What is the management and treatment for a pregnant woman diagnosed with cholestasis of pregnancy?

Management and Treatment of Cholestasis of Pregnancy

Ursodeoxycholic acid (UDCA) should be offered as first-line treatment for cholestasis of pregnancy, with delivery timing based on bile acid levels - at 36 weeks for levels ≥100 μmol/L and between 36-39 weeks for levels <100 μmol/L. 1, 2

Diagnosis and Assessment

• Diagnosis is based on:

  • Pruritus (especially on palms and soles) in the second or third trimester
  • Elevated serum bile acid levels (>10 μmol/L)
  • Elevated liver enzymes (AST, ALT may be 10-20 times normal)
  • Exclusion of other causes of liver dysfunction 1, 2

• Laboratory testing:

  • Serum bile acids (primary diagnostic test)
  • Liver function tests (AST, ALT, bilirubin, alkaline phosphatase)
  • Consider viral hepatitis and autoimmune hepatitis testing if diagnosis is unclear 2

Treatment

Medical Management

1. Ursodeoxycholic acid (UDCA):

   • Dosage: 10-15 mg/kg/day 2
   • Benefits: Improves maternal pruritus, reduces serum bile acid levels and liver enzymes, may decrease adverse fetal outcomes 1, 2
   • Monitor: Weekly bile acid levels after 32 weeks' gestation 1

2. Alternative treatments (if UDCA is insufficient):

   • Cholestyramine: Administer at least 4 hours apart from UDCA; monitor for vitamin K deficiency 2
   • Rifampicin: For severe cases unresponsive to UDCA (150 mg twice daily); monitor for hepatotoxicity 2

3. Symptomatic relief:

   • 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 2

Fetal Surveillance and Delivery Timing

Risk Stratification Based on Bile Acid Levels

1. High risk (≥100 μmol/L):

   • Offer delivery at 36 0/7 weeks' gestation
   • Risk of stillbirth increases substantially after 35 weeks 1, 2

2. Moderate risk (40-99 μmol/L):

   • Recommend delivery between 36 0/7 and 39 0/7 weeks' gestation 1, 2

3. Lower risk (<40 μmol/L):

   • Recommend delivery between 37 0/7 and 39 0/7 weeks' gestation 1, 2

Antenatal Monitoring

• Begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal testing 1
• More frequent monitoring for those with bile acid levels ≥100 μmol/L 2
• Weekly bile acid measurements from 32 weeks' gestation 1, 2
• Regular monitoring of liver function tests 2

Delivery Considerations

• Administer antenatal corticosteroids for fetal lung maturity if delivery is planned before 37 weeks 1, 2
• Use continuous fetal monitoring during labor due to higher risk of stillbirth 2
• Consider earlier delivery (34-36 weeks) for:
  • Bile acid levels ≥100 μmol/L
  • Unremitting maternal pruritus
  • History of ICP-related stillbirth
  • Evidence of worsening hepatic function 2

Postpartum Care

• Pruritus typically resolves within days after delivery
• Liver function tests and bile acids should normalize within 2-4 weeks
• If abnormalities persist beyond 6 weeks postpartum, evaluate for underlying chronic liver disease
• Consider genetic screening if there is a family history of hepatobiliary disease 2

Important Cautions

• Even with normal bile acid levels (<13 μmol/L) and normal fetal monitoring, sudden fetal death can occur, as demonstrated in case reports 3
• Symptoms may precede bile acid elevation; repeat testing is essential when clinical suspicion is high 4
• Do not rely solely on antepartum testing, as sudden stillbirth can occur even after normal fetal testing 2
• Avoid premature delivery without confirmed diagnosis 2

The evidence strongly supports that proper management with UDCA and appropriate timing of delivery based on bile acid levels can significantly reduce maternal symptoms and potentially improve fetal outcomes in cholestasis of pregnancy.