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Management of an ICP pregnancy

Note: Following the publication of the paper by Ovadia et al (2019), this information will be revised to take account of the findings of that research.

There is as yet no standard management programme for ICP, either in the UK or the rest of the world. The information and references below reflect current practice, and may change as more research is done and our understanding of the condition improves.

  • You may be offered a drug, ursodeoxycholic acid (also referred to as urso or UDCA; see our page about UDCA for more details) that can help improve your liver function and ease the itching. Some researchers also believe that it will help to protect your baby.
  • If UDCA doesn’t work (and by this we mean that your bile acids don’t improve despite you taking the maximum dosage you can), some specialists in ICP also add a drug called rifampicin. This is a very powerful antibiotic that has been used for other liver diseases where cholestasis is occurring. It has been shown to improve bilirubin levels and result in enhanced bile acid detoxification (meaning that it could help to reduce bile acid levels in some women with ICP). However, it must only be used with specilaist guidance, as it can actually have a detrimental effect on your liver. It is given in addition to UDCA, not instead of it.
  • You may be asked to come into hospital more frequently to have your baby’s heart rate monitored (this is called a cardiotocograph) or to have additional ultrasound scans of your baby to check on your baby’s well-being and growth. There is no evidence that this is of any use in an ICP pregnancy, but click here to see what we say about this.
  • You may be asked to be mindful of your baby’s movements. This is something that applies to all pregnant women, and you should immediately contact your hospital if your baby’s movements change, slow down or stop.

Your baby may have to be delivered early.

  • ICP is associated with an increased risk of premature birth. This may be because your body goes into labour early, in which case it is called a spontaneous preterm birth, or because your doctors decide to deliver your baby early, called iatrogenic preterm birth.

    Your doctor may decide to deliver your baby early because they feel that the risk of continuing the pregnancy outweighs the risks associated with being born early. In ICP the specific risk that doctors worry about when making the decision to deliver babies early is the risk of stillbirth.

    Because of the risk of stillbirth, most women with ICP have been giving birth to their babies early. Induction has typically been recommended at around 37–38 weeks of pregnancy, but research published in 2019 suggests that around 90 per cent of women will be able to delay induction until 39 weeks of pregnancy. However, some women with severe ICP (greater than 100 µmol/L) may need to meet their babies from 34–35 weeks of pregnancy onward. It is essential that bile acids are tested frequently in ICP to ensure that women whose levels may rise above 100 µmol/L are identified, and that the results of these tests are received quickly.

As you can see, the decision about when you should meet your baby is not an easy one to make. We therefore suggest that you talk to your doctor about what is best for you and your baby, taking into account what is known from currrent research.

References

Ovadia C, Seed PT, Sklavounos A, Geenes V, Di Illio C, Chambers J et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. The Lancet 2019; DOI: http://dx.doi.org/10.1016/S0140-6736(18)31877-4.

Geenes V, Chappell LC, Seed PT, Steer PJ, Knight, M, Williamson C. Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: a prospective population-based case-control study. Hepatology 2014; First published online 26 February 2014; DOI: 10.1002/hep.26617
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Kohari KS, Carroll R, Capogna S, Ditchik A, Fox NS, Ferrara LA. Outcome after implementation of a modern management strategy for intrahepatic cholestasis of pregnancy. J Matern Fetal Neonatal Med 2016; 15: 1–17. DOI: 10.1080/14767058.2016.1212833 [Epub ahead of print]

Lo JO, Shaffer BL, Allen AJ, Little SE, Cheng YW, Caughey AB. Intrahepatic cholestasis of pregnancy and timing of delivery. J Matern Fetal Neonatal Med 2015; 28(18):2254–8.

Marschall HU. Management of intrahepatic cholestasis of pregnancy. Expert Rev Gastroenterol Hepatol 2015; 9(10): 1273–1279

Ovadia C, Williamson C. Intrahepatic cholestasis of pregnancy: recent advances. Clin Dermatol 2016; 34(3): 327–334. doi: 10.1016/j.clindermatol.2016.02.004.

Puljic A, Kim E, Page J, Esakoff T, Shaffer B, LaCoursiere DY, Caughey AB. The risk of infant and fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age. Am J Obstet Gynecol 2015; 212(5):667.e1-5

Royal College of Gynaecologists. Obstetric Cholestasis (Green-top Guideline No. 43). https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg43/ (currently awaiting revision).