Intrahepatic cholestasis of pregnancy (Green-top Guideline No. 43)


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the Royal College of Obstetricians, Gynaecologists

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Key recommendations

  • The diagnosis of intrahepatic cholestasis of pregnancy (ICP) should be considered in pregnant women who have itching in skin of normal appearance and raised peak random total bile acid concentration of 19 micromol/L or more. [Grade D]
  • Additional laboratory and/or imaging investigations are not recommended unless itch is associated with atypical clinical symptoms, the presence of relevant comorbidities, or in early onset severe ICP. Consider additional postnatal investigations in women in whom resolution of abnormal liver function tests is delayed or does not occur. [Grade C]
  • Consider discussing the care of women with severe, very early or atypical presentation of what appears to be ICP with a hepatologist. [Grade D]
  • Confirm the diagnosis of ICP in the postnatal period at least 4 weeks after birth, with resolution of itching and liver function tests returning to normal (including bile acids). [Grade D]
  • Advise women with isolated ICP and a singleton 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. [Grade A]
  • Advise women with ICP and a twin pregnancy that the risk of stillbirth is higher compared with a twin pregnancy without ICP. [Grade D]
  • Clinicians should be aware that fetal ultrasound and/or cardiotocography (CTG) do not predict or prevent stillbirth in ICP. [Grade D]
  • Advise women with ICP that the presence of risk factors or co-morbidities (such as gestational diabetes and/or pre-eclampsia and/or multifetal pregnancy) appear to increase the risk of stillbirth and may influence decision-making around timing of planned birth. [Grade D]
  • Advise women that there are no treatments that improve pregnancy outcome (or raised bile acid concentrations) and treatments to improve maternal itching are of limited benefit. [Grade A]
  • Do not routinely offer ursodeoxycholic acid for the purpose of reducing adverse perinatal outcomes in women with ICP. [Grade A]

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