will be needed; this can be used vaginally.
We recommend that you see your GP or practice nurse to discuss this with him or her and ask to be referred to a menopause specialist. You will also need to have a liver blood test performed before you start to take HRT.
Good sources of information about menopause can be found at Menopause Support and My Menopause Doctor.
Will I get ICP again?
Women who have ICP in one pregnancy have around an 80% chance of developing it in a future pregnancy. There are no current studies that can give a definitive recurrence rate.
The current RCOG Guideline recommends a baseline liver blood test and bile acid test at booking (typically around 12 weeks of pregnancy).
If you are expecting more than one baby this increases your risk of developing it.
If you have or have had IVF (fertility) treatment this also seems to be associated with an increased risk of developing ICP.
And although it’s not typical, ICP can present before 28 weeks of pregnancy (called the first and second trimesters) as opposed to the usual onset, which is in the third trimester (28 weeks onwards). The earliest reported diagnosis has been at 8 weeks of pregnancy. Your health professional may not know this can happen, so you may need to be prepared to be assertive about having the blood tests you require if this happens to you.
References
Longer-term effects
Girling J, Knight CL, Chappell L; on behalf of the Royal College of Obstetricians and Gynaecologists. Intrahepatic cholestasis of pregnancy. BJOG 2022; 1–20. https://doi.org/10.1111/1471-0528.17206.
Martineau M, Raker C, Powrie R, Williamson C. Intrahepatic cholestasis of pregnancy is associated with an increased risk of gestational diabetes. Eur J Obstet Gynecol Reprod Biol 2014; 176: 80–5. https://doi.org/10.1016/j.ejogrb.2013.12.037.
Martineau MG, Raker C, Dixon PH, Chambers J, Machirori M, King NM, Hooks ML, Manoharan R, Chen K, Powrie R, Williamson C. The metabolic profile of intrahepatic cholestasis of pregnancy is associated with impaired glucose tolerance, dyslipidemia, and increased fetal growth. Diabetes Care 2015; 38: 243–8. https://doi.org/10.2337/dc14-2143.
Papacleovoulou G, Abu-Hayyeh S, Nikolopoulou E, Briz O, Owen BM, Nikolova V, Ovadia C, Huang X, Vaarasmaki M, Baumann M, Jansen E, Albrecht C, Jarvelin MR, Marin JJ, Knisely AS, Williamson C. Maternal cholestasis during pregnancy programs metabolic disease in offspring. J Clin Invest 2013; 123: 3172–81. https://doi.org/10.1172/JCI68927.
Wikström Shemer EA, Stephansson O, Thuresson M, Thorsell M, Ludvigsson JF, Marschall HU. Intrahepatic cholestasis of pregnancy and cancer, immune-mediated and cardiovascular diseases: a population-based cohort study. J Hepatol 2015; 63(2): 456–61. https://doi.org/10.1016/j.jhep.2015.03.010.
Why am I still itching? and Contraception
Girling J, Knight CL, Chappell L; on behalf of the Royal College of Obstetricians and Gynaecologists. Intrahepatic cholestasis of pregnancy. BJOG 2022; 1–20. https://doi.org/10.1111/1471-0528.17206.
Marschall HU. Management of intrahepatic cholestasis of pregnancy. Expert Rev Gastroenterol Hepatol 2015; 9(10): 1273–1279. https://doi.org/10.1586/17474124.2015.1083857.
Will I get ICP again?
Girling J, Knight CL, Chappell L; on behalf of the Royal College of Obstetricians and Gynaecologists. Intrahepatic cholestasis of pregnancy. BJOG 2022; 1–20. https://doi.org/10.1111/1471-0528.17206.
Ovadia C, Williamson C. Intrahepatic cholestasis of pregnancy: recent advances. Clin Dermatol 2016; 34: 327–34. https://doi.org/10.1016/j.clindermatol.2016.02.004.
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