From the Guidelines
The diagnosis of cholestatic jaundice in pregnancy should be based on a serum bile acid level >10 mmol/L in the setting of pruritus, typically during the second or third trimester, as recommended by the most recent guidelines 1.
Diagnosis Approach
The approach to diagnosing cholestatic jaundice in pregnancy involves a combination of clinical assessment, laboratory testing, and imaging studies. Initial evaluation should include liver function tests, with a focus on serum bile acids, which are typically elevated in intrahepatic cholestasis of pregnancy (ICP), the most common cause of cholestatic jaundice in pregnancy.
- Other essential laboratory tests include:
- Alkaline phosphatase (often physiologically elevated in pregnancy)
- Gamma-glutamyl transferase (GGT)
- Bilirubin levels (both total and direct)
- Transaminases (ALT and AST)
- A complete blood count, coagulation profile, and hepatitis serology should also be performed to rule out other causes of liver dysfunction.
- Ultrasound of the liver and biliary tract is the preferred imaging modality during pregnancy to exclude biliary obstruction.
Clinical Presentation and Timing
Symptoms typically include pruritus, particularly on the palms and soles, which often precedes jaundice. The diagnosis is confirmed when elevated bile acids and liver enzymes are present in a pregnant woman with pruritus, after excluding other causes of liver dysfunction. Timing is important, as ICP typically presents in the third trimester. Early diagnosis is crucial as cholestatic jaundice in pregnancy is associated with adverse fetal outcomes, including preterm birth, meconium staining, and stillbirth, necessitating increased fetal surveillance and possibly early delivery depending on severity 1.
Management and Treatment
Treatment should be offered with oral ursodeoxycholic acid in a total daily dose of 10–15 mg/kg, as it has been shown to improve pruritus, serum bile acid levels, and serum alanine aminotransferase levels, and decrease adverse outcomes, including preterm birth and stillbirth 1.
- Additional treatment of pruritus can be attempted with cholestyramine and rifampicin.
- Delivery is advised to be based on serum total bile acid levels, with recommendations for delivery at 36 weeks or at diagnosis if after 36 weeks for levels >100 mmol/L, and between 36 and 39 weeks of gestation for levels <100 mmol/L 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Diagnosis of Cholestatic Jaundice in Pregnancy
- Cholestatic jaundice of pregnancy is generally a self-limiting condition that occurs in the last trimester and disappears within 1-2 weeks after delivery 2
- The diagnosis of intrahepatic cholestasis of pregnancy (ICP) is based on symptoms of pruritus that typically include the palms and soles, as well as elevated bile acid levels 3
- Other liver function tests such as alanine aminotransferase and aspartate aminotransferase are also frequently elevated, and other causes of liver dysfunction should be ruled out 3
Clinical Presentation and Laboratory Findings
- Symptoms of ICP include pruritus, jaundice, and elevated bile acid levels 2, 3
- Laboratory findings may include elevated serum aminotransferase activities and serum bile acid levels 4
- The severity of ICP can be assessed by the number of severity criteria, such as early itching and premature delivery 5
Management and Treatment
- Ursodeoxycholic acid treatment has been shown to improve maternal pruritus symptoms, as well as biochemical tests 3, 4
- Ursodeoxycholic acid is safe and more effective than cholestyramine in intrahepatic cholestasis of pregnancy 4
- Delivery may be considered at 37 weeks' gestation due to the increased risk of stillbirth in the setting of ICP 3
Fetal Risks and Outcomes
- Fetal risks of ICP include increased risk of preterm birth, meconium-stained amniotic fluid, respiratory distress syndrome, or stillbirth 3
- The risk of adverse neonatal outcomes increases with increasing bile acid levels 3
- Perinatal mortality and morbidity rates may be higher than previously thought, emphasizing the importance of proper diagnosis and management 5, 6