Intrahepatic Cholestasis of Pregnancy (IHCP)—also known as obstetric cholestasis—is a unique, multifactorial liver disorder that occurs during pregnancy. It’s characterized primarily by unexplained itching (pruritus) and deranged liver function, specifically elevated bile acid levels. Although typically emerging in the third trimester, symptoms may appear earlier, making vigilant maternal monitoring crucial.
What Triggers Suspicion?
The hallmark symptom of IHCP is intense itching, often starting on the palms and soles and worsening at night. Notably, this occurs without a primary skin condition. While skin trauma from scratching (dermatographia artefacta) is common, it’s non-specific and can mimic eczema, atopic eruptions, or prurigo.
Other clinical signs may include:
- Pale stools
- Dark-colored urine
- Jaundice (in severe cases)
Laboratory Clues
To confirm IHCP, the following lab parameters are essential:
Liver Function Tests (LFTs): Elevated SGOT, SGPT, and GGT levels. Bilirubin may occasionally rise. Alkaline phosphatase (placental origin) is not useful diagnostically.
Serum Bile Acids: This is the most specific test.
Prothrombin Time: Assesses clotting status due to risk of vitamin K deficiency.
Bile acid levels should be interpreted using pregnancy-adjusted reference ranges.
Diagnostic Classification
| Diagnosis | Symptoms | Peak Bile Acid Concentration |
| Gestational Pruritus | Itching only | <19 μmol/L |
| Mild IHCP | Itching | 19–39 μmol/L |
| Moderate IHCP | Itching | 40–99 μmol/L |
| Severe IHCP | Itching | ≥100 μmol/L |
Each unit rise in bile acid increases the fetal morbidity risk by 1–2%.
Complications
Maternal:
Vitamin K deficiency → Postpartum hemorrhage (PPH)
Fetal:
Preterm birth
Meconium-stained amniotic fluid
Fetal distress
Stillbirth (especially with bile acid levels >100 μmol/L)
Note: There is no defined safe bile acid threshold—adverse outcomes can occur even at lower levels.
Management & Surveillance
Maternal:
Weekly LFTs and bile acids until delivery
Abnormal trends despite treatment should prompt evaluation for alternate diagnoses
Fetal:
Ultrasound, Doppler, and NSTs are unreliable for predicting fetal compromise
Continuous intrapartum fetal monitoring is advised
Treatment of Pruritus:
- Topical emollients and antihistamines: Symptomatic relief
- Ursodeoxycholic acid (UDCA): 10–15 mg/kg/day up to 25 mg/kg/day; reduces maternal itch and bile acid levels, but fetal benefit remains unclear
- Vitamin K supplementation (5–10 mg/day) if clotting is impaired
- Dexamethasone: For fetal lung maturity
- Rifampicin: Under clinical trials
Timing of Delivery
Advise women with isolated ICP and a singlet on pregnancy that the risk of stillbirth only increases above population rate once their serum bile acid concentration is 100 micromol/L or more.
- In women with peak bile acids 19–39 micromol/L (mild ICP) and no other risk factors, advise them that the risk of stillbirth is similar to the background risk. Consider options of planned birth by 40 weeks’ gestation or ongoing antenatal care according to national guidance.
- In women with peak bile acids 40–99 micromol/L (moderate ICP) and no other risk factors, advise them that the known risk of stillbirth is similar to the background risk until 38–39 weeks’ gestation. Consider planned birth at 38–39 weeks’ gestation
- In women with peak bile acids 100 micromol/L or more (severe ICP), advise them that the risk of stillbirth is higher than the background risk. Consider planned birth at 35–36 weeks’ gestation
In Summary
IHCP is a high-risk pregnancy complication marked by intense itching and raised liver bile acids.
It necessitates multidisciplinary surveillance to prevent adverse outcomes.
While maternal symptoms usually resolve post-delivery, fetal complications can be fatal if not timely managed.
Stay vigilant, act early, and prioritize maternal and fetal well-being. If you’re experiencing unexplained itching during pregnancy, consult your obstetrician for evaluation—early detection can make all the difference.