Management of an ICP pregnancy
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; see our page about UDCA for more details) that can help improve your liver function and ease the itching. Some researchers also believe that it will help to protect your baby.
- If UDCA doesn’t work (and by this we mean that your bile acids don’t improve despite you taking the maximum dosage you can), 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 specilaist guidance, as it can actually have a detrimental effect on your liver. It is given in addition to UDCA, not instead of it.
- 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, or because your doctors decide to deliver your baby early, called iatrogenic preterm birth.
Your doctor may decide to deliver your baby early because they feel that 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 decision to deliver babies early is the risk of stillbirth.
As studies have shown that the majority of stillbirths in women with ICP occur after 37 weeks of pregnancy, many doctors aim to deliver babies from affected pregnancies at between 37 and 38 weeks of pregnancy in an attempt to reduce this risk.
However, there has been research to suggest that if the bile acid levels have always remained under 40 µmol/L, the pregnancy could be allowed to progress as normal, permitting spontaneous labour to occur. But in the absence of large trials to prove that this is safe (and researchers still also have to prove that bile acids have been the cause of stillbirth), many doctors are continuing to deliver the baby by 37–38 weeks. This approach also relies on the fast return of bile acid results (withing 24 hours), because we know from our own research how quickly bile acids can rise (and fall).
A more recent study (Geenes et al. 2014; see References below) suggests that some babies may need to be born earlier than 37 weeks in severe ICP, depending on the level of the bile acids (severe ICP is defined by researchers as bile acid levels being greater than 40 µmol/L).
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.
Our suggested management guideline, based on practice in UK hospitals, can be found here.
Geenes V, Chappell LC, Seed PT, Steer PJ, Knight, M, Williamson C. Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: a prospective population-based case-control study. Hepatology 2014; First published online 26 February 2014; DOI: 10.1002/hep.26617
Kohari KS, Carroll R, Capogna S, Ditchik A, Fox NS, Ferrara LA. Outcome after implementation of a modern management strategy for intrahepatic cholestasis of pregnancy. J Matern Fetal Neonatal Med 2016; 15: 1–17. DOI: 10.1080/14767058.2016.1212833 [Epub ahead of print]
Lo JO, Shaffer BL, Allen AJ, Little SE, Cheng YW, Caughey AB. Intrahepatic cholestasis of pregnancy and timing of delivery. J Matern Fetal Neonatal Med 2015; 28(18):2254–8.
Marschall HU. Management of intrahepatic cholestasis of pregnancy. Expert Rev Gastroenterol Hepatol 2015; 9(10): 1273–1279
Ovadia C, Williamson C. Intrahepatic cholestasis of pregnancy: recent advances. Clin Dermatol 2016; 34(3): 327–334. doi: 10.1016/j.clindermatol.2016.02.004.
Puljic A, Kim E, Page J, Esakoff T, Shaffer B, LaCoursiere DY, Caughey AB. The risk of infant and fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age. Am J Obstet Gynecol 2015; 212(5):667.e1-5
Royal College of Gynaecologists. Obstetric Cholestasis (Green-top Guideline No. 43). https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg43/ (currently awaiting revision).