Summary
Definition
History and exam
Key diagnostic factors
- pruritus
- excoriations without rash
Other diagnostic factors
- mild jaundice
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
Diagnostic tests
1st tests to order
- bile acids
- liver function tests
Tests to consider
- coagulation profile
- hepatitis C virology
- liver and biliary tract ultrasound
- complete blood count
- autoantibody tests
Treatment algorithm
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
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 DifferentialsGuidelines
- 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)
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