TREATMENT OF INTRAHEPATIC CHOLESTASIS OF PREGNANCY (OBSTETRIC CHOLESTASIS)

Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis, is a pregnancy-specific liver condition with onset most commonly in the third trimester.

Maternal signs and symptoms of ICP include pruritus and raised serum bile acids; abnormal liver function (ALT/AST) is also a common feature. The pruritus can cause sleep disturbance and can adversely affect quality of life, but ICP is otherwise not detrimental to maternal health. ICP is, however, associated with serious risks to the fetus, including stillbirth, rates of which are thought to be particularly elevated with maternal serum bile acid concentrations >100 µmol/L. Other adverse outcomes associated with ICP include neonatal respiratory distress secondary to meconium aspiration, preterm delivery (spontaneous and iatrogenic) and the potential for fetal and neonatal bleeding disorders. Fetal monitoring has not been shown to predict or to reduce the risk of adverse perinatal outcomes in pregnancies affected by ICP, but may be offered to provide reassurance. Regular monitoring of maternal serum bile acid levels and liver function is routine; serum bile acid levels may predict the risk of stillbirth and the requirement for delivery. All women with ICP should be offered consultant-led care and delivery at a hospital unit.

Symptomatic treatments to reduce the sensation of itch include topical emollients (with or without menthol) and sedating antihistamines. The most widely used pharmacological treatment to reduce bile acid concentrations in ICP is ursodeoxycholic acid (UDCA). Rifampicin is also occasionally used on a case-by-case basis as an adjunct to UDCA if bile acid levels are extremely high.

ICP is associated with an increased risk of vitamin K deficiency due to reduced enterohepatic recirculation of bile acids and resultant malabsorption of fats and fat-soluble vitamins. Although there are no randomised controlled clinical trials that support or refute the use of vitamin K, the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines recommend maternal and neonatal vitamin K supplementation.

Exposure to the medications included in this monograph at any stage in pregnancy would not usually be regarded as medical grounds for termination of pregnancy or any additional fetal monitoring. However, other risk factors may be present in individual cases which may independently increase the risk of adverse pregnancy outcome. Clinicians are reminded of the importance of consideration of such factors when performing case-specific risk assessments.