Management of intrahepatic cholestasis of pregnancy

Abstract

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease during pregnancy, characterized by otherwise unexplained pruritus in late second and third trimester of pregnancy and elevated bile acids and/or transaminases. ICP is associated with an increased risk of adverse perinatal outcomes for the fetus and the later development of hepatobiliary disease for the mother. Bile acids should be monitored throughout pregnancy since fetal risk is increased at serum bile acids >40 µmol/l. Management of ICP consists of treatment with ursodeoxycholic acid, which reduces pruritus. Early elective delivery is common practice but should be performed on an individualized basis as long as strong evidence supporting this practice is lacking. Mothers should be followed-up for normalization of liver function tests 6–12 weeks after delivery. Future research in large-scale studies is needed to address the impact of ursodeoxycholic acid and early elective delivery on fetal outcome.

Keywords:

• bile acids
• early delivery
• obstetric cholestasis
• progesterone sulfates
• ursodeoxycholic acid

Financial & competing interests disclosure

The author has signed consultancy agreements (via University of Gothenburg) with Albireo, AstraZeneca, Intercept and Metabogen. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease during pregnancy with incidence rates between 0.2 and 2% in different countries.

• ICP is characterized by otherwise unexplained pruritus in late second and third trimester of pregnancy, elevated bile acids and/or transaminases, and spontaneously relief of symptoms and complete normalization of biochemical aberrations within a few weeks after delivery.

• ICP has a complex etiology with endocrine, genetic, and environmental components.

• ICP is associated with increased fetal risk of impaired perinatal outcome.

• ICP is associated with increased maternal risk of hepatobiliary disease.

• Ursodeoxycholic acid reduces pruritus but the effect on fetal outcome still is unknown.

• There is lack of strong evidence to support or refute the common practice of induced delivery at 37–38 weeks of gestation.