Obstetric cholestasis / Intrahepatic Cholestasis of Pregnancy

Question 1

according to 2022 green-top guideline, when should you confirm the diagnosis of ICP (intrahepatic cholestasis of pregnancy) POSTnatally?

Answer 1

at least 4 weeks postnatally, with resolution of itching and LFTs + bile acids returning to normal

Question 2

bile acid threshold for diagnosis ICP

Answer 2

19 or more

Question 3

with ICP + singleton pregnancy, at what bile acid level is the risk of stillbirth increased beyond population rate?

Answer 3

bile acids 100 or more

Question 4

what peak bile acid level in ICP singleton pregnancy makes you confident to offer planned birth by 40 weeks?

Answer 4

19 - 39

N.B. that the presence of additional risk factors e.g. GDM may change this recommendation

Question 5

what peak bile acid level in ICP (singleton) makes you offer planned birth by 38 - 39 weeks?

Answer 5

bile acids 40 - 99
stillbirth risk in this category is similar to background risk for a singleton until 38 - 39 weeks’ gestation (but higher above this)

N.B. that the presence of additional risk factors e.g. GDM may change this recommendation

Question 6

at what gestation do you consider planned birth for ICP with peak bile acids 100 or more

Answer 6

35 - 36 weeks

Question 7

at what bile acid level is stillbirth rate raised in ICP in a twin/multiple pregnancy?

Answer 7

(I believe) any level of ICP has a higher stillbirth rate for multiple pregnancies

Question 8

classifications for mild, moderate and severe ICP (intrahepatic cholestasis of pregnancy)

Answer 8

mild 19 - 39
moderate 40 - 99
severe 100+

Question 9

routine viral and autoimmune tests and liver ultrasound to exclude other causes of the clinical picture of ICP intrahepatic cholestasis of pregnancy are no longer recommended by RCOG because…
When would you still do these tests?

Answer 9

the likelihood of a new diagnosis on these grounds is extremely unlikely.

Only do these tests if it’s an atypical picture, e.g. markedly elevated transaminases, early onset of ICP in the 1st or 2nd trimester, rapidly progressive biochemical picture, non-resolution postnatally

Question 10

Women and pregnant people with gestational pruritus may develop ICP up to **weeks after initial presentation

Answer 10

15 weeks after initial presentation!

Question 11

Women with ICP may have a higher chance of developing…

Answer 11

pre-eclampsia or gestational diabetes
(and these may impact planned birth gestation)

Question 12

All women with itch and an initial raised bile acid level, should have a second bile acid measurement repeated around **weeks later before any diagnostic or care decisions are determined

Answer 12

1 week later
this is because they may have an initial very high reading (>100!) which comes down on its own
After a week, the future testing frequency can be determined on an individual basis
Mostly weekly, although may not bother if >100 as it might not impact decision-making

Question 13

Is there any improvement in perinatal outcomes with ICP + urosdeoxycholic acid?

Answer 13

no
but perhaps a small reduction in itch

Question 14

In ICP, when would you consider offering vitamin K treatment

Answer 14

if evidence of fat malabsorption (steatorrhoea)
or abnormal prothrombin time

Question 15

if someone has ICP, at what bile acid levels would you recommend continuuous CTG in labour? (assuming no other co-morbidities)

Answer 15

100+

There is insufficient evidence for or against CEFM in women with peak bile acids <100 micromol/L. But there may be co-morbidities that necessitate CTG, and a higher risk of mec.