Further Outpatient Care

Patients with intrahepatic cholestasis of pregnancy (ICP) should have regular antenatal testing (starting at 32-34 weeks) with consideration for Doppler flow studies of the umbilical artery.

Deterrence/Prevention

The recurrence rate for ICP is believed to be 45-70%.^[16]In patients with a history of ICP, oral contraceptives containing estrogen should be used with caution and at the lowest possible dose. Exogenous estrogen in these patients can lead to cholestasis outside of pregnancy. Conversely, patients who exhibit cholestasis with the use of OCPs should be evaluated for ICP during pregnancy.

The past consensus has been that ICP is a contraindication for OCP use. However, some authors suggest that the newer low-dose pills can be safely used as long as liver function test results are followed and patients are aware of possible recurrence risks.^[79]

For all patients with ICP, serum bile acid levels and liver function tests should be drawn 3-6 months postpartum. If bile acid levels remain elevated at 6 months’ postpartum, further evaluation is indicated to rule out an underlying genetic disorder or chronic liver disease. There is no data about the advisability of monitoring patients with a history of ICP during subsequent pregnancies. As recurrence rates are high for ICP, especially those with a genetic predisposition, the authors recommend a baseline bile acid level and liver enzymes and repeat levels if symptoms occur. Patients should be closely monitored for pruritus throughout pregnancy and UDCA should be initiated at the first signs of ICP even prior to receipt of the laboratory results.

Complications

ICP presents greater risk to the fetus than to the mother.^[80]ICP increases the rate of preterm delivery with the associated mortality and morbidity. In addition, the fetus is at an increased risk for stillbirth. The major concern for the mother is for postpartum hemorrhage if her vitamin K level is low, leading to an increase in prothrombin time.

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Author

Fidelma B Rigby, MD Associate Professor, Department of Obstetrics and Gynecology, Section of Maternal-Fetal Medicine, Virginia Commonwealth University Medical Center

Fidelma B Rigby, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Stacey Ehrenberg-Buchner, MD Fellow in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System

Stacey Ehrenberg-Buchner, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine

Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Medical Society of Virginia, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, AAGL, North American Menopause Society, American Medical Association, Association of Reproductive Health Professionals

Disclosure: Nothing to disclose.

Acknowledgements

George A VanBuren, MD Assistant Professor, Department of Reproductive Biology, Case Western Reserve University School of Medicine

George A VanBuren, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.