What are the treatment options for pruritus (itching) in pregnancy?

Treatment of Pruritus in Pregnancy

Ursodeoxycholic acid (UDCA) at a dose of 10-15 mg/kg/day in divided doses is the first-line treatment for pruritus in pregnancy, particularly for intrahepatic cholestasis of pregnancy (ICP). 1, 2

Diagnostic Approach

When evaluating pruritus in pregnancy, consider:

• Distribution of pruritus (palms and soles involvement is common in ICP)
• Presence or absence of rash (ICP typically has no primary rash)
• Timing (pruritus often worsens at night)
• Laboratory evaluation:
  • Serum bile acid levels (most sensitive for ICP)
  • Liver function tests (ALT, AST, bilirubin, GGT)

Treatment Algorithm

First-Line Treatments

1. Non-pharmacological measures:

   • Emollients to prevent skin dryness
   • Cooling gels (e.g., menthol gels)
   • Avoiding hot baths/showers
   • Keeping nails short
   • Loose-fitting cotton clothing
   • Lukewarm water for bathing
   • Oatmeal baths

2. Pharmacological treatment:

   • UDCA 10-15 mg/kg/day divided into 2-3 daily doses 1, 2
     • Improvement typically occurs within 1-2 weeks
     • Can titrate up to 21-25 mg/kg/day if pruritus persists
     • Most effective for ICP but may help other forms of cholestatic pruritus

Second-Line Treatments

1. Cholestyramine (4-16 g daily in divided doses) 2

   • Must be separated from other medications by at least 4 hours
   • Monitor for vitamin K deficiency (check INR/PT)
   • Administer vitamin K supplementation if deficiency develops

2. Rifampicin (300-600 mg daily) 2, 1

   • Can be combined with UDCA for refractory cases
   • Monitor for hepatotoxicity (occurs in approximately 5% of patients)
   • Neonates of women treated with rifampicin should receive vitamin K

Third-Line/Adjunctive Treatments

1. Antihistamines for symptomatic relief and sleep 1, 3

   • Diphenhydramine or hydroxyzine (limited efficacy but can help with sleep)

2. Topical treatments

   • Low to mid-potency topical corticosteroids for localized pruritus
   • Avoid extensive use of high-potency corticosteroids (risk of low birth weight)

3. S-adenosyl-L-methionine (SAMe) (1,000-1,200 mg daily) 2, 1

   • May have additive effect with UDCA

Special Considerations

For Intrahepatic Cholestasis of Pregnancy

• Begin antenatal fetal surveillance at diagnosis
• Consider delivery at 36-38 weeks depending on bile acid levels:
  • <40 μmol/L: Lower risk
  • 40-99 μmol/L: Moderate risk (0.3% IUFD risk)
  • ≥100 μmol/L: High risk (3.4% IUFD risk) - consider delivery at 36 weeks or at diagnosis if after 36 weeks 2, 1

For Cholestatic Liver Disease

• UDCA is considered safe during pregnancy, particularly in the second and third trimesters 2
• Monitor coagulation tests (INR) in women with cholestasis, especially if using cholestyramine 2

For Other Causes of Pruritus

• Identify and treat underlying cause when possible
• Persistent symptoms or abnormal liver tests beyond 6 weeks postpartum warrant evaluation for underlying chronic liver disease 1

Common Pitfalls to Avoid

1. Failing to repeat bile acid testing if initial results are normal but pruritus persists
2. Inadequate dosing of UDCA or not titrating up when needed
3. Not separating UDCA and cholestyramine administration by at least 4 hours
4. Overlooking vitamin K deficiency, especially if cholestyramine is used
5. Delaying treatment, which may prolong maternal discomfort and potentially impact fetal outcomes

By following this treatment algorithm and considering the special circumstances of pregnancy, pruritus can be effectively managed while minimizing risks to both mother and fetus.