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Intrahepatic Cholestasis of Pregnancy (ICP)

RCOG Intrahepatic cholestasis of pregnancy (Green-top Guideline No. 43). Published Aug 2022.

Background Information

Severity Peak bile acid concentration (mmol/L)
Mild 19-39
Moderate 40-99
Severe ≥100
 

Guidelines

The predominant impact on the mother is itching, which can be severe and may affect sleep​​​​​​.

There is also an increased risk of developing:
  • Pre-eclampsia
  • Gestational diabetes

Increased risk of:
  • Still birth (if severe ICP - peak bile acid >100 mmol/L)
    • If bile acid is mildly / moderately elevated (<100 mmol/L), the risk is similar to those without ICP
 
  • Preterm birth
  • Meconium-stained amniotic fluid
  • Receiving neonatal care

There is no single diagnostic test for ICP.

RCOG recommends to consider ICP if:
  • Itching with normal skin appearance, AND
  • ↑ Peak random total bile acid concentration (>19 mmol/L)

The diagnosis is more likely if the itching and raised bile acids resolve after birth.
 

RCOG: "Additional laboratoryand/or imaginginvestigations arenot recommendedin every woman, butcould be consideredon an individualbasis."

Advise women that there are no treatment that improve pregnancy outcome.
 

Consider the following to reduce itching:
  • Topical emolients
  • Anti-histamines (e.g. chlorphenamine)

Only consider vitamin K if there is:
  • Evidence of reduced dietary fat absorption (e.g. steatorrhoea) AND/OR
  • Abnormal prothrombin time

Do NOT routinely offer ursodeoxycholic acid (as there are no evidence of significant benefit).

The timing of birth largely depends on the severity of ICP:
 
ICP severity Peak bile acid concentration (mmol/L) Timing of Birth
Mild 19-39 Planned birth before 40 weeks
Moderate 40-99 Planned birth at 38-39 weeks
Severe ≥100 Planned birth at 35-36 weeks
 

ICP on its own does NOT impact choosing the mode of birth.

References

Author: Adams Lau
Reviewer:
Last edited: 27/04/25