Intrahepatic Cholestasis of Pregnancy

Background

Intrahepatic cholestasis of pregnancy (ICP), previously termed "obstetric cholestasis," is a pregnancy-specific liver disorder characterised by pruritus and raised serum bile acids, resolving after birth. This is the second edition of the guideline (first published 2006), reflecting a shift toward bile-acid-level-stratified risk assessment and individualised delivery planning rather than a uniform "deliver at term" approach.

Clinical Presentation

• Pruritus without a rash is the cardinal symptom — itching of normal-appearing skin, classically affecting the palms of the hands and soles of the feet, though it can be generalised.
• Usually begins after 28 weeks' gestation but can present earlier.
• Severity ranges from mild to intense and persistent, and is characteristically worse at night, disturbing sleep.
• Jaundice is a rare associated finding and, when present, should prompt consideration of other or additional pathology.

Diagnostic Criteria

• ICP should be considered in any pregnant woman with pruritus of normal-appearing skin and a raised peak random total bile acid concentration of 19 micromol/L or more, once other causes of pruritus and abnormal liver function have been excluded (e.g. viral hepatitis, pre-eclampsia, other cholestatic/hepatobiliary disease, gallstones, and pre-existing liver conditions).
• Bile acids can be abnormal even when liver function tests (LFTs) are normal — LFT derangement (raised transaminases) commonly accompanies ICP but bile acid level, not LFTs, is the key severity marker.
• Severity stratification by peak bile acid concentration:
  • Mild ICP: 19–39 micromol/L
  • Moderate ICP: 40–99 micromol/L
  • Severe ICP: 100 micromol/L or more

Fetal and Maternal Risks

• Stillbirth risk correlates with peak bile acid level rather than with pruritus severity:
  • Mild ICP (19–39 micromol/L): stillbirth risk is not significantly different from a pregnancy without ICP.
  • Moderate ICP (40–99 micromol/L): stillbirth risk remains comparable to the background population until around 38–39 weeks.
  • Severe ICP (≥100 micromol/L): stillbirth risk is significantly higher than background — approximately 3 in 100 women with severe ICP experience a stillbirth after 36 weeks.
• Other associations include spontaneous and iatrogenic preterm birth and, less consistently, meconium-stained liquor.
• Maternal risks are generally limited to symptom burden (sleep disturbance from pruritus) and a rare risk of vitamin-K-responsive coagulopathy from fat-malabsorption-related vitamin K deficiency.

Monitoring

• Weekly (or more frequent, guided by clinical picture) repeat liver function tests and bile acid measurement to track trend and severity.
• Advise women to monitor and report fetal movements; routine additional ultrasound surveillance beyond standard antenatal care is not required, as antenatal cardiotocography and ultrasound do not reliably predict or prevent stillbirth in ICP.

Management

• Symptomatic relief: emollients (e.g. aqueous cream, with or without menthol), antihistamines (sedating options may help sleep), cool baths, and loose-fitting cotton clothing.
• Ursodeoxycholic acid (UDCA): may modestly reduce pruritus and may reduce the chance of spontaneous preterm birth in some women, but current evidence does not show that UDCA reduces stillbirth risk. It should not be used as a substitute for appropriately timed delivery, and its use should be individualised and discussed with the woman.
• Vitamin K may be considered for women with evidence of malabsorption (e.g. steatorrhoea) or deranged clotting.
• There is no treatment proven to improve fetal outcomes or lower bile acid levels — management is centred on monitoring, symptom control, and risk-stratified timing of birth.

Delivery Timing

Delivery timing is individualised by peak bile acid concentration, balancing stillbirth risk against the risks of iatrogenic prematurity; options (induction of labour, planned caesarean, or awaiting spontaneous labour) should be discussed with the woman:

• Mild ICP (19–39 micromol/L): planned birth by the estimated due date (around 40 weeks) may be considered.
• Moderate ICP (40–99 micromol/L): planned birth at around 38–39 weeks' gestation may be recommended.
• Severe ICP (≥100 micromol/L): planned birth at around 35–36 weeks' gestation may be recommended, with continuous intrapartum fetal (CTG) monitoring given the elevated stillbirth risk.

High-Yield Exam Points

• Diagnostic threshold: pruritus + peak random total bile acids ≥19 micromol/L, after excluding other causes.
• Severity bands drive management: mild 19–39, moderate 40–99, severe ≥100 micromol/L — know these thresholds cold.
• Stillbirth risk tracks bile acid level, not itch severity or LFT derangement alone; risk is materially increased only in the severe (≥100 micromol/L) category.
• UDCA helps symptoms and may reduce preterm birth, but is not shown to reduce stillbirth — do not select it as a stillbirth- prevention strategy in exam scenarios.
• Delivery timing scales inversely with severity: term-ish for mild, ~38–39 weeks for moderate, ~35–36 weeks for severe.
• Routine ultrasound/CTG surveillance is not recommended as a means of predicting or preventing stillbirth in ICP — a common exam distractor.

Source: RCOG Green-top Guideline No. 43 (2nd edition) (Published 9 August 2022 (authors: Girling, Knight, Chappell))

Read the original on rcog.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated Published 9 August 2022 (authors: Girling, Knight, Chappell)

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