From the Guidelines
Cholestasis in pregnancy should be treated with ursodeoxycholic acid (UDCA) at a dose of 10-15 mg/kg/day divided into 2-3 doses, as it is the most effective treatment for reducing maternal symptoms and improving laboratory abnormalities, as recommended by the Society for Maternal-Fetal Medicine 1. The treatment of cholestasis in pregnancy has two main goals: to reduce the maternal symptoms of pruritus and to reduce the risk for adverse perinatal outcomes.
- The most commonly used treatment for cholestasis of pregnancy is UDCA, which has been shown to be effective in relieving pruritus and improving laboratory abnormalities, with no known adverse effects on the fetus 1.
- The typical starting dose for UDCA treatment is 10-15 mg/kg per day, which can be divided into 2 or 3 daily doses, with a maximum dose of 21 mg/kg per day if necessary 1.
- Alternative treatments, such as S-adenosyl-methionine and cholestyramine, can be considered for patients who cannot take UDCA or who have continued symptoms on the maximum dosage, but they are less effective and have a higher risk of side effects 1.
- Delivery timing is crucial, with consideration for delivery at 36-37 weeks to reduce the risk of stillbirth, especially in patients with total bile acid levels of 100 mmol/L or higher, as recommended by the Society for Maternal-Fetal Medicine 1.
- Patients with cholestasis of pregnancy should be referred to maternal-fetal medicine for increased fetal monitoring, including weekly non-stress tests starting at 32 weeks and regular ultrasounds to assess fetal growth, and should receive antenatal corticosteroids for fetal lung maturity if delivering before 37 weeks of gestation 1.
- The use of UDCA has been associated with a reduced risk of preterm birth, fetal distress, and neonatal intensive care unit admission, although the evidence is not conclusive, and the decision to use UDCA should be individualized based on the patient's specific situation and the risks and benefits of treatment 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Definition and Diagnosis of Cholestasis in Pregnancy
- Cholestasis in pregnancy, also known as intrahepatic cholestasis of pregnancy (ICP), is a pregnancy-specific liver disease that typically presents in the third trimester 2.
- The diagnosis of ICP is based on symptoms of pruritus, typically including the palms and soles, as well as elevated bile acid levels and other liver function tests such as alanine aminotransferase and aspartate aminotransferase 3.
- Other causes of liver dysfunction should be ruled out to confirm the diagnosis of ICP 3.
Risks and Complications Associated with Cholestasis in Pregnancy
- ICP is associated with an increased risk of adverse perinatal outcomes, including spontaneous preterm delivery, meconium staining of the amniotic fluid, and stillbirth 2, 4.
- The risk of adverse neonatal outcomes increases with increasing bile acid levels 3.
- Fetal risks of ICP include increased risk of preterm birth, meconium-stained amniotic fluid, respiratory distress syndrome, or stillbirth 3.
Treatment and Management of Cholestasis in Pregnancy
- Ursodeoxycholic acid (UDCA) is the most commonly used treatment for ICP and has been shown to improve maternal pruritus symptoms and biochemical tests 3, 5.
- UDCA has multiple mechanisms of action, including stabilizing plasma membranes, halting apoptosis, and inducing changes in the expression of metabolizing enzymes and transporters 6.
- While UDCA improves maternal symptoms, no treatment has been shown to definitively improve fetal outcomes 3, 4.
- Delivery may be considered at 37 weeks' gestation due to the increased risk of stillbirth in the setting of ICP 3, 4.