Management of an ICP pregnancy
Note: the information on this page was written before the third edition of the RCOG Green-Top Guideline on ICP was published on 9 August 2022. We will update the information as soon as we can, but in the meantime you can find the Guideline here.
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. The most recent trial of UDCA, called PITCHES, has shown that although it can help improve your liver blood test results and reduce your itch by a very small amount, overall it did not reduce bile acid levels. Read what we say about this here. The most recent research on UDCA (Ovadia et al 2021) has shown that it can reduce the risk of spontaneous premature birth, particularly for those women whose bile acid levels are greater than 40 µmol/L.
- 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 specialist guidance, as it can actually have a detrimental effect on your liver. It is given in addition to UDCA, not instead of it. A new trial, called TURRIFIC, is currently under way in Australia to evaluate its efficacy. ICP Support is a collaborator on this study.
- 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 (UDCA may help to reduce this risk), or because your doctors decide to deliver your baby early, called iatrogenic preterm birth.
- Your doctor may recommend that your baby is born earlier because 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 recommendation for earlier birth 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.