Cholestasis of pregnancy

Last reviewed: March 2019

Last updated: October 2017

Summary

May be associated with an increased risk of adverse pregnancy outcomes, including premature birth, intra-uterine fetal demise, and placental abruption in severe disease.

There is an increased risk of respiratory distress syndrome in neonates, owing to meconium aspiration syndrome, which is unpredictable by available methods of surveillance.

The only definitive cure is delivery of the baby.

The condition is associated with a history of hepatitis C and there may be an association with long-term liver disease.

Mild disease with bile acid levels <40 micromol/L or mild itching can be treated with bile-sequestering agents and antihistamines, such as colestyramine and hydroxyzine. However, if tolerated no treatment is necessary.

Severe disease with bile acid levels >40 micromol/L or severe pruritus remote from term can be treated effectively with ursodeoxycholic acid.

Close fetal surveillance with delivery near term can be expected with premature delivery reserved for those with severe, worsening disease despite treatment.

Definition

Intrahepatic cholestasis of pregnancy (ICP) is a pruritic condition during pregnancy caused by impaired bile flow allowing bile salts to be deposited in the skin and the placenta. The cause is a combination of hormonal, genetic, and environmental factors. ICP may predispose mothers to vitamin K deficiency and the fetus to adverse pregnancy outcomes that may include prematurity, intra-uterine fetal demise, and respiratory distress syndrome. [1] Evidence C Obstetrical adverse events: poor-quality evidence found higher incidence of respiratory distress syndrome in neonates delivered of mothers who suffered from intrahepatic cholestasis of pregnancy. [2]

History and exam

Key diagnostic factors

presence of risk factors
pruritus, sparing the face
excoriations without rash

Full details

Other diagnostic factors

mild jaundice

Full details

Risk factors

previous hx of intrahepatic cholestasis of pregnancy (ICP)
hx hepatitis C
FHx of intrahepatic cholestasis of pregnancy
age >35 years
multiple pregnancy

Full details

Diagnostic investigations

1st investigations to order

bile acids
LFTs
coagulation profile
fasting serum cholesterol
hepatitis C virology

Full details

Investigations to consider

liver biopsy

Full details

Treatment algorithm

ACUTE

Contributors

Authors VIEW ALL 

Robert H. Debbs, DO, FACOOG

Associate Professor of Obstetrics and Gynecology

Division of Maternal Fetal Medicine

University of Pennsylvania School of Medicine

Director

Pennsylvania Hospital Maternal Fetal Medicine Network

Philadelphia

Disclosures

RHD declares that he has no competing interests.

Acknowledgements

Dr Robert H. Debbs would like to gratefully acknowledge Dr Derek Jurus, a previous contributor to this monograph. DJ declares that he has no competing interests.

Peer reviewers VIEW ALL 

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

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

Disclosures

VB declares that he has no competing interests.

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Cholestasis of pregnancy

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

symptomatic mild disease (bile acids <40 micromol/L)

severe disease (bile acids ≥40 micromol/L) + gestational age <37 weeks

severe disease (bile acids ≥40 micromol/L) + gestational age ≥37 weeks

Contributors

Authors VIEW ALL 

Robert H. Debbs, DO, FACOOG

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Frank Lammert, MD

Disclosures

Ron Librizzi, DO, FACOOG

Disclosures

Vincenzo Berghella, MD, FACOG

Disclosures

Differentials

Guidelines

Patient leaflets

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