Intrahepatic Cholestasis of Pregnancy (ICP)

Definition

Typically, Intrahepatic-Cholestasis of Pregnancy (ICP) is a serious condition/disorder of the liver that develops during late pregnancy in some expectant women. The disorder is also commonly known as cholestasis of pregnancy, prurigo gravidarum, obstetric cholestasis, or jaundices of pregnancy by some doctors (Lammert et al, 2000). It is a medical condition during which there is cholestasis occurrence in a pregnant woman. The condition is typically characterized by instances of extremely troublesome itching of particular parts of the body’s skin which can also spread to other parts of the body, and can later result into certain complications for both the expecting mother and her fetus (Tunzi & Gray, 2007).

Some of the most common symptoms of ICP include itching limited only to the soles and palms, especially during the evening, skin rash occurrences, slow response or failure of anti-histamines or other recommended anti-itch remedies (Tunzi & Gray, 2007). However, there are other less common symptoms, which include lighter stool, fatigue, darker urine, slow or increased time for blood clotting, instances of decreased appetite, increased nausea, and jaundice among other negligible symptoms. The abovementioned common symptoms, especially itching may grow mild towards the later periods of pregnancy, and until the child’s birth. However, once the new baby is born, the itches usually disappear within some few week for many women.           

Cholestasis during Pregnancy

Facts

According to Lammert et al (2000), ICP is a rescindable form of hormone dependent cholestasis, which in common cases occurs during late pregnancy among women who are genetically pre-disposed. It currently emerges as one of the most common pregnancy-related disorder of the liver, characterized by general itching that commences with pruritus of the hands’ palm and feet soles, but can later manifest to other vital body parts. It common cases, the ICP liver disorder appears during the late periods of second trimester and during the early 3^rd trimester during pregnancy.   

The conditions for cholestasis commonly impairs the discharge of gastrointestinal fluids (bile) right from the liver cells, hence the bile accumulates in the liver leading to the malfunction of the liver. The term Cholestasis refers to a reduced bile flow down the bile ducts from the liver (Lammert et al, 2000). During this reduced flow, some bile contents leak out into the woman’s bloodstream, particularly the bile salts. It due to the problem of internal release of bile within the liver that gives the condition its name as “Intrahepatic Cholestasis.” Nonetheless, the actual cause of ICP is still not yet established and precisely understood, although a number of researchers and scholars attribute the disorder to hormonal and genetic aspects, which are most likely to become handy in disease’s pathogenesis (Geenes et al, 2014). Some aspects of estrogens, especially the glucuronide’s estradiol-17B-β was proved to lead to cholestasis during animals’ study. It reduces hepatocytes’ bile acid intake. A number of studies also suggest that progesterone could also be playing an important role in prompting ICP.

Cholestasis of Pregnancy Symptoms

Elsewhere, the genetic (inherent) factors that have been associated with the ICP include the clustering of the disorder in families, the ICP recurrence amongst 45 to 70 percent of ensuing pregnancies, and geographic variations in the ICP rates. All these suggest the disease’s genetic components. As well, approximately 15% of the ICP disorder cases are linked to adenosine tri-phosphate conjoining cassette, a subfamily-B –, member four (AB-CB4/abc4) gene. This involves the genetic mutation of hepatocellular MDCB4 – ABCB4 transport protein that regulates phosphatidylcholine secretion into bile. The gene is also identified as multi-drug resilient protein3(MDR3), which encodes and triggers the transmission of phospho-lipids through the hepatocytes’ canalicular membrane (Lammert et al, 2000). Therefore, the genetic mutations influencing the transportation of hepatic-bile-salt molecules are also found to be prevalent among patients with PFIC (progressive familiar intrahepatic cholestasis). Research reveals that mothers of PFIC patients have frequent incidences of ICP disorder (Geenes et al, 2014). This proves the association of these genes with the ICP pre-disposure.

Unfortunately, there is no known precise cure for ICP, although a number of medical mitigation or control measures are commonly applied for temporary reliefs. Disordered pregnant women may be prescribed to use Ursodeoxycholic Acid (UDCA), which only relieves the itches by reducing the amounts or levels of bile acids or salts (Geenes et al, 2014). As well, prescription to Vitamin K supplements may as well minimize the hemorrhage risks at delivery. Vitamin K is fundamentally known for boosting or enhancing the blood clotting mechanisms. Bland moistening creams might also be useful in easing the itching by providing temporary relief. Other measures that might somehow work for some expecting women with ICP disorder include keeping the body cool by taking cool baths or shower, soaking hands and feet in ice-cold water before going to bed, and leaving the body uncovered during the night.      

Intrahepatic Cholestasis of Pregnancy Treatment

Nursing Responsibilities

The core role of nurses in this context will be to monitor the patients (in this case, pregnant women) with ICP disorder conditions, and to pass the medication prescriptions or control measures to them. Nurses can also advice on the best mitigation measures for easing the itching or how to undertake measures for the temporary reliefs. They monitor the progress of the mother and the unborn baby by conducting regular antenatal checks, alongside taking regular blood tests (advised to be after every 2 weeks) in order to keep track of the liver functionality and the level  bile salts or acids present in the mother’s bloodstream. Above all, nurses act as caregivers and teachers for the disordered patients, and communicators between the patients and doctors. In a nutshell, nurses serve as the patients’ caregivers, decision-makers, communicator, care management, advocate, and teacher. They conduct physical tests and maintain patients’ health records.    

Nursing Teachings

For diagnosis of ICP disorder, nurses are taught and made to understand that the available and most reliable test for the ICP detection is through serum-bile-acid test. The diagnosis is quite certain whenever the bile-acids level shoot beyond the normal level. Nurses must also understand that whenever they undertake the ICP checks, a routine test of expectant mothers’ liver functioning, which measures the blood liver enzymes must also be performed. Being the patients’ teachers, nurses assist patients in gaining a comprehensive knowledge concern their health, conditions, and relevant medications. They teach the patients to best understand their conditions, know the best control measures, and follow the appropriate medical prescriptions for an improved health.    

Cultural Impacts

Research evidences of ICP prevalence and family-clustering amongst particular ethnic blocks may somehow illuminate on the geographical variation incidences and cultural influences. For instance, the overall population of Chile has approximately 16% ICP incidences, while the Chilean sub-populations such as Araucanos Indians have about 28% incidences. According to Geenes et al (2014), ICP is approximated to affect and have influence over about 1% of expectant women across the Northern regions, or those of the ancestry of Northern European. In other regions, the ICP disorder has been found to be more common amongst certain populations including those women of the Araucanian Indian origins across Chile, and women of the Scandinavian ancestry. However, the condition is less reported among other world populations. 

References

Geenes, V., Chappell, L. C., Seed, P. T., Steer, P. J., Knight, M. & Williamson, C. (2014). Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: A prospective population-based case-control study. Hepatology. 59(4), 1482–91.

Lammert, F., Marschall, H. U., Glantz, A. & Matern, S. (2000). Intrahepatic cholestasis of pregnancy: Molecular pathogenesis, diagnosis and management. Journal of Hepatology, 33(6), 112–121.

Tunzi, M. & Gray, G. R. (2007). Common skin conditions during pregnancy. Am FAM Physician, 75 (2), 211–8.