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Cholestasis of pregnancy — Clinical Guidelines

Overview

Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder characterized by elevated serum bile acids, pruritus, and poses significant risks to fetal well-being, including preterm delivery, meconium-stained amniotic fluid, and stillbirth 3.

Diagnosis

Measure serum bile acid levels and liver transaminases for diagnosis 3.

Fasting bile acid levels are often used for diagnosis, though non-fasting levels can also be informative 2.

Bile acid levels ≥100 μmol/L indicate higher risk of adverse perinatal outcomes 2.

Management

First-line treatment: Ursodeoxycholic acid (UDCA) for managing maternal symptoms 3.

Antenatal fetal surveillance: Initiate monitoring at diagnosis or when delivery would be indicated by abnormal fetal testing results 3.

Consider timing of delivery: Elective delivery may be warranted if bile acid levels remain elevated or fetal compromise is detected 3.

Special Populations

Pregnancy: ICP management focuses on maternal symptom relief and close fetal monitoring to prevent adverse outcomes 3.

Comorbidities: Azathioprine use during pregnancy may be associated with increased risk of ICP, warranting caution 1.

Key Recommendations

Measure serum bile acid and liver transaminase levels in suspected cases (Evidence: Strong 3).

Use ursodeoxycholic acid as the first-line treatment for maternal symptoms (Evidence: Strong 3).

Initiate antenatal fetal surveillance at diagnosis or when indicated by abnormal fetal testing results (Evidence: Strong 3).

Consider elective delivery if bile acid levels remain elevated or fetal compromise is detected (Evidence: Moderate 2).

Exercise caution with azathioprine use in pregnant women due to potential association with ICP (Evidence: Weak 1).

References

1 Kwon Y, Lee N, Kim Y. Intrahepatic cholestasis of pregnancy associated with azathioprine: first quantitative disproportionality analysis using the FDA adverse event reporting system. Journal of pharmacy & pharmaceutical sciences : a publication of the Canadian Society for Pharmaceutical Sciences, Societe canadienne des sciences pharmaceutiques 2025. link 2 Hobson SR, Cohen ER, Gandhi S, Jain V, Niles KM, Roy-Lacroix MÈ et al.. Guideline No. 452: Diagnosis and Management of Intrahepatic Cholestasis of Pregnancy. Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC 2024. link 3 Lee RH, Mara Greenberg, Metz TD, Pettker CM. Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy: Replaces Consult #13, April 2011. American journal of obstetrics and gynecology 2021. link 4 Miragoli M, Kadir SH, Sheppard MN, Salvarani N, Virta M, Wells S et al.. A protective antiarrhythmic role of ursodeoxycholic acid in an in vitro rat model of the cholestatic fetal heart. Hepatology (Baltimore, Md.) 2011. link 5 Olson SL. Bedside musical care: applications in pregnancy, childbirth, and neonatal care. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN 1998. link

Cholestasis of pregnancy