Intrahepatic cholestasis of pregnancy Green- top Guideline No. 43 June 2022 by dr maria rafi

 

 Outline on Intrahepatic Cholestasis of Pregnancy (ICP)

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🌟 Introduction

• Prevalence:
  • Influenced by genetic and environmental factors.
  • Affects 0.7% of pregnancies in multi-ethnic populations in the UK.
  • Higher prevalence in Indian-Asian and Pakistani-Asian women (1.2%–1.5%).

• Definition: Multifactorial condition causing:

• • Pruritus without a primary skin condition.
  • Elevated maternal bile acid levels.
  • Symptoms commonly emerge in the third trimester but can occur earlier.
• Diagnosis: Must rule out alternative diagnoses (e.g., pre-eclampsia).
• Postnatal Follow-up: Essential to check liver function for persistent abnormalities.

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🩺 Diagnosis

• Criteria:
  • Itching with normal skin appearance.
  • Peak bile acid concentration ≥19 micromol/L.
• Confirmation:
  • Symptoms and bile acid levels return to normal after birth.
  • Structured history and examination to exclude other causes.
• Monitoring:
  • Repeat liver function tests and bile acid measurements if symptoms persist.

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📚 Clinical Features

• Symptoms:
  • Itching varies in intensity (mild to unbearable) and distribution (focal to widespread).
  • Negative impact on mental well-being for some women.
• Key Findings:
  • Liver failure (e.g., prolonged prothrombin time) is not a typical feature.
• 
  

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🧪 Evidence and Research

• Literature Search:
  • Extensive review of databases like Cochrane, EMBASE, and PubMed.
  • Systematic reviews and meta-analyses support current guidelines.
• Key Insights:
  • Bile acid concentration (>100 micromol/L) linked to stillbirth risk.
  • Transaminase levels alone do not indicate fetal risk.

📖 Terminology

• Suggested terms for diagnosis:
  • Gestational Pruritus: Itching with bile acids <19 micromol/L.
  • Mild ICP: Bile acids 19–39 micromol/L.
  • Moderate ICP: Bile acids 40–99 micromol/L.
  • Severe ICP: Bile acids ≥100 micromol/L.

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🔬 Role of Other Investigations

• Individualized Approach:
  • Routine additional investigations are not recommended for every woman.
  • Consider based on:
    • Atypical clinical symptoms.
    • Presence of comorbidities.
    • Early-onset severe ICP.
• Postnatal Investigations:
  • Recommended if liver function tests fail to normalize or resolution is delayed.
• Specialist Hepatology Advice:
  • Seek consultation for severe, early, or atypical presentations of suspected ICP.

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🩺 Postnatal Resolution

• Confirm the diagnosis of ICP at least 4 weeks post-birth.
• Criteria for resolution:
  • Itching subsides.
  • Liver function tests and bile acid levels return to normal.

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🌟 Maternal Morbidity

• Predominant Symptom:
  • Severe itching that fluctuates and may disrupt sleep.
• Associated Risks:
  • Higher likelihood of developing:
    • Pre-eclampsia.
    • Gestational diabetes.
  • Importance of:
    • Regular blood pressure and urine monitoring.
    • Testing for gestational diabetes as per national guidelines.

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⚠️ Risk of Stillbirth

• Isolated ICP in Singleton Pregnancy:
  • Peak bile acids 19–39 micromol/L:
    • Risk of stillbirth is similar to the background population rate.
  • Peak bile acids 40–99 micromol/L:
    • Risk remains similar to background risk until 38–39 weeks' gestation.
  • Peak bile acids ≥100 micromol/L:
    • Risk of stillbirth is higher than the background rate.
• Influence of Risk Factors:
  • Co-morbidities such as:
    • Gestational diabetes.
    • Pre-eclampsia.
    • Multifetal pregnancy.
  • These conditions increase the risk of stillbirth and may influence decisions around the timing of planned birth.
• Twin Pregnancies with ICP:
  • Risk of stillbirth is higher compared to twin pregnancies without ICP.

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🤰 Risk of Perinatal Morbidity

• Preterm Birth:
  • Moderate or severe ICP increases the chance of:
    • Spontaneous preterm birth.
    • Iatrogenic preterm birth (medically indicated).
• Meconium-Stained Amniotic Fluid:
  • Increased likelihood during labor and birth in moderate/severe ICP cases.
• Fetal Well-Being:
  • Babies born to mothers with moderate/severe ICP are more likely to face complications.

• 🌟 How Should Women and fetus with ICP Be Monitored?

• 🩺 Consultant-Led Care

  • 👩‍⚕️ Women with ICP should be reviewed in a consultant-led maternity unit for optimal management and care.

  🌟 Fetal Monitoring

  Guidance for Women

  • 🤱 Monitor fetal movements closely./FKCC
  • 🚨 Seek immediate care at the maternity unit if there are any concerns.(reduce fetal movement)

  Ineffective Tools

  • ⚠️ Ultrasound and CTG are not reliable for predicting or preventing stillbirth in ICP cases.

  
  

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💊 Role of Drug Treatment in ICP

General Considerations

• Limited Efficacy:
  • No drug treatments have proven to:
    • Improve pregnancy outcomes.
    • Reduce bile acid concentrations significantly.
  • Primary goal: Reduce maternal itching, albeit with limited success.

Ursodeoxycholic Acid (UDCA)

• Evidence-Based Findings:
  • No reduction in stillbirth or adverse outcomes.
  • Minimal improvement in itching (5 mm reduction on a 100 mm scale).
  • May reduce spontaneous preterm birth in bile acids ≥40 micromol/L but does not prevent stillbirth.
• Recommendation:
  • Do not routinely offer UDCA for improving perinatal outcomes.

Other Treatments

• Topical Emollients:
  • Consider aqueous creams (with/without menthol) for itching relief.
  • Low evidence but widely used without harmful effects.
• Antihistamines:
  • Chlorphenamine may help, particularly at night due to its sedative properties.
  • Effectiveness for itching relief is uncertain.
• Other Agents:
  • Not recommended outside of research settings.
  • Specialist opinion required for severe cases before considering rifampicin.

Vitamin K Use

• Indication:
  • Only consider for reduced fat absorption (e.g., steatorrhea) or abnormal coagulation studies.
  • Routine use is not recommended.

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🤰 Timing and Mode of Birth

• • Timing of Birth

    • Mild ICP (Bile Acids 19–39 µmol/L):

      • Planned birth by 40 weeks or ongoing antenatal care.
      • Risk of stillbirth is similar to the background rate.
      • Decision should be made collaboratively with the patient.

    • Moderate ICP (Bile Acids 40–99 µmol/L):

      • Consider planned birth at 38–39 weeks.
      • Risk of stillbirth increases slightly after 38–39 weeks.

    • Severe ICP (Bile Acids ≥100 µmol/L):

      • Plan delivery at 35–36 weeks, considering individual risks.
      • Risk of stillbirth is significantly higher (3.44%) after 35 weeks.

    • Comorbidities (e.g., gestational diabetes, pre-eclampsia, multifetal pregnancy):

      • May necessitate earlier intervention.

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    Mode of Birth

    • ICP does not directly influence the mode of birth.
    • Decisions should follow routine obstetric practice:
      • Induction of labor is preferred for planned early births unless contraindicated.
      • Continuous Electronic Fetal Monitoring (CEFM):
        • Recommended for bile acids ≥100 µmol/L.
        • Individualized decision for bile acids <100 µmol/L.

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    🩺 Monitoring in Labour

    • Continuous Monitoring:
      • Offer for severe ICP (bile acids ≥100 µmol/L).
      • Decision for moderate ICP based on comorbidities and preferences.
    • Meconium-Stained Amniotic Fluid:
      • More common in moderate and severe ICP, influencing the need for CEFM.

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    💊 Follow-Up and Postnatal Care

    Postnatal Follow-Up

    • Resolution of Symptoms:
      • Itching and abnormal liver function should resolve within a few weeks post-birth.
      • Conduct follow-up at least 4 weeks postpartum to confirm normalization.
    • Persistent Symptoms:
      • If abnormalities persist beyond 6 weeks, consider other diagnoses and refer to a hepatologist.

    Contraceptive and Hormonal Advice

    • General Advice:
      • ICP does not restrict contraceptive options, except in cases of previous cholestasis with combined hormonal contraception.
    • Preferred Methods:
      • Progestogen-only or non-hormonal methods.
    • Hormone Replacement Therapy (HRT):
      • Can be offered if there are no other contraindications.
      • Monitor for recurrence of symptoms during HRT use.

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    🌟 Future Pregnancies

    • Recurrence Risk:
      • Women with ICP have an increased likelihood of recurrence of 70% in subsequent pregnancies.
    • Baseline Monitoring:
    • Perform liver function tests and bile acid concentrations at booking.
    • Repeat testing if clinically indicated.
    • reference
    • https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/intrahepatic-cholestasis-of-pregnancy-green-top-guideline-no-43/