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 micromol/L. Other adverse outcomes associated with ICP include neonatal respiratory distress secondary to meconium aspiration, and preterm delivery (spontaneous and iatrogenic). 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 concentrations and liver function is routine; serum bile acid concentrations may predict the risk of stillbirth and the requirement for early 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 treat ICP is ursodeoxycholic acid (UDCA); however, the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (produced in 2022) do not recommend routine use of UDCA for the purpose of reducing adverse perinatal outcomes in women with ICP. Rifampicin is occasionally used on a case-by-case basis as an adjunct to UDCA in women with severe ICP who are not responding to UDCA alone.

ICP may be 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. The RCOG guidelines recommend maternal vitamin K supplementation only if there appears to be reduced absorption of dietary fats and/or evidence of abnormal prothrombin time.
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.