Cholestasis of Pregnancy

Overview

Definition

Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis (OC) is a multifactorial condition of pregnancy characterised by pruritus in the absence of a skin rash with elevated total bile acids (TBAs), neither of which has an alternative cause and both of which resolve after birth (1).

Incidence

ICP has an incidence of 0.7% in the white UK population. It affects 1.2% to 1.5% of the UK Asian population.

ICP can recur if women have had ICP in a previous pregnancy.

Implications for women and babies

The importance of ICP relates to the potential increased risk of adverse fetal outcomes including prematurity (iatrogenic & spontaneous), meconium passage in labour, admission to NICU and stillbirth. It is also associated with significant maternal morbidity secondary to symptoms of intense pruritis which can lead to significant sleep deprivation

Severity of ICP can be determined by the magnitude of elevation in bile acids. Whilst liver transaminases may be raised in ICP they should not be used to diagnose the condition or inform decisions around induction of labour.

Diagnosis and Management

Clinical Features

Classically the presentation is in the second or third trimester with intense pruritis on the soles and palmar surfaces which can cause significant morbidity through sleep deprivation. Excoriations may be associated but no rash should be apparent. Pale stools and dark urine may rarely be a feature

Diagnosis

This is confirmed by elevated TBAs in the presence of a history of pruritis commencing in mid trimester. Whilst transaminases may be raised, a diagnosis of ICP cannot be made without elevation in TBAs.

Severity

The severity of ICP is determined by the highest recorded bile acids, even if they decrease during surveillance. Monitoring is usually undertaken by community midwives with support from their local antenatal clinic. Management pathways are then dependent on the level of TBA (1,2):

• Mild - In women with peak bile acids 19–39 micromol/L (mild ICP) and no other risk factors, the risk of stillbirth is similar to the background risk. Consider options of planned birth by 40 weeks' gestation or ongoing antenatal care (1). 
• Moderate - In women with peak bile acids 40–99 micromol/L (moderate ICP) and no other risk factors, the known risk of stillbirth is similar to the background risk until 38–39 weeks' gestation. Consider planned birth at 38–39 weeks' gestation (1).
• Severe - In women with peak bile acids 100 micromol/L or more (severe ICP), the risk of stillbirth is higher than the background risk. Consider planned birth at 35–36 weeks' gestation (1). 

Medication

There are no treatments that improve pregnancy outcome (or raised bile acid concentrations) and treatments to improve maternal itching are of limited benefit (1). Medication that are sometimes used to help with the pruritis symptoms as follows (2):

• Chlorphenamine - the sedative effects of Chlorphenamine may help facilitate sleep but has no direct effect on improving symptoms of itching. A single 4mg oral dose at night may be prescribed for women with ICP.
• Aqueous cream with Menthol -  may reduce symptoms of itching in some women but this is not backed up with evidence from clinical trials
• [Ursodeoxycholic acid (URSO) - should not be routinely prescribed for women with a diagnosis of ICP. It is not recommended for improving perinatal outcomes. It has a small role in symptom treatment for the women with intense symptoms not responding to antihistamines and topical treatment (3).]
  
  

Referral

Referral

All patients with ICP should be referred for follow up in antenatal clinic and this is normally arranged by their community midwife.

Follow up

Check LFTs 6 weeks post-partum to ensure LFTs have returned to normal

Women with ICP in a previous pregnancy

Women who have had ICP in a previous pregnancy should have a baseline set of LFTs including a TBA at booking or shortly after.

Resources

(1) Intrahepatic cholestasis of pregnancy (Green-top Guideline No. 43) | RCOG

(2) Intrahepatic cholestasis of pregnancy - Diagnosis and Managment - NBT guidelines (11.11.22)

(3) Intrahepaticcholestasisofpregnancy - UHBW guidelines (March 2023)

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