From the Guidelines
The recommended treatment for intrahepatic cholestasis of pregnancy (ICP) is ursodeoxycholic acid (UDCA), typically prescribed at doses of 10-15 mg/kg/day divided into 2-3 doses. This medication helps reduce bile acid levels, alleviate maternal itching, and may improve fetal outcomes 1. Treatment should begin as soon as the diagnosis is confirmed and continue until delivery. In addition to UDCA, antihistamines like diphenhydramine (25-50 mg every 4-6 hours) or hydroxyzine (25 mg every 6-8 hours) may provide symptomatic relief from itching, though they don't address the underlying condition. Topical emollients and cool baths can also help manage itching symptoms. For severe cases not responding to UDCA, rifampicin (150-300 mg twice daily) may be added as second-line therapy under specialist supervision 1. Close maternal and fetal monitoring is essential, including weekly liver function tests, bile acid measurements, and fetal surveillance. Due to increased risks of stillbirth, early delivery at 36-37 weeks is often recommended. UDCA works by replacing toxic bile acids, protecting hepatocytes, improving bile flow, and reducing inflammation, making it effective for both maternal symptoms and potentially reducing complications for the baby.
Some key points to consider in the management of ICP include:
- The diagnosis of ICP is based on a serum bile acid level >10 mmol/L in the setting of pruritus, typically during the second or third trimester 1.
- Treatment with UDCA should be offered in a total daily dose of 10–15 mg/kg 1.
- For women with ICP, serum bile acids should be measured at least weekly from 32 weeks’ gestation to identify those with concentrations >40 μmol/L who are at an increased risk of adverse pregnancy outcomes 1.
- In women with post-prandial serum bile acid concentrations >100 μmol/L, the risk of stillbirth increases after 35 weeks’ gestation, and elective early delivery should be planned at this stage of pregnancy to reduce the risk of fetal death 1.
Overall, the management of ICP should be individualized and based on the severity of symptoms and the risk of adverse pregnancy outcomes. UDCA is the first-line treatment for ICP, and it should be used in conjunction with close maternal and fetal monitoring to minimize the risks associated with this condition.
From the Research
Treatment Options for Intrahepatic Cholestasis of Pregnancy (ICP)
- The primary treatment for ICP is ursodeoxycholic acid (UDCA) 2, 3, 4, 5, 6
- UDCA has been shown to improve pruritus, liver function tests, and bile acid levels in patients with ICP 2, 3, 4, 5, 6
- The recommended dosage of UDCA varies, but studies have shown that low doses (300-450 mg/day) can be effective in improving biochemical markers and clinical symptoms in almost 90% of ICP patients 3
- UDCA monotherapy is recommended as the first line therapy for ICP due to its efficacy, cost-effectiveness, and convenience 2
- S-adenosylmethionine (SAMe) has also been studied as a potential treatment for ICP, but UDCA has been shown to be more effective in reducing total bile acid concentration and facilitating deliveries at term 2
Efficacy and Safety of UDCA in ICP
- UDCA has been shown to be safe and effective in improving pruritus and liver function in ICP patients, with no significant adverse effects on mothers and fetuses 4, 5, 6
- A meta-analysis of 12 randomized controlled trials found that UDCA was associated with resolution of pruritus, decrease of serum levels of alanine aminotransferase, and reduced serum levels of bile acid 5
- UDCA has also been shown to reduce adverse maternal and fetal outcomes, including premature births, fetal distress, and respiratory distress syndrome 5