What is the summary of the National Institute for Health and Care Excellence (NICE) guideline for intrahepatic cholestasis of pregnancy (ICP)?

From the Guidelines

The National Institute for Health and Care Excellence (NICE) guideline for intrahepatic cholestasis of pregnancy (ICP) recommends a comprehensive management approach, including the use of ursodeoxycholic acid (UDCA) as the first-line agent for the treatment of maternal symptoms of ICP, as stated in the Society for Maternal-Fetal Medicine Consult Series #53 1.

Key Recommendations

• UDCA should be used as the first-line agent for the treatment of maternal symptoms of ICP 1, with a typical starting dose of 10-15 mg/kg per day, which can be divided into 2 or 3 daily doses.
• Liver function tests and bile acid levels should be monitored regularly, typically every 1-2 weeks, to assess the effectiveness of treatment and adjust the dose as needed.
• Women with ICP should be offered increased antenatal monitoring, including more frequent fetal growth scans and cardiotocography after 34 weeks, to monitor fetal well-being and detect any potential complications early.
• The timing of birth should be discussed with women, typically offering induction between 37 and 39 weeks depending on severity, with earlier timing for bile acids >100 μmol/L due to increased stillbirth risk, as recommended by the Society for Maternal-Fetal Medicine Consult Series #53 1.

Treatment and Management

• UDCA helps reduce bile acids and alleviate pruritus, which is the hallmark symptom of ICP, and has been shown to improve maternal symptoms and reduce the risk of preterm birth and fetal distress 1.
• Second-line treatments for severe pruritus that doesn't respond to UDCA include antihistamines, cholestyramine, or rifampicin (under specialist supervision), although these may have limited benefit and significant side effects.
• Antenatal corticosteroids for fetal lung maturity should be administered to patients delivering before 37 0/7 weeks of gestation if not previously administered, to reduce the risk of respiratory distress syndrome and other neonatal complications.

Delivery and Postpartum Care

• The optimal time to deliver patients with ICP is at 36 weeks of gestation, as calculated by Lo et al in a decision-analytic model, which balances the neonatal mortality and morbidities associated with early delivery and the risk of stillbirth associated with ICP 1.
• After delivery, liver function typically normalizes within 4-6 weeks, and follow-up testing is recommended to confirm resolution and monitor for any potential complications.

From the Research

Summary of NICE Guideline for Intrahepatic Cholestasis of Pregnancy (ICP)

• The National Institute for Health and Care Excellence (NICE) guideline for ICP is not directly mentioned in the provided studies, however, the studies provide information on the diagnosis, management, and treatment of ICP.
• According to the studies, ICP is a reversible pregnancy-specific cholestatic condition characterized by pruritus, elevated liver enzymes, and increased serum bile acids 2, 3, 4.
• The diagnosis of ICP is based on fasting or non-fasting bile acid levels, and the classification of disease severity is important for determining treatment and management 5.
• The treatment of ICP typically involves the administration of ursodeoxycholic acid to lower the levels of total bile acids (TBA) and possibly reduce pruritus 2, 3, 4.
• The management of ICP requires careful monitoring of maternal hepatic function tests and serum bile acid levels, as well as the assessment of fetal well-being and timely delivery after completion of fetal pulmonary maturity 3, 4, 5.
• The studies suggest that ICP is associated with an increased risk of adverse perinatal outcomes, including preterm birth, neonatal respiratory distress, and stillbirth, particularly when bile acid levels are ≥100 μmol/L 5.
• The guidelines for the management of ICP vary, reflecting the heterogeneity of the literature and the challenges of diagnosing and managing the condition 6.

Key Recommendations

• Pregnant individuals with ICP should be diagnosed using fasting or non-fasting bile acid levels, and the disease severity should be classified to determine treatment and management 5.
• Ursodeoxycholic acid should be administered to lower the levels of TBA and possibly reduce pruritus 2, 3, 4.
• Maternal hepatic function tests and serum bile acid levels should be carefully monitored, and fetal well-being should be assessed to determine the timing of delivery 3, 4, 5.
• Elective birth should be considered after completion of fetal pulmonary maturity, particularly when bile acid levels are ≥100 μmol/L 5.

Diagnosis and Management

• ICP should be diagnosed based on clinical symptoms, such as pruritus, and laboratory abnormalities, including elevated serum bile acids and abnormal liver function tests 2, 3, 4.
• The management of ICP requires a multidisciplinary approach, involving obstetric care providers, including obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, and radiologists 5.