What is the treatment for cholestasis of pregnancy in the third trimester with severe itching of both hands?

Management of Cholestasis of Pregnancy with Hand Pruritus in the Third Trimester

Ursodeoxycholic acid (UDCA) at a dose of 10-15 mg/kg/day is the first-line treatment for cholestasis of pregnancy with pruritus. 1

Diagnosis Confirmation

• Diagnosis is based on:
  • Pruritus (especially on hands in this case) in second or third trimester
  • Elevated serum bile acid levels >10 μmol/L
  • Elevated liver enzymes (AST, ALT up to 10-20 times normal)
  • Total bilirubin usually <6 mg/dL
  • Exclusion of other causes of liver dysfunction 1

Treatment Algorithm

First-Line Treatment

• UDCA (10-15 mg/kg/day in divided doses) 1
  • Improves maternal pruritus
  • Reduces serum bile acid levels and liver enzymes
  • May decrease adverse fetal outcomes including preterm birth and stillbirth
  • Safe during pregnancy and breastfeeding

Additional Symptomatic Management for Pruritus

• Avoid hot baths/showers
• Use emollients to prevent skin dryness
• Apply cooling gels (e.g., menthol) to affected areas
• Keep nails short to minimize skin damage from scratching 1

Second-Line Options for Refractory Pruritus

• Cholestyramine (anion exchange resin)

  • Note: Separate administration from UDCA by at least 4 hours
  • May exacerbate vitamin K deficiency; monitor coagulation (INR) 1

• Rifampicin (for severe cases unresponsive to UDCA)

  • Starting dose 150 mg twice daily
  • Monitor for hepatotoxicity
  • Warn about discoloration of bodily secretions 1

Monitoring and Delivery Planning

Maternal Monitoring

• Regular assessment of:
  • Serum bile acid levels
  • Liver function tests (ALT, AST)
  • Coagulation parameters if on cholestyramine

Fetal Surveillance

• Begin antenatal fetal surveillance when delivery would be performed in response to abnormal testing or at time of diagnosis if made later in gestation 1

Timing of Delivery Based on Bile Acid Levels

• Total bile acid levels ≥100 μmol/L:

  • Offer delivery at 36 0/7 weeks gestation (or at diagnosis if after 36 weeks)
  • Risk of stillbirth increases substantially around this gestational age 1

• Total bile acid levels <100 μmol/L:

  • Recommend delivery between 36 0/7 and 39 0/7 weeks gestation 1
  • Consider delivery at term for those with total bile acid levels <40 μmol/L 1

• Administer antenatal corticosteroids for fetal lung maturity if delivery before 37 weeks 1

Important Clinical Considerations

• Pruritus typically resolves after delivery, but if it persists beyond 6 weeks postpartum, evaluate for underlying chronic liver disease 1

• Avoid preterm delivery before 37 weeks in patients with clinical diagnosis of ICP without laboratory confirmation of elevated bile acid levels 1

• While ICP poses minimal risk to the mother, it carries significant risks for the fetus including preterm birth, meconium-stained amniotic fluid, and stillbirth 1, 2

• The risk of ICP recurrence in subsequent pregnancies is 40-60% 3

• Though typically a third-trimester condition, rare cases have been reported in early pregnancy, even as early as 5-10 weeks gestation 4, 5