Treatment of Cholestasis of Pregnancy with Itching of Normal-Appearance Skin and Peak Bile Acids ≥100 µmol/L (Severe ICP)
Clinical scenario
This protocol applies to pregnant women presenting with itching of skin of normal appearance in whom laboratory testing reveals a raised peak random total bile acid concentration of 100 µmol/L or more — the threshold defining severe intrahepatic cholestasis of pregnancy (ICP).
Defining severe ICP
ICP is considered in any pregnant woman with pruritus and normal-looking skin when the peak bile acid concentration is raised. Concentrations at or above 100 µmol/L characterise the severe end of the spectrum and carry an elevated risk of stillbirth beyond the background rate, making prompt, structured management important.
Management approach — partial overview
Structured care for severe ICP in this setting involves measures targeting skin symptom relief alongside specific guidance on timing and mode of birth — the complete sequenced protocol, including the full scope of interventions and their conditions of use, is available below.
References
DOI: 10.1111/1471-0528.17206
- The diagnosis of ICP should be considered in pregnant women who have itching in skin of normal appearance and raised peak random total bile acid concentration of 19 micromol/L or more.
- Severe ICP: itching and raised peak bile acid concentrations ≥100 micromol/L.
- Consider topical emollients such as aqueous cream (with or without menthol added) to ameliorate skin symptoms.
- Consider antihistamine agents, such as chlorphenamine, particularly at night although the effectiveness of this treatment is uncertain in women with ICP.
- Other common antihistamine agents including loratadine and cetirizine are also used in pregnancy for other indications but do not have sedative side-effects.
- If women have symptoms such as steatorrhoea, coagulation assessment should be performed and use of vitamin K treatment considered (prescribed as a water-soluble formulation such as menadiol sodium phosphate at a dose of 10 mg daily).
- Consider planned birth at 35–36 weeks' gestation in women with severe ICP with peak bile acids 100 micromol/L or more; advise them that the risk of stillbirth is higher than the background risk.
- If planned early birth is indicated, induction of labour should be considered unless other reasons for caesarean birth are present.
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