Obstetrics

Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy causes pruritus without a primary rash and raised bile acids, usually late in pregnancy; peak bile acids stratify stillbirth risk and guide shared decisions about monitoring and planned birth.

In a nutshell

Intrahepatic cholestasis of pregnancy presents with itch without a primary rash and raised bile acids. RCOG classifies peak bile acids as mild 19–39, moderate 40–99 and severe 100 or more micromol/L. The peak level and additional risks guide shared decisions about planned birth; ursodeoxycholic acid may help itch but does not prevent stillbirth, and ICP alone does not mandate caesarean birth.

Classic presentation

A person at 32 weeks has severe nocturnal itching of the palms and soles without a rash. Bile acids are 65 micromol/L. Arrange obstetric-led care, repeat bloods, assess fetal movements and discuss planned birth around 38–39 weeks if no other risk factors, with review if the level rises.

Key points

Itch without a primary rash is the classic presentation; scratch marks are secondary.
Diagnose and risk-stratify with peak serum bile acids; 19–39 is mild, 40–99 moderate and 100 or more severe.
If itch persists despite normal initial tests, repeat bile acids and liver tests.
UDCA may slightly reduce itch but does not prevent stillbirth.
For a singleton without additional risks, discuss birth by 40 weeks for 19–39, 38–39 weeks for 40–99 and 35–36 weeks for 100 or more.
ICP does not itself require planned caesarean birth and should resolve after delivery.

First-line investigation

Serum bile acids and liver function tests, with repeat testing if itch persists and assessment for other liver or pregnancy disease when atypical.

Management

Confirm and stratify

Check bile acids and liver tests, repeat if symptoms persist, exclude important alternative diagnoses and record the peak bile-acid category.^1,2

Relieve itch and arrange obstetric care

Offer skin measures and consider UDCA for maternal itch with realistic counselling; arrange obstetric-led follow-up, repeat blood tests and fetal-movement safety-netting.^1,2,3

Balance fetal risk and prematurity

Use the peak bile-acid category, gestation and additional risks to agree planned birth and any preterm-birth preparation; do not rely on routine extra scans to predict stillbirth.^1,2,4

Plan birth and follow up

Discuss induction, planned caesarean or waiting for labour according to the individual plan, monitor appropriately in labour, then confirm resolution of itch and liver tests and counsel about recurrence.^2,1

Exam traps

A normal first bile-acid result does not exclude ICP when itch continues.
Do not use itch severity or transaminases instead of the peak bile-acid level to estimate stillbirth risk.
UDCA is not a stillbirth-prevention treatment.
ICP alone is not an indication for caesarean birth.
Do not order extra fetal growth scans solely because of ICP; use the agreed risk-based plan.
Do not tell everyone to avoid oestrogen contraception after ICP; review new itch and ensure tests have normalised.

Illustrations

Intrahepatic cholestasis on liver histologyH&E liver histology showing canalicular bile plugs and cholestatic pigment within hepatocytes, illustrating the cholestatic process; the clinical hallmark is itch without a primary rash.Nephron, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.