ICP Diagnosis & Treatment Flowchart

An overview of diagnosis and recommended treatment protocols when Intrahepatic Cholestasis of Pregnancy is suspected.

Suspected Intrahepatic Cholestasis of Pregnancy (Itching, dark urine, nausea)

  1. Take a history including family history, any history of liver disorders
  2. Laboratory evaluation with CMP and Total Bile Acid tests (Bile acids do not need to be fasting)

Bile acids normal (<10 µmol/L) and LFTs normal

"

Not diagnosable ICP

"

If symptoms continue, repeat CMP and Bile acid testing in 1-2 weeks

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If repeat testing continues to be normal with continued symptoms, can consider diagnosis of ICP on a clinical basis and delivery can occur no earlier than 37 0/7 weeks. Risks are minimal with low bile acid levels.If repeat testing continues to be normal with continued symptoms, can consider diagnosis of ICP on a clinical basis and delivery can occur no earlier than 37 0/7 weeks. Risks are minimal with low bile acid levels.

Bile acids 10-40 µmol/L

"

Mild ICP
Stillbirth risk is 0.13%

"
  • Ursodiol1
  • Antepartum testing2
  • Delivery 36 0/7-39 0/7 weeks
  • Betamethasone if delivery before 37 0/7 weeks
  • Consider repeat bile acid testing3

Bile acids 41-99 µmol/L

"

Severe ICP
Stillbirth risk is 0.28%

"
  • Ursodiol1
  • Antepartum testing2
  • Delivery 36 0/7-39 0/7 weeks with delivery in the EARLY portion of the window
  • Betamethasone if delivery before 37 0/7 weeks
  • Consider repeat bile acid testing3

Bile acids greater than 100 µmol/L

"

Severe ICP with increased risk of complications
Stillbirth risk of 3.44%

"
  • Ursodiol1; consideration of other medications for control
  • Antepartum testing2
  • Delivery at the latest at 36 0/7 weeks
  • Consideration for delivery 34-36 weeks with unremitting itching, history of prior stillbirth due to ICP or worsening hepatic function
  • Betamethasone

Footnotes:

  1. Ursodiol dosing should be between 10-21 mg/kg/day; usual starting doses are 300 mg twice or three times daily or 500 mg twice daily. Can be adjusted as needed
  2. Antepartum testing is thought to be beneficial but cannot prevent all stillbirths. No frequency has been determined. Should start at which point delivery would occur for failed testing, usually around 32 weeks.
  3. Repeat bile acid testing: Serial testing at a specific interval (ie weekly) has not been recommended by SMFM but repeat testing can be performed in patients who continue to have symptoms to better stratify risks and determine appropriate delivery timing.

References:

Society for Maternal-Fetal Medicine (SMFM), Lee RH, Pettker CM. Society for Maternal-Fetal Medicine (SMFM) Consult Series #53: Intrahepatic Cholestasis of Pregnancy. Am J Obstet Gynecol. 2020 Nov 13:S0002-9378(20)31284-9. doi: 10.1016/j.ajog.2020.11.002. Epub ahead of print. PMID: 33197417. [smfm.org]

Ovadia C, et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet. 2019 Mar 2;393(10174):899-909. doi: 10.1016/S0140-6736(18)31877-4. Epub     2019 Feb 14. Erratum in: Lancet. 2019 Mar 16;393(10176):1100. PMID: 30773280; PMCID: PMC6396441.