The diagnosis of Cholestasis is based on symptoms and high Total bile acids in blood work. As there may be an underlying cause for the elevated bile acid levels in some patients with liver dysfunction, your doctor will confirm this.
A more serious cause is likely to be found in cases that are more severe or occur earlier during pregnancy. Your doctor will review your medical history, take a detailed history of your symptoms and conduct an examination to determine the cause. The doctor will send blood work to confirm the diagnosis.
Serum Bile Acids
The best way to diagnose intrahepatic pregnancy cholestasis is with serum bile acid testing. Based on current recommendations, this testing is easy to perform at any time of the day.
There are many bile acid tests that can be performed depending on where you live. All of them can be used to diagnose. Bile acids over 10 umol/L indicate ICP. Studies in the past have shown that bile acid levels above 10 umol/L indicate ICP. This is despite tests showing that this level is within the normal range. Because these tests only measure select bile acids, fractionated bile acid testing can be used to diagnose ICP at a lower level.
Results for bile acid in the United States can take up to 36 hours to 10 days for results. These are specialized tests that are only available in a handful of laboratories.
Cholesteasis can be diagnosed even though normal bile acids are not able to rule it out. Itching can be caused by a chemical called lysophosphatidic acids and not directly by an elevation in bile acid levels. Itching can even occur weeks before there is an increase in blood bile acids levels. Studies have shown this. Itching should not be ignored if it persists.
Even after diagnosis, pregnant women should monitor their bile acid levels. Studies in the past have indicated a higher risk of pregnancy complications if there is a high level of bile acid. ICP cases that are mild have bile acid levels below 40 umol/L. ICP cases that are severe have bile acid levels above 40 umol/L. Preterm labour, respiratory problems after birth and meconium staining the amniotic liquid are all more common with bile acid levels above 40. Recent analysis of many cholestasis-related pregnancies revealed that most complications are caused by bile acid levels above 100. This requires a more aggressive management strategy. Although there is not consensus about how often bile acid should be measured, it is recommended that they be followed, particularly near the end of pregnancy, so that delivery timings can be planned.
If bile acid testing cannot be performed, symptoms should be used to diagnose the problem. Although liver function testing is possible, it cannot be used to diagnose liver disease. It is harder to know the best time for delivery if bile acid levels have not been determined. Recent presentations by leaders in the field recommended that deliveries should be made between 36 and 37 weeks gestation if bile acids levels are not available. Without knowing the level, the full risk to the baby’s health is unknown.
For more information about the different bile acids tests and their respective reference ranges, please visit the Diagnostic Testing Page.
Liver Function Testing (or Complete Metabolic Panel).
About 60% of women with Intrahepatic Chelestasis of Pregnancy have high liver functions during pregnancy. Normal liver function panels do not rule out the condition, as bile acid testing must still be done. Your doctor may be able to provide more information if liver function results are returned within hours rather than days.
Liver function testing involves many components. These are important points to remember about Intrahepatic Cholestasis during pregnancy.
- Aspartate Aminotransferase and Alanine Aminotransferase are enzymes that are released when liver cells become damaged. They can also be increased in a pregnancy with cholestasis. The ALT is the most sensitive for diagnosing Intrahepatic Chelestasis of Pregnancy. AST is next. These enzymes can be elevated if you have ICP. However, they can also be affected by other conditions. For diagnosis, bile acid levels will still be needed.
- Alkaline Phosphatase : The placenta produces alkaline phosphatase and it is usually elevated during pregnancy. The elevation of ALP/ALK, alkaline phosphatase, does not necessarily indicate Intrahepatic Cholestasis.
- Bilirubin: Bilirubin can be elevated in a few cases (estimated to be below 10%). Jaundice may also be caused by elevated bilirubin. It is rare for bilirubin to be elevated.
- These tests are not specific for ICP, but you can discuss with your doctor what they may mean if there are any abnormalities.
Understanding the Uncommon Nature Of Intrahepatic Cholestasis in Pregnancy
Intrahepatic Cholestasis of Pregnancy, a rare condition that affects approximately 6,000 Americans annually, may be a mystery to some doctors. The condition is rare in practice and doctors may not have the latest guidelines for management and diagnosis.
For proper diagnosis, you may be asked to give information to your doctor. ICP Care provides a comprehensive and concise overview for providers. ***HERE Recent guidelines developed by SMFM also clarify many points of diagnosis and management. These can be provided to your doctor. An OB who specializes in high-risk pregnancies may refer you to a Maternal Fetal Medicine Specialist (MFM span>).
Promoting Intrahepatic Cholestasis for Pregnancy Awareness
Although it can be frustrating to find out that your doctor doesn’t know all the details of managing a pregnancy with ICP complications, there are many organizations working to educate and spread awareness. We honor each ICP-related death and offer support to the grieving mothers.
We care deeply about the empowerment of every person with ICP, to be able to advocate for proper testing and medication, early delivery and to save every baby’s lives.
Find out more about ICP Care’s efforts in spreading awareness and donate to the cause.