Management of Intrahepatic Cholestasis of Pregnancy

Diagnosis

The American College of Obstetricians and Gynecologists recommends that ICP is diagnosed based on pruritus with total serum bile acid levels >10 μmol/L 3, 4
Laboratory testing should include serum bile acids and liver function tests, such as ALT, AST, and bilirubin, to confirm diagnosis 5
If initial bile acid levels are normal but pruritus persists, testing should be repeated as bile acid elevation may lag behind symptom onset 6
The American Association for the Study of Liver Diseases suggests that liver biopsy is generally not warranted for diagnosis 4

The American College of Obstetricians and Gynecologists recommends UDCA at 10-15 mg/kg/day as the first-line treatment for ICP to improve maternal symptoms and potentially reduce adverse perinatal outcomes 1, 2, 3
Clinical improvement in pruritus usually occurs within 1-2 weeks, while biochemical improvement typically takes 3-4 weeks 1
If pruritus is not relieved, the dose can be titrated up to a maximum of 21-25 mg/kg/day 1, 7
S-adenosyl-methionine may improve pruritus but is less effective than UDCA and can be used in combination with UDCA for additive effect 1, 7
Rifampicin can be combined with UDCA for refractory cases 1, 8

The American College of Obstetricians and Gynecologists recommends follow-up laboratory testing to guide delivery timing, especially in severe cases 1
Bile acid levels correlate with risk of intrauterine fetal demise, with highest risk when levels exceed 100 μmol/L 3
Antepartum fetal surveillance should begin at a gestational age when delivery would be performed in response to abnormal testing 1, 5

The American College of Obstetricians and Gynecologists recommends delivery at 36 0/7 weeks or at diagnosis if after 36 weeks for patients with total bile acid levels ≥100 μmol/L 3, 5
For patients with total bile acid levels <100 μmol/L, delivery should occur between 36 0/7 and 39 0/7 weeks 5
For patients with total bile acid levels <40 μmol/L, consider delivery at term 3
Administer antenatal corticosteroids for fetal lung maturity if delivery occurs before 37 weeks 5

UDCA treatment should be discontinued at delivery 8
If symptoms persist, consider gradual reduction of UDCA 2-4 weeks postpartum 8
If symptoms or abnormal liver tests persist for 4-6 weeks after delivery, repeat biochemical testing 1
Persistent abnormalities after delivery should prompt investigation for underlying chronic liver diseases 7, 4, 8

The American College of Obstetricians and Gynecologists notes that ICP is associated with increased rates of preterm birth, meconium-stained amniotic fluid, fetal distress, and stillbirth 2
Women with ICP may have an increased risk of preeclampsia 2