What is the management and treatment for a pregnant woman with cholestasis of pregnancy (intrahepatic cholestasis of pregnancy, ICP)?

Management of Cholestasis in Pregnancy

Treat all pregnant women with confirmed intrahepatic cholestasis of pregnancy (ICP) with ursodeoxycholic acid (UDCA) 15-20 mg/kg/day, and deliver based on bile acid levels: at 36 0/7 weeks for levels ≥100 μmol/L, between 36 0/7 and 39 0/7 weeks for levels 40-99 μmol/L, and at term for levels <40 μmol/L. 1

Diagnostic Workup

Laboratory confirmation is mandatory before treatment or delivery decisions:

• Measure non-fasting serum bile acids AND liver transaminases (ALT/AST) in all patients with suspected ICP—pruritus alone is insufficient for diagnosis 1, 2
• Non-fasting bile acid levels are the diagnostic gold standard 1
• Do NOT start UDCA before obtaining initial labs, as treatment can mask elevated bile acids and prevent definitive diagnosis 2
• Normal initial labs do not exclude ICP—pruritus can precede biochemical abnormalities by several weeks, requiring repeat testing every 1-2 weeks if symptoms persist 1, 2
• Screen for alternative diagnoses including viral hepatitis, autoimmune hepatitis, and biliary obstruction 1

Risk Stratification Algorithm

Bile acid concentration determines all management decisions: 1

• <40 μmol/L: Lower risk—expectant management to term

• 40-99 μmol/L: Increased risk—delivery between 36 0/7 and 39 0/7 weeks

• ≥100 μmol/L: Substantially increased stillbirth risk—delivery at 36 0/7 weeks

• Monitor bile acids at least weekly from 32 weeks gestation to identify rising concentrations 1

Pharmacological Treatment

UDCA is the first-line agent for all confirmed ICP cases: 1

• Dose at 15-20 mg/kg/day divided in 2-3 doses 1
• UDCA reduces spontaneous preterm birth risk and may protect against stillbirth 1
• UDCA improves maternal pruritus symptoms and normalizes biochemical markers 3, 4

For refractory pruritus despite UDCA:

• Consider cholestyramine, colestipol, or rifampicin as second-line agents, though evidence is limited 1

Fetal Surveillance Protocol

• Begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal testing, or at time of diagnosis if made later in gestation 1
• Do NOT initiate fetal surveillance in patients with pruritus but persistently normal bile acids, as evidence does not support increased fetal risk in this population 2

Delivery Timing Based on Bile Acid Levels

This is the critical management decision that balances stillbirth risk against prematurity complications: 1

• Bile acids ≥100 μmol/L: Deliver at 36 0/7 weeks gestation 1
• Bile acids 40-99 μmol/L: Deliver between 36 0/7 and 39 0/7 weeks gestation 1
• Bile acids <40 μmol/L: Expectant management to term (37-39 weeks) 4

Absolutely do NOT deliver at <37 weeks without laboratory confirmation of elevated bile acids—this causes iatrogenic prematurity-related morbidity when diagnosis remains uncertain 2

Critical Pitfalls to Avoid

• Never diagnose ICP based solely on pruritus—this leads to unnecessary preterm deliveries with associated neonatal morbidity 2
• Never start UDCA empirically before obtaining initial bile acid levels—this prevents accurate diagnosis 2
• Never assume normal initial labs permanently rule out ICP—biochemical abnormalities may develop weeks after symptom onset, requiring serial testing 1, 2
• Never deliver preterm without laboratory confirmation—the risks of prematurity outweigh uncertain benefits 2

Multidisciplinary Care

• Manage women with ICP using a multidisciplinary team including physicians, obstetricians, and midwives with expertise in liver disease in pregnancy 1

Postpartum Follow-Up

• Ensure bile acids, ALT/AST, and bilirubin return to normal within 3 months of delivery 1
• Investigate for underlying chronic liver disease if abnormalities persist beyond 3 months postpartum 1, 2
• Refer to a liver specialist if serologic abnormalities persist, as this suggests an underlying hepatobiliary condition rather than ICP 2