Management of Intrahepatic Cholestasis of Pregnancy with Normal LFTs
Do not deliver preterm (<37 weeks) in patients with suspected IHCP but normal bile acids—repeat testing if pruritus persists, and only proceed with early delivery once elevated bile acids are laboratory-confirmed. 1
Diagnostic Approach
Initial Testing and Interpretation
Measure both serum bile acids AND liver transaminases when IHCP is suspected, as this is the recommended diagnostic workup (GRADE 1B). 1
Normal LFTs do not exclude IHCP—pruritus can precede the rise in serum bile acid levels by several weeks. 1
Repeat bile acid and transaminase measurements if pruritus persists without another explanation, as the biochemical abnormalities may develop later in the disease course. 1
Critical Diagnostic Caveat
Avoid empiric ursodeoxycholic acid (UDCA) treatment before obtaining laboratory confirmation, as starting UDCA at the time of testing may prevent detection of elevated bile acids or transaminases, making definitive diagnosis impossible. 1
The diagnosis of IHCP requires laboratory confirmation of elevated bile acids—clinical symptoms alone are insufficient to justify preterm delivery. 1
Management Strategy for Normal Laboratory Values
Symptomatic Management
Consider empiric UDCA for severe pruritus only after initial testing is complete and while awaiting repeat results, understanding this may complicate subsequent diagnosis. 1
UDCA is the first-line agent for maternal symptom relief (GRADE 1A) and can be used for symptomatic treatment. 1
Surveillance Approach
Do NOT initiate antenatal fetal surveillance in patients with pruritus but persistently normal bile acids, as the evidence does not support increased fetal risk in this population. 1
Antenatal fetal surveillance should only begin once IHCP is confirmed with elevated bile acids, at a gestational age when delivery would be performed in response to abnormal testing (GRADE 2C). 1
Delivery Timing Decisions
Firm Recommendations
Strongly recommend AGAINST preterm delivery at <37 weeks in patients with clinical suspicion of IHCP but no laboratory confirmation of elevated bile acids (GRADE 1B). 1
This recommendation prioritizes avoiding iatrogenic prematurity-related morbidity when the diagnosis remains uncertain. 1
Special Circumstances (37-38 Weeks)
For patients at 37-38 weeks with persistent pruritus but no bile acid results available, management requires shared decision-making that weighs:
- Uncertainty of diagnosis
- Risks of IHCP versus early-term delivery
- Patient values and preferences 1
Diagnostic certainty improves if there are elevated transaminases or a history of IHCP in previous pregnancies—delivery may be reasonable in these specific situations even without bile acid results. 1
Consider using enzymatic bile acid assays to shorten turnaround time when IHCP is suspected in early-term gestations. 1
Follow-Up Protocol
Repeat Testing Strategy
Serial bile acid and transaminase measurements should continue if pruritus persists, as biochemical abnormalities may emerge weeks after symptom onset. 1
The frequency of repeat testing should be guided by symptom severity and clinical suspicion, typically every 1-2 weeks until symptoms resolve or diagnosis is confirmed.
Post-Delivery Evaluation
Reevaluate liver function tests after delivery in patients with persistent pruritus or other hepatobiliary symptoms (right upper quadrant pain, jaundice). 1
Refer to a liver specialist if serologic abnormalities persist postpartum, as this suggests an underlying hepatobiliary condition rather than IHCP. 1
Key Clinical Pitfalls
Avoid the temptation to diagnose IHCP based solely on pruritus—this leads to unnecessary preterm deliveries with associated neonatal morbidity. 1
Do not assume normal initial labs rule out IHCP permanently—the biochemical signature may develop later, requiring vigilance and repeat testing. 1
Resist pressure for early delivery without laboratory confirmation—the SMFM explicitly recommends against this practice (GRADE 1B), as the risks of prematurity outweigh uncertain benefits. 1