From the Guidelines
Intrahepatic cholestasis of pregnancy (ICP) typically develops in the second or third trimester of pregnancy, with most cases presenting in the third trimester. The condition is characterized by intense itching, particularly on the palms and soles, without a rash, and is caused by impaired bile flow in the liver leading to bile acid accumulation in the bloodstream. According to the most recent and highest quality study 1, ICP is diagnosed on the basis of clinical presentation of pruritus in the second and third trimester with a total serum bile acid level >10 mmol/L.
Key Points
- ICP can occur as early as the first trimester in rare cases, but most women develop symptoms between weeks 25 and 32 of pregnancy.
- Early-onset ICP (before 20 weeks) is less common but may indicate a more severe form of the condition or a genetic predisposition.
- Women with a personal or family history of ICP, multiple pregnancies, or previous liver disease are at higher risk.
- Diagnosis involves blood tests showing elevated bile acids and liver enzymes.
- Management typically involves ursodeoxycholic acid (UDCA) at doses of 10-15 mg/kg/day to reduce bile acids and improve symptoms, along with close maternal and fetal monitoring, as recommended by 1 and supported by 1.
Risks and Complications
- ICP increases risks of fetal distress, preterm birth, and stillbirth, with the risk of stillbirth being associated with the total bile acid level, as reported in 1.
- The highest risk for stillbirth occurs in women with total bile acid levels of 100 mmol/L, whereas women with lower bile acid levels may have a lower risk, but still require close monitoring, as suggested by 1.
Treatment and Monitoring
- Treatment should begin with ursodeoxycholic acid in a daily divided dosage to total of 10–15 mg/kg/d, as recommended by 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 the Society for Maternal-Fetal Medicine recommending delivery at 36 weeks or at diagnosis if after 36 weeks for women with total bile acid levels >100 mmol/L, as stated in 1.
From the Research
Intrahepatic Cholestasis of Pregnancy (ICP) Development Stage
- ICP can develop during the second or third trimester of pregnancy 2, 3, 4
- The exact timing of ICP development can vary, but it typically appears in the last trimester of gestation 5
- Some studies suggest that ICP can occur as early as 26 weeks of gestation, while others report it occurring at a mean gestational age of 31.2 ± 2.7 weeks 3, 6
- The condition is characterized by pruritus and elevated blood bile acid levels, and its development is influenced by genetic, hormonal, and environmental factors 2, 3
Key Factors Associated with ICP Development
- Elevated levels of gestational hormones and genetic predispositions, including mutations in hepatobiliary transport proteins, play a major role in the development of ICP 2
- The condition is associated with an increased risk of perinatal complications, such as premature birth, respiratory disorders, and stillbirth 2, 4, 6
- Ursodeoxycholic acid (UDCA) treatment can improve maternal and fetal outcomes in women with ICP, by reducing bile acid levels and pruritus 3, 5, 6