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Intrahepatic cholestasis of pregnancy

Last reviewed: 10 Apr 2025
Last updated: 19 Mar 2025

Summary

Definition

History and exam

Key diagnostic factors

  • pruritus
  • excoriations without rash
Full details

Other diagnostic factors

  • mild jaundice
Full details

Risk factors

  • family history of ICP
  • previous history of ICP
  • history of hepatitis C infection
  • cholelithiasis
  • chronic hepatitis B infection
  • multifetal pregnancy
  • assisted reproduction
  • ethnicity
Full details

Diagnostic tests

1st tests to order

  • bile acids
  • liver function tests
Full details

Tests to consider

  • coagulation profile
  • hepatitis C virology
  • liver and biliary tract ultrasound
  • complete blood count
  • autoantibody tests
Full details

Treatment algorithm

ACUTE

gestational pruritus (serum bile acid concentrations <10 micromol/L)

mild intrahepatic cholestasis of pregnancy (serum bile acid concentrations ≥10 [or nonfasting, ≥19] and <40 micromol/L)

moderate intrahepatic cholestasis of pregnancy (serum bile acid concentrations ≥40 and <100 micromol/L)

severe intrahepatic cholestasis of pregnancy (serum bile acid concentrations ≥100 micromol/L)

Contributors

Authors

Catherine Williamson, FRCP, FMedSci

Professor of Women’s Health

King’s College London

Honorary Consultant in Obstetric Medicine

Guy’s and St Thomas’ NHS Foundation Trust

London

UK

Disclosures

CW is an author of a number of references cited in this topic. She consults for Mirum Pharmaceuticals and GSK and has been reimbursed for her time given to advise on ileal bile acid inhibitors. She has been a member of two Medical Research Council Boards (Public Health and Systems Medicine Board and Public Health Strategy Board) and is on the Scientific Committee of the Society for Endocrinology. CW has grants from NIHR, Diabetes UK, Lauren Page Trust, and ICP Support.

Caroline Ovadia, BMBCh, MA, PhD, MRCOG

Clinical Senior Lecturer in Obstetrics

King’s College London

Honorary Consultant Obstetrician

Guy’s and St Thomas’ NHS Foundation Trust

London

UK

Disclosures

CO is an author of a number of references cited in this topic. She has consulted for Mirum Pharmaceuticals.

Acknowledgements

Professor Catherine Williamson and Dr Caroline Ovadia would like to gratefully acknowledge Dr Robert H. Debbs and Dr Derek Jurus, previous contributors to this topic.

Disclosures

RHD and DJ declare that they have no competing interests.

Peer reviewers

Frank Lammert, MD

Director

Department of Internal Medicine II

Professor Internal Medicine

Saarland University Hospital

Homburg

Germany

Disclosures

FL declares that he has no competing interests.

Ron Librizzi, DO, FACOOG

Director

Maternal Fetal Medicine

Virtua Health System

Associate Professor of Obstetrics and Gynecology

Thomas Jefferson University School of Medicine

Philadelphia

PA

Disclosures

RL declares that he has no competing interests.

Vincenzo Berghella, MD, FACOG

Director

Maternal Fetal Medicine

Professor

Obstetrics and Gynecology

Thomas Jefferson University School of Medicine

Philadelphia

PA

Disclosures

VB declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Ovadia C, Seed PT, Sklavounos A, et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet. 2019 Mar 2;393(10174):899-909.Full text  Abstract

Girling J, Knight CL, Chappell L, et al. Intrahepatic cholestasis of pregnancy: green-top guideline no. 43 June 2022. BJOG. 2022 Aug 9 [Epub ahead of print].Full text  Abstract

Glantz A, Marschall HU, Mattsson LA. Intrahepatic cholestasis of pregnancy: relationships between bile acid levels and fetal complication rates. Hepatology. 2004 Aug;40(2):467-74.Full text  Abstract

Society for Maternal-Fetal Medicine; Lee RH, Greenberg M, Metz TD, et al. Society for Maternal-Fetal Medicine consult series #53: Intrahepatic cholestasis of pregnancy: replaces consult #13, April 2011. Am J Obstet Gynecol. 2021 Feb;224(2):B2-9.Full text  Abstract

European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, European Association for the Study of the Liver. EASL clinical practice guidelines on the management of liver diseases in pregnancy. J Hepatol. 2023 Sep;79(3):768-828.Full text  Abstract

Walker KF, Chappell LC, Hague WM, et al. Pharmacological interventions for treating intrahepatic cholestasis of pregnancy. Cochrane Database Syst Rev. 2020 Jul 27;7(7):CD000493.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Differentials

    • Acute viral hepatitis
    • HELLP syndrome
    • Acute fatty liver of pregnancy
    More Differentials
  • Guidelines

    • Pregnancy-related gastrointestinal and liver disease
    • Intrahepatic cholestasis of pregnancy – diagnosis and management: a consensus statement of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ)​
    More Guidelines
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