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, regular monitoring of maternal serum bile acids and LFTs is essential, typically coordinated by the maternity unit, alongside assessment of fetal wellbeing. Although cardiotocography may be used initially, it does not reliably predict future fetal outcomes ¹.

Treatment options include ursodeoxycholic acid (UDCA), which has been traditionally prescribed to improve maternal symptoms and biochemical markers. However, recent high-quality evidence from the PITCHES trial indicates that UDCA does not significantly improve maternal bile acid levels, pruritus, or perinatal outcomes, leading to more cautious use and consideration of individual patient factors before prescribing ¹. Sedating antihistamines such as chlorphenamine or promethazine may be offered off-label to alleviate nocturnal itching, with reassuring safety data in pregnancy ¹. Vitamin K supplementation is recommended to prevent deficiency-related maternal and neonatal hemorrhage due to impaired fat-soluble vitamin absorption ¹.

Fetal monitoring should be individualized, and elective early delivery may be considered on a case-by-case basis to reduce the risk of stillbirth, especially in severe cases with high bile acid levels 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.

In summary, management integrates biochemical monitoring, symptom control, consideration of UDCA use with updated evidence, vitamin K supplementation, and individualized fetal surveillance with possible early delivery to optimize maternal and fetal outcomes in ICP ¹ (Sentilhes et al., 2023).