How should I manage a pregnant patient diagnosed with ICP, particularly regarding monitoring and treatment options?

Management of a pregnant patient diagnosed with intrahepatic cholestasis of pregnancy (ICP) involves prompt referral to secondary care for confirmation and ongoing monitoring. Initial diagnosis requires liver function tests (LFTs) and serum bile acid measurements to confirm ICP and exclude other hepatic or obstetric conditions such as pre-eclampsia or viral hepatitis ¹. Once confirmed, the patient should have regular monitoring of serum bile acids and LFTs, typically coordinated by the maternity unit, alongside fetal wellbeing assessments, although cardiotocography does not reliably predict future fetal outcomes ¹.

Treatment options include consideration of ursodeoxycholic acid (UDCA), which has been traditionally used to improve maternal symptoms and biochemical markers; however, recent high-quality evidence from the PITCHES trial indicates that UDCA may not significantly improve maternal bile acid levels, itch, or perinatal outcomes ¹. Therefore, its use should be individualized and discussed carefully with the patient, following local protocols and specialist advice (Sentilhes et al., 2023). Symptomatic relief for pruritus can be provided with sedating antihistamines such as chlorphenamine or promethazine, which have reassuring safety profiles in pregnancy ¹. Vitamin K supplementation is recommended to reduce the risk of maternal and fetal hemorrhage due to fat-soluble vitamin malabsorption caused by cholestasis ¹.

Fetal monitoring should be ongoing, with consideration of elective early delivery on a case-by-case basis to reduce the risk of fetal mortality, especially in severe cases or when bile acid levels are markedly elevated ¹ (Sentilhes et al., 2023). Postnatally, liver function should be reassessed from 2 weeks after delivery to confirm resolution; persistent abnormalities beyond 8 weeks warrant specialist referral to exclude alternative diagnoses ¹.