Intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) affects around 1% of pregnancies in the UK. It is It is the most common liver disease of pregnancy generally seen in the third trimester.

Features

• Pruritus - may be intense - typical worse palms, soles and abdomen
• No rash (although skin changes may be seen due to scratching)
• Raised bile acids (diagnostic; ≥19 µmol/L)
• Mild elevation of ALT / AST
• Normal or mildly raised bilirubin

It is associated with an increased risk of premature birth. It is not generally associated with increased maternal morbidity

Management

• weekly liver function tests
• Stillbirth risk only rises significantly when bile acids ≥100 µmol/L
  • Mild ICP (19–39 µmol/L): risk similar to background; consider planned birth by 40 weeks or routine antenatal care.
  • Moderate ICP (40–99 µmol/L): risk remains low until 38–39 weeks; consider delivery at 38–39 weeks.
  • Severe ICP (≥100 µmol/L): increased stillbirth risk; consider delivery at 35–36 weeks.
• Symptomatic relief of itch with emollients
• No treatments improve fetal outcomes
  • Do not routinely use ursodeoxycholic acid to reduce perinatal risk.

Recurrence of intrahepatic cholestasis of pregnancy is 45-90% in subsequent pregnancies.

Acute fatty liver of pregnancy