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Intrahepatic cholestasis of pregnancy

Key sources
The following summarized guidelines for the evaluation and management of intrahepatic cholestasis of pregnancy are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL 2023), the Royal College of Obstetricians and Gynaecologists (RCOG 2022), the Society for Maternal-Fetal Medicine (SMFM 2021), the American Association for the Study of Liver Diseases (AASLD 2021), the Italian Association for the Study of the Liver (AISF 2016), and the American College of Gastroenterology (ACG 2016).
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Guidelines

1.Screening and diagnosis

Diagnosis: as per RCOG 2022 guidelines, suspect ICP in pregnant patients presenting with itching of normal-appearing skin and raised peak random total bile acid concentration of ≥ 19 mcmol/L.
B
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  • Differential diagnosis

2.Diagnostic investigations

History and physical examination: elicit a structured history and perform a physical examination to exclude other causes of itching and liver dysfunction in patients with suspected ICP.
B

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  • Liver function tests (baseline)

  • Liver function tests (monitoring)

  • Diagnostic imaging

  • Screening for HCV infection

3.Medical management

General principles
As per RCOG 2022 guidelines:
Consider discussing the care of patients with severe, very early, or atypical presentation of ICP with a hepatologist.
C
Review patients with ICP within a consultant-led maternity unit.
B

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  • UDCA

  • Antihistamines

  • Vitamin K

  • Other agents

4.Nonpharmacologic interventions

Topical emollients: consider offering topical emollients such as aqueous cream (with or without menthol added) to ameliorate skin symptoms.
C

5.Therapeutic procedures

Delivery: as per EASL 2023 guidelines, offer planned elective early delivery after 35 weeks of gestation to reduce the risk of fetal death in patients with post-prandial serum bile acid concentrations ≥ 100 mcmol/L.
A

6.Patient education

General counseling, management of symptoms
Counsel patients with ICP that the predominant symptom is itching and it can be severe, may fluctuate, and may markedly affect sleep.
B
Counsel patients that there are no treatments improving pregnancy outcome (or raised bile acid concentrations) and treatments to improve maternal itching are of limited benefit.
B

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  • General counseling (risk of preterm birth)

  • General counseling (risk of stillbirth)

  • General counseling (risk of meconium-stained amniotic fluid)

  • General counseling (risk of postpartum hemorrhage)

  • General counseling (fetal monitoring)

  • General counseling (neonatal care)

  • General counseling (mode of birth)

7.Follow-up and surveillance

Surveillance for preeclampsia and diabetes: obtain BP and urine monitoring and testing for gestational diabetes according to national guidance since patients with ICP have a higher risk of developing preeclampsia and gestational diabetes.
B

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  • Fetal monitoring

  • Confirmation of resolution

  • Subsequent contraception and hormone therapy

  • Evaluation in future pregnancies