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How is ICP treated?

Note: the information on this page has been updated following the publication of the third edition of the RCOG Green-Top Guideline on 9 August 2022.

There is no consensus on the best way to treat ICP. Many hospitals have adopted a policy of ‘active management’ with ICP pregnancies in anticipation that this approach might reduce any risk to the unborn baby. The term ‘active management’ is used to describe various strategies that hospitals use to monitor your ICP pregnancy, and may include some or all of the following:

  • Blood tests (non-fasting bile acids and liver blood tests). Recent research by Ovadia et al (2019) has shown that bile acids are more directly linked to the risk of stillbirth and are therefore vital in the management of ICP.
  • Fetal movement monitoring (cardiotocographs (CTGs) and growth scans). There is no evidence to show that CTGs are of any benefit in the management of ICP. While they may bring reassurance to the woman, they should not be relied on as confirmation that all is well with the unborn baby. It is important therefore that women continue to monitor their baby’s pattern of movements at all times.
  • Treatment with ursodeoxycholic acid (UDCA). A trial of UDCA (called PITCHES; Chappell et al 2019) showed that this drug does not reduce bile acids or itch for most women who have ICP. However, the most recent research (Ovadia 2021) has shown that it can reduce the risk of spontaneous premature birth, particularly for those women whose bile acids are greater than 40 µmol/l. Some researchers still feel that it may be useful for the small group of women who have very severe ICP, but further research is needed on this.

How is ICP treated?

  • Treatment with other drugs.
  • Many hospitals are still advising induction at around 37 weeks. Research by Ovadia et al (2019) has shown that some women will be able to wait until 39 weeks for induction (the RCOG Guideline supports 40 weeks if bile acids remain under 40 µmol/L). Other women with severe ICP (bile acids over 100 µmol/L) may need to meet their babies as early as 34–35 weeks of pregnancy – see our recommended protocol for managing ICP.

It should be noted that none of these interventions is proven to protect your baby against the small risk of stillbirth.

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References

Girling J, Knight CL, Chappell L; on behalf of the Royal College of Obstetricians and Gynaecologists. Intrahepatic cholestasis of pregnancy. BJOG 2022; 1–20. https://doi.org/10.1111/1471-0528.17206.

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; https://doi.org/10.1016/S0140-6736(18)31877-4.

Ovadia C, Sajous J, Seed PT, Patel K, Williamson NJ, Attilakos G, Azzaroli F, Bacq Y, Batsry L, Broom K, Brun-Furrer R, Bull L, Chambers J, Cui Y, Ding M, Dixon PH, Estiù MC, Gardiner FW, Geenes V, Grymowicz M, Günaydin B, Hague WM, Haslinger C, Hu Y, Indraccolo U, Juusela A, Kane SC, Kebapcilar A, Kebapcilar L, Kohari K, Kondrackienė J, Koster MPH, Lee RH, Liu X, Locatelli A, Macias RIR, Madazli R, Majewska A, Maksym K, Marathe JA, Morton A, Oudijk MA, Öztekin D, Peek MJ, Shennan AH, Tribe RM, Tripodi V, Özterlemez NT, Vasavan T, Audris Wong LF, Yinon Y, Zhang Q, Zloto K, Marschall H-U, Thornton J, Chappell LC, Williamson C. Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis. Lancet Gastroenterology & Hepatology 2021; Online 26 April. https://doi.org/10.1016/S2468-1253(21)00074-1