When an itch during pregnancy is a sign your baby is at risk

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When Magdalen Rees was 35 weeks pregnant with her first child, she developed a severe itch across her abdomen.
‘It seemed to be deep under my skin,’ she recalls. ‘Though mild at first, it became so intense that no amount of scratching would satisfy it.’
But when Magdalen mentioned it to the midwife at an antenatal appointment the following week, she was reassured it was simply due to the skin stretching and told to use a moisturiser. 

Mild itching in pregnancy is usually nothing to worry about — it’s often due to the increased blood supply, or the skin being stretched. 
‘It seemed more intense than that,’ says Magdalen, 35, who runs an IT company with her husband Dudley, 39, and lives in Winchester. 
‘But the midwife was so sure, I thought no more of it.’
Three weeks later her waters broke. At the hospital, a midwife checked Magdalen over and listened for the baby’s heartbeat. 
‘Then, without a word, she left the room,’ says Magdalen.
‘Two or three minutes later she returned with a doctor. They both looked very serious and at that point I began to worry,’ she says.
‘The doctor tried, and failed, to find the baby’s heartbeat using a handheld scanner. But I told myself babies wriggle and get into funny positions. Any minute now we would hear the reassuring thud, thud, thud.’ 

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But that didn’t happen. Magdalen’s apparently healthy baby — a boy — had died. The couple named their stillborn son Henry.
‘Despite the amazing support of family and friends, we struggled desperately,’ recalls Magdalen.
Eleven months later, their daughter Sienna was born. 

‘She gave us a reason to smile and feel normal again.’

Three years later, in 2010, Magdalen became pregnant for the third time. 
At 32 weeks, she developed an itch she instantly recognised from when she’d been expecting Henry. 
But now it was spreading from her tummy to her arms, legs and back. 
Although Magdalen had an itch on her abdomen, ICP itching is most common on the soles of the feet and the palms of the hands
Although Magdalen had an itch on her abdomen, ICP itching is most common on the soles of the feet and the palms of the hands
This time, Magdalen thought she knew the cause. Her sister Nyree had just had a baby, and during her pregnancy she’d developed a terrible itch that was diagnosed as intrahepatic cholestasis of pregnancy (ICP) — a liver disorder doctors said could kill her baby if it went untreated. 
ICP is a liver disease specific to pregnancy — it affects around 5,000 women in the UK each year, and is caused by high levels of bile acids (chemicals in the liver that aid digestion). 

It is characterised by unexplained itching, usually with no rash, though this isn’t always the case; women may notice their urine has become darker, and they may feel generally unwell and tired.

The disease can occur as early as six weeks, although is more common later in pregnancy. 
It’s thought that pregnancy hormones affect the liver’s ability to transport some chemicals, including bile acids, which build up in the blood and stimulate the nerves under the skin that cause itching, explains Catherine Williamson, an obstetric physician and professor of women’s health at King’s College London. 
Bile acids are toxic if they accumulate — animal studies suggest that in very severe cases, the raised bile acids can affect some babies’ hearts, causing changes in the heartbeat that cannot be picked up on a standard foetal heart monitor.
This year, a study led by Professor Williamson at Imperial College London found that severe ICP triples the risk of stillbirth — in very severe cases, the risk of stillbirth is nine times higher than a normal pregnancy.

There are around 4,000 stillbirths a year in the UK, and in a third of cases the cause is unclear, says stillbirth and neonatal death charity Sands. 
This new research, which was funded by Sands, may help to explain some of these cases.
Knowing what her itching could mean, Magdalen was terrified she would lose her baby. 
‘I alerted my obstetrician, who ordered blood tests straight away,’ she says.
In a woman who is not pregnant, bile acids at the level of 6μmol/L (the concentration in the blood measured in micromols per litre) are normal. In pregnancy, ICP is diagnosed when the mother’s bile acid level is more than 14μmol/L, and the risk of stillbirth goes up when they rise to more than 40μmol/L. 
Over the next few days, Magdalen’s bile acid levels climbed from 14μmol/L to 72μmol/L.
She was treated with a medication called ursodeoxycholic acid (known as UDCA or urso), a bile acid that displaces the more harmful bile acids in the blood, relieving itching and protecting the baby. 

Despite treatment, her bile acid levels continued to rise and her baby girl, Lila, had to be induced at 35 weeks, weighing 5lb 13oz. 
With a combination of urso and early delivery, the risk of stillbirth in an ICP pregnancy is believed to be the same as that for a normal pregnancy. 
‘Dudley and I were so relieved to have Lila safe and well — but sad that my itching with Henry was not taken seriously, and that his death was not prevented,’ she says.
‘We had no proof I’d had ICP then, but it seemed too much of a coincidence.’


Although Magdalen had an itch on her abdomen, ICP itching is most common on the soles of the feet and the palms of the hands. 
This can lead to confusion, says Jenny Chambers, founder of the charity ICP Support. 
‘Some doctors test for bile acids only when there is itching on the hands and feet, but we know some women itch elsewhere, too.’ 
ICP Support says any persistent itch, however mild, must be investigated. 
Evidence as to the long-term effect ICP has on the health of the mother or baby is mixed. 
Some studies suggest gallstones are more common in women with the condition, and a Swedish study published this year in the Journal of Hepatology found that women with ICP are also more likely to have diabetes in pregnancy.  
When ICP is suspected, the speed at which blood results are returned — critical if a baby’s life is in danger — can vary across the UK; it can be done in just a few hours, but often it takes longer. 

‘Lila was induced because my bile acids had reached 114μmol/L in a test I’d had the day before,’ says Magdalen, now a trustee for ICP Support. 
‘In other hospitals, results can take up to two weeks to come back, which could be too late.’ 
Mags Barr, 39, a hotel receptionist from Bristol, has suffered ICP in all four of her pregnancies.
She says: ‘When I was expecting my first child, Keira, now nine, I had blood taken and was diagnosed and treated with urso as soon as I mentioned that my hands and feet were intensely itchy at 32-33 weeks.’ 
Three years later, Mags was pregnant with her second baby. She and her partner, Phil Butler, 37, a retail manager, had moved, and her new midwifery team had never even heard of ICP. 

When she developed the same tell-tale itch, she persuaded her previous midwife to talk to the new team. She was diagnosed with ICP, treated with urso, and her daughter Tia, was delivered safely.
When the itch returned three years later during her third pregnancy, Mags begged the hospital to test her blood — but they did not check her bile acid level. 
She finally asked the midwife at her GP practice to run a blood test, which showed her bile acid levels were more than 40. 
She was sent to hospital, yet staff there still failed to treat her with urso, even after she asked, and instead said they’d induce her four days later. 
But the day before her induction, Mags’s contractions started. 
‘An ultrasound showed our baby had no heartbeat, and our daughter, Naomi, was delivered silent.
‘Nothing can ever prepare you for that,’ Mags says. ‘When I was expecting my son, Evan, now 21 months old, I couldn’t bear to go back to the same hospital.’
This time Mags itched from the 28th week of pregnancy, but her condition was immediately picked up and treated. 
‘It is tragic that just because of variations in the way different hospitals manage ICP, women are still losing babies that they should be taking home,’ she says.
icpsupport.org