ob.intrahepatic-cholestasis-of-pregnancy.v1PRODUCTION

ob.intrahepatic-cholestasis-of-pregnancy.v1

Intrahepatic Cholestasis of Pregnancy (ICP)

obstetricssubacuteacuteadultpregnancy

Hard-required inputs

0 / 13

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

ICP = pruritus (palms/soles, worse nocturnally, often without primary rash) + elevated non-fasting total bile acids ≥ 10 µmol/L ± mild transaminitis, presenting in 2nd/3rd trimester (typically > 24 wk). FETAL stillbirth risk is bile-acid-concentration-dependent (Ovadia 2019 IPD meta-analysis PMID 30773280: ≥ 100 µmol/L → HR 30.5 vs lowest tier). Delivery-timing decision is the primary clinical lever (SMFM Consult #53 Lee 2021 PMID 33197417: 36+0 wk if bile acids ≥ 100; 36+0–39+0 wk if < 100). UDCA is first-line for maternal SYMPTOM relief (GRADE 1A) but PITCHES RCT (Chappell 2019 Lancet PMID 31378395) showed no fetal-outcome benefit — counsel accordingly.

Inputs

Actions

Advance rule

Set

Advance when

GA + clinical phenotype documented; ICP pretest probability set; bile-acid tier informed delivery-timing decision framework

Patient inputs (16)

multifetal_gestation_status*history • CONTEXT

Multifetal gestation increases ICP risk and severity; influences delivery-timing decision and surveillance frequency

known_liver_disease_or_hepatitis*history • CONTEXT

not present

Pre-existing liver disease (PBC, PSC, hepatitis B/C, autoimmune hepatitis) alters the differential and may co-present

pruritus_distribution_severity_and_timing*symptom • ENTRY

Classic distribution (palms/soles, worse nocturnally) without primary rash differentiates ICP from PUPPP / atopic eruption / scabies

gestational_age_weeks*demographic • FRAME

ICP typically presents in 2nd/3rd trimester (median ~ 30 wk); delivery-timing decisions hinge on exact GA + bile acid tier (SMFM 2021 PMID 33197417)

serum_total_bile_acids_non_fasting*lab • INITIAL_WORKUP

Defining lab; risk stratifies into < 40 / 40-99 / ≥ 100 µmol/L tiers (Ovadia 2019 PMID 30773280); ≥ 100 triggers 36+0 wk delivery (SMFM 2021)

liver_function_tests_alt_ast_bilirubin_ggt*lab • INITIAL_WORKUP

AST/ALT typically 2-10x ULN; total + direct bilirubin (jaundice is uncommon); GGT informs cholestasis vs hepatocellular pattern; baseline + serial trending

pt_inr_baseline*lab • INITIAL_WORKUP

Vitamin-K-dependent factor depletion in prolonged cholestasis → coagulopathy + PPH risk; PT/INR guides vitamin K supplementation

cbc_with_platelets*lab • INITIAL_WORKUP

Baseline; thrombocytopenia raises HELLP suspicion (different engine); polycythemia rare

viral_hepatitis_serology_hav_hbv_hcv_hev*lab • INITIAL_WORKUP

Viral hepatitis is the primary differential; HEV important in endemic regions; HBV/HCV screening also pre-natal standard

right_upper_quadrant_ultrasound*imaging • INITIAL_WORKUP

not present

Rule out biliary obstruction (choledocholithiasis, cholecystitis, biliary dilation); ICP imaging is typically normal (no biliary dilation, no hepatic mass)

fetal_heart_rate_baseline*vital • MONITORING

Continuous EFM in admitted patients or non-stress testing in outpatients drives antenatal fetal surveillance decisions (SMFM 2021 GRADE 2C)

maternal_temperature*vital • RED_FLAGS

Fever favors infective hepatitis or chorioamnionitis differential, not ICP

maternal_bp*vital • RED_FLAGS

New HTN + proteinuria + transaminitis is pre-eclampsia/HELLP, not ICP — different engine

prior_icp_or_familial_cholestasishistory • CONTEXT

not present

Recurrence ~ 60-90% in subsequent pregnancies; familial clustering (ABCB4/ABCB11 transporter polymorphisms) raises pretest probability

estrogen_or_progesterone_exposure_historyhistory • CONTEXT

not present

Estrogen exposure (combined OC, IVF cycles) is a trigger for cholestasis; counsel postpartum contraception choice based on biochem recovery

antenatal_fetal_surveillance_nst_or_bppimaging • MONITORING

not present

SMFM 2021 GRADE 2C — start at GA when delivery would be triggered by abnormal results; frequency individualised by bile acid tier

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement

informationallife_threateningicp_overlap_with_AFLP_or_HELLP
New HTN + proteinuria + thrombocytopenia + marked transaminitis (HELLP) OR hypoglycemia + coagulopathy + encephalopathy (AFLP) on top of ICP-pattern pruritus → reroute to ob.hellp-syndrome.v1 or ob.acute-fatty-liver-of-pregnancy.v1; ICP is NOT the primary driver.
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereicp_bile_acids_ge_100_severe
Severe ICP — total bile acids ≥ 100 µmol/L; stillbirth HR 30.5 vs lowest tier (Ovadia 2019 PMID 30773280); deliver at 36+0 wk per SMFM 2021 GRADE 1B (PMID 33197417).
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateicp_bile_acids_40_to_99_intermediate
Intermediate ICP — total bile acids 40-99 µmol/L; stillbirth risk ~ 0.28% (Ovadia 2019 PMID 30773280). UDCA + delivery 36+0 to 39+0 wk individualised per SMFM 2021 GRADE 1C.
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateicp_with_coagulopathy_pph_risk
ICP with prolonged PT/INR or markedly elevated bilirubin → vitamin K1 supplementation + PPH preparedness; type and screen pre-delivery; LMWH withheld peri-delivery per standard protocol.
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmildicp_bile_acids_lt_40_mild
Mild ICP — total bile acids < 40 µmol/L; stillbirth risk ~ 0.13% (Ovadia 2019 PMID 30773280). UDCA for maternal pruritus; delivery 39+0 wk per SMFM 2021 (PMID 33197417 GRADE 1C).
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmildicp_recurrence_subsequent_pregnancy
Recurrence in subsequent pregnancy after prior ICP (~ 60-90% recurrence per SMFM 2021 PMID 33197417); early presentation + early bile acid measurement + early UDCA initiation if confirmed.
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

ICP pruritus management + delivery timing — UDCA first-line for maternal symptoms (SMFM Consult #53 Lee 2021 PMID 33197417 GRADE 1A; PITCHES RCT Chappell 2019 Lancet PMID 31378395 — no fetal benefit) + adjunctive antihistamines + vitamin K if coagulopathy + bile-acid-tiered delivery (Ovadia 2019 IPD meta-analysis PMID 30773280)

axis: icp_pruritus_and_delivery_timing

Selected axis "ICP pruritus management + delivery timing — UDCA first-line for maternal symptoms (SMFM Consult #53 Lee 2021 PMID 33197417 GRADE 1A; PITCHES RCT Chappell 2019 Lancet PMID 31378395 — no fetal benefit) + adjunctive antihistamines + vitamin K if coagulopathy + bile-acid-tiered delivery (Ovadia 2019 IPD meta-analysis PMID 30773280)" by default fallback (first axis)

ursodiol
first line
bile_acid_choleretic
10-15 mg/kg/day PO divided BID-TID (typical 300 mg PO BID-TID for 60 kg patient) • PO • BID-TID (max: up to 21 mg/kg/day in refractory cases per SMFM 2021)
triggers: icp_pruritus_with_elevated_bile_acids
PregCat: former B — broad clinical experience in 2nd/3rd trimester ICP without safety signal; LactMed-checked. | Lactation: compatible — LactMed notes minimal transfer into breast milk and considered compatible with breastfeeding. | First-line for maternal SYMPTOM relief per SMFM Consult #53 Lee 2021 (PMID 33197417, GRADE 1A); PITCHES RCT (PMID 31378395) showed UDCA does NOT reduce adverse perinatal composite (RR 0.85, 95% CI 0.62-1.15) so counsel maternal pruritus-relief indication only, not fetal-protective; titrate to symptom response over 1-2 weeks.
rxcui 11065
diphenhydramine
add on
first_generation_antihistamine_h1
25-50 mg PO q6h PRN pruritus • PO • q6h PRN (max: 300 mg/24h)
triggers: icp_pruritus_inadequately_controlled_on_udca
PregCat: former B — extensive pregnancy exposure data without teratogenic signal. | Lactation: compatible with caution per LactMed — small amounts in breast milk; may cause infant sedation or reduce milk supply with prolonged high-dose use; occasional doses generally acceptable. | Adjunct PRN pruritus relief when UDCA insufficient; nocturnal dosing exploits sedation effect to improve sleep disrupted by ICP pruritus.
rxcui 3498
hydroxyzine
add on
first_generation_antihistamine_h1
25 mg PO q6-8h PRN pruritus • PO • q6-8h PRN (max: 100 mg/24h)
triggers: icp_pruritus_inadequately_controlled_on_diphenhydramine
PregCat: former C — animal teratogenicity at supratherapeutic doses; human data limited but no clear teratogenic signal; cautious clinical use throughout pregnancy. | Lactation: limited-data per LactMed — small amounts likely in milk; cautious use; observe infant for sedation. | Second-line antihistamine for refractory ICP pruritus; longer half-life than diphenhydramine; preferred for daytime pruritus when sedation is acceptable.
rxcui 5553
phytonadione
add on
vitamin_k1_fat_soluble_vitamin
10 mg PO daily (or 1-10 mg SC if oral malabsorption) • PO/SC • daily until delivery
triggers: prolonged_pt_inr_in_icp, markedly_elevated_bilirubin_with_cholestasis
PregCat: former C — labeling categorises as C but used commonly throughout pregnancy when indicated; benefit-risk overwhelmingly favors use when coagulopathy present. | Lactation: compatible per LactMed — vitamin K is routinely given to newborns at birth and small amounts in milk are insufficient for newborn vitamin K stores anyway; no maternal concern. | Replaces vitamin-K-dependent factors depleted by prolonged cholestasis; reduces PPH risk; PT/INR recheck after 24-48 h; not needed if PT normal.
rxcui 8308
topical emollients and cooling agents
add on
symptomatic_pruritus_management
triggers: icp_pruritus_any_severity
PregCat: N/A — topical non-pharm; FDA labeling does not assign for emollients/menthol-based topicals. | Lactation: compatible — topical only, no systemic absorption concern. | Adjunctive non-pharm: emollient creams, colloidal oatmeal baths, cool compresses, light cotton clothing; first-line behavioral measures before escalating pharm therapy and continued throughout treatment.
delivery at 36+0 weeks gestation
first line
delivery_timing_obstetric_decision
triggers: bile_acids_ge_100_micromol_per_L
PregCat: N/A — obstetric decision, not a drug. | Lactation: N/A — delivery event. | SMFM Consult #53 Lee 2021 (PMID 33197417) GRADE 1B — bile acids ≥ 100 µmol/L stratifies to highest stillbirth risk tier (HR 30.5 per Ovadia 2019 IPD meta-analysis PMID 30773280); delivery at 36+0 wk balances stillbirth risk against neonatal morbidity of preterm delivery.
delivery at 36+0 to 39+0 weeks gestation
first line
delivery_timing_obstetric_decision
triggers: bile_acids_lt_100_micromol_per_L
PregCat: N/A — obstetric decision. | Lactation: N/A. | SMFM Consult #53 Lee 2021 (PMID 33197417) GRADE 1C — bile acids < 100 µmol/L (intermediate or low tier per Ovadia 2019 PMID 30773280) supports delivery 36+0 to 39+0 wk individualised by tier (40-99 favors earlier within window; < 40 typically 39+0).
antenatal corticosteroids for fetal lung maturity
add on
fetal_lung_maturation
triggers: delivery_anticipated_before_37_weeks_no_prior_course
PregCat: N/A — administered for fetal benefit; per SMFM 2021 (PMID 33197417) GRADE 1A. | Lactation: N/A — single course before delivery. | Betamethasone 12 mg IM q24h x 2 doses (or dexamethasone 6 mg IM q12h x 4 doses) per ALPS framework via ob.preterm-labor.v1 if delivery anticipated < 37 wk and no prior course; reduces neonatal respiratory morbidity.

outpatient playbook — drug actions (3)

1. ursodiol PO BID-TID
rxcui 11065
10-15 mg/kg/day divided BID-TID (300 mg PO BID-TID typical) • PO • BID-TID
trigger: Pruritus with bile acids ≥ 10 µmol/L
SMFM 2021 PMID 33197417 GRADE 1A; PITCHES counsel symptom-relief only
2. diphenhydramine PO PRN
rxcui 3498
25-50 mg PO q6h PRN • PO • q6h PRN
trigger: Inadequate pruritus control on UDCA, especially nocturnal
LactMed-compatible adjunct antihistamine; exploits sedation for sleep
3. phytonadione PO daily
rxcui 8308
10 mg PO daily • PO • daily
trigger: PT/INR prolonged or markedly elevated bilirubin
Replaces vitamin-K-dependent factors; reduces PPH risk

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Pruritus (especially palms and soles, worse at night, often without rash) in second/third trimester — gateway symptom (SMFM Consult #53 Lee 2021 PMID 33197417); Non-fasting serum total bile acids ≥ 10 µmol/L in symptomatic pregnant patient — defining laboratory criterion (SMFM 2021 PMID 33197417); Mild-to-moderate AST/ALT elevation (typically < 5x ULN) in second/third trimester pregnancy with pruritus — supports ICP (Glantz 2004 PMID 15368452).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Intrahepatic Cholestasis of Pregnancy (ICP)** (ob.intrahepatic-cholestasis-of-pregnancy.v1).
Phenotype framing: Viral hepatitis (HAV, HBV, HCV, HEV — HEV especially in endemic regions; severe in pregnancy); pre-eclampsia / HELLP (HTN + proteinuria + low platelets + transaminitis); AFLP (Swansea criteria; hypoglycemia + coagulopathy + encephalopathy); choledocholithiasis / cholecystitis (RUQ pain + biliary dilation on US); drug-induced liver injury (medication history; especially antibiotics, antiepileptics); autoimmune hepatitis (ANA, SMA, anti-LKM); primary biliary cholangitis (AMA-positive); PUPPP / atopic eruption / pemphigoid gestationis / scabies (rash-dominant skin disorders).
Scope: ICP = pruritus (palms/soles, worse nocturnally, often without primary rash) + elevated non-fasting total bile acids ≥ 10 µmol/L ± mild transaminitis, presenting in 2nd/3rd trimester (typically > 24 wk). FETAL stillbirth risk is bile-acid-concentration-dependent (Ovadia 2019 IPD meta-analysis PMID 30773280: ≥ 100 µmol/L → HR 30.5 vs lowest tier). Delivery-timing decision is the primary clinical lever (SMFM Consult #53 Lee 2021 PMID 33197417: 36+0 wk if bile acids ≥ 100; 36+0–39+0 wk if < 100). UDCA is first-line for maternal SYMPTOM relief (GRADE 1A) but PITCHES RCT (Chappell 2019 Lancet PMID 31378395) showed no fetal-outcome benefit — counsel accordingly.

No severity triggers fired against current inputs.

Plan

Regimen axis: **ICP pruritus management + delivery timing — UDCA first-line for maternal symptoms (SMFM Consult #53 Lee 2021 PMID 33197417 GRADE 1A; PITCHES RCT Chappell 2019 Lancet PMID 31378395 — no fetal benefit) + adjunctive antihistamines + vitamin K if coagulopathy + bile-acid-tiered delivery (Ovadia 2019 IPD meta-analysis PMID 30773280)**.
1. ursodiol 10-15 mg/kg/day PO divided BID-TID (typical 300 mg PO BID-TID for 60 kg patient) PO BID-TID (bile_acid_choleretic, first line) — PregCat: former B — broad clinical experience in 2nd/3rd trimester ICP without safety signal; LactMed-checked. | Lactation: compatible — LactMed notes minimal transfer into breast milk and considered compatible with breastfeeding. | First-line for maternal SYMPTOM relief per SMFM Consult #53 Lee 2021 (PMID 33197417, GRADE 1A); PITCHES RCT (PMID 31378395) showed UDCA does NOT reduce adverse perinatal composite (RR 0.85, 95% CI 0.62-1.15) so counsel maternal pruritus-relief indication only, not fetal-protective; titrate to symptom response over 1-2 weeks.
2. diphenhydramine 25-50 mg PO q6h PRN pruritus PO q6h PRN (first_generation_antihistamine_h1, add on) — PregCat: former B — extensive pregnancy exposure data without teratogenic signal. | Lactation: compatible with caution per LactMed — small amounts in breast milk; may cause infant sedation or reduce milk supply with prolonged high-dose use; occasional doses generally acceptable. | Adjunct PRN pruritus relief when UDCA insufficient; nocturnal dosing exploits sedation effect to improve sleep disrupted by ICP pruritus.
3. hydroxyzine 25 mg PO q6-8h PRN pruritus PO q6-8h PRN (first_generation_antihistamine_h1, add on) — PregCat: former C — animal teratogenicity at supratherapeutic doses; human data limited but no clear teratogenic signal; cautious clinical use throughout pregnancy. | Lactation: limited-data per LactMed — small amounts likely in milk; cautious use; observe infant for sedation. | Second-line antihistamine for refractory ICP pruritus; longer half-life than diphenhydramine; preferred for daytime pruritus when sedation is acceptable.
4. phytonadione 10 mg PO daily (or 1-10 mg SC if oral malabsorption) PO/SC daily until delivery (vitamin_k1_fat_soluble_vitamin, add on) — PregCat: former C — labeling categorises as C but used commonly throughout pregnancy when indicated; benefit-risk overwhelmingly favors use when coagulopathy present. | Lactation: compatible per LactMed — vitamin K is routinely given to newborns at birth and small amounts in milk are insufficient for newborn vitamin K stores anyway; no maternal concern. | Replaces vitamin-K-dependent factors depleted by prolonged cholestasis; reduces PPH risk; PT/INR recheck after 24-48 h; not needed if PT normal.
5. topical emollients and cooling agents (symptomatic_pruritus_management, add on) — PregCat: N/A — topical non-pharm; FDA labeling does not assign for emollients/menthol-based topicals. | Lactation: compatible — topical only, no systemic absorption concern. | Adjunctive non-pharm: emollient creams, colloidal oatmeal baths, cool compresses, light cotton clothing; first-line behavioral measures before escalating pharm therapy and continued throughout treatment.
6. delivery at 36+0 weeks gestation (delivery_timing_obstetric_decision, first line) — PregCat: N/A — obstetric decision, not a drug. | Lactation: N/A — delivery event. | SMFM Consult #53 Lee 2021 (PMID 33197417) GRADE 1B — bile acids ≥ 100 µmol/L stratifies to highest stillbirth risk tier (HR 30.5 per Ovadia 2019 IPD meta-analysis PMID 30773280); delivery at 36+0 wk balances stillbirth risk against neonatal morbidity of preterm delivery.
7. delivery at 36+0 to 39+0 weeks gestation (delivery_timing_obstetric_decision, first line) — PregCat: N/A — obstetric decision. | Lactation: N/A. | SMFM Consult #53 Lee 2021 (PMID 33197417) GRADE 1C — bile acids < 100 µmol/L (intermediate or low tier per Ovadia 2019 PMID 30773280) supports delivery 36+0 to 39+0 wk individualised by tier (40-99 favors earlier within window; < 40 typically 39+0).
8. antenatal corticosteroids for fetal lung maturity (fetal_lung_maturation, add on) — PregCat: N/A — administered for fetal benefit; per SMFM 2021 (PMID 33197417) GRADE 1A. | Lactation: N/A — single course before delivery. | Betamethasone 12 mg IM q24h x 2 doses (or dexamethasone 6 mg IM q12h x 4 doses) per ALPS framework via ob.preterm-labor.v1 if delivery anticipated < 37 wk and no prior course; reduces neonatal respiratory morbidity.

Setting playbook (outpatient) — Primary venue — confirm ICP by bile acid measurement, initiate UDCA for maternal pruritus, schedule weekly biochem trending + antenatal fetal surveillance, deliver per bile acid tier (SMFM 2021)
9. ursodiol PO BID-TID 10-15 mg/kg/day divided BID-TID (300 mg PO BID-TID typical) PO BID-TID — Pruritus with bile acids ≥ 10 µmol/L (SMFM 2021 PMID 33197417 GRADE 1A; PITCHES counsel symptom-relief only)
10. diphenhydramine PO PRN 25-50 mg PO q6h PRN PO q6h PRN — Inadequate pruritus control on UDCA, especially nocturnal (LactMed-compatible adjunct antihistamine; exploits sedation for sleep)
11. phytonadione PO daily 10 mg PO daily PO daily — PT/INR prolonged or markedly elevated bilirubin (Replaces vitamin-K-dependent factors; reduces PPH risk)

Non-pharmacologic actions:
- Emollients + colloidal oatmeal baths + cool compresses (symptomatic adjunct)
- Schedule delivery at 36+0 wk if bile acids ≥ 100 µmol/L (SMFM 2021 GRADE 1B)
- Schedule delivery 36+0-39+0 wk if bile acids < 100 µmol/L (SMFM 2021 GRADE 1C)
- Antenatal corticosteroids if delivery anticipated < 37 wk
- Counsel ~ 60-90% recurrence in subsequent pregnancies

AVOID / contraindication checks:
- Cholestyramine NOT recommended interferes with vitamin K absorption increases PPH risk superseded by UDCA (SMFM 2021 PMID 33197417)
- Rifampicin second line only with hepatology and MFM input not routine in US (SMFM 2021)
- Do not deliver preterm without laboratory confirmation of elevated bile acids (SMFM 2021 GRADE 1B; Lee PMID 33197417)
- Counsel UDCA relieves maternal pruritus only PITCHES RCT showed no fetal benefit (PITCHES Chappell 2019 PMID 31378395)
- Bile acids ge 100 mandates 36+0 wk delivery due to stillbirth HR 30.5 (Ovadia 2019 PMID 30773280; SMFM 2021 PMID 33197417)
- Postpartum estrogen containing contraception caution can retrigger cholestasis use progestin only or non hormonal until biochem normalised

Monitoring

Regimen monitoring:
- Weekly serum total bile acids until delivery
- Weekly ALT/AST + total bilirubin + PT/INR
- PT/INR re-check 24-48 h after vitamin K supplementation
- Antenatal fetal surveillance (NST and/or BPP) per bile acid tier (SMFM 2021 GRADE 2C)
- Continuous EFM intrapartum
- Pruritus VAS 0-10 at each visit to track UDCA response
- Postpartum biochem at 6 wk and 3 mo (if not normalised, hepatology referral)

Setting (outpatient) monitoring:
- Weekly bile acids + LFTs + PT/INR
- Antenatal fetal surveillance per bile acid tier
- Pruritus VAS 0-10 each visit

Follow-up plan: Symptoms typically resolve within days to a few weeks postpartum; bile acids + LFTs normalise within 4-8 wk. Persistent biochemical abnormalities > 3 mo postpartum → outpatient hepatology referral (rule out underlying PBC, PSC, hepatitis B/C, autoimmune hepatitis). Counsel ~ 60-90% recurrence in subsequent pregnancies + early presentation in any future pregnancy with pruritus. Estrogen-containing contraception relative caution (can re-trigger cholestasis; progestin-only or non-hormonal preferred until biochem normalised). Mental-health screen (EPDS) — chronic pruritus + stillbirth fear carries psychological burden.
- Close-out criterion: Postpartum biochem normalised, recurrence + contraception counseling delivered, hepatology referral if persistent abnormalities, mental-health support arranged

Monitoring phase: Weekly serum total bile acids + ALT/AST + total bilirubin + PT/INR until delivery. Antenatal fetal surveillance (NST and/or BPP) starting at GA when delivery would be triggered by abnormal results (SMFM 2021 GRADE 2C); frequency individualised by bile acid tier. Pruritus severity scoring (visual analog 0-10). PT/INR re-check after vitamin K supplementation. Cervical readiness assessment for delivery timing. Continuous EFM intrapartum.

Disposition

Current setting: outpatient — Primary venue — confirm ICP by bile acid measurement, initiate UDCA for maternal pruritus, schedule weekly biochem trending + antenatal fetal surveillance, deliver per bile acid tier (SMFM 2021)

Disposition criteria:
- Tolerating UDCA + pruritus controlled + biochem stable → continue outpatient until delivery date
- Delivery date reached per bile acid tier → admit for induction or cesarean

Escalation triggers (move to higher acuity):
- Bile acids ≥ 100 µmol/L → schedule 36+0 wk delivery
- New HTN + proteinuria + transaminitis → ob.pre-eclampsia.core.v1
- Hypoglycemia + coagulopathy + encephalopathy → ob.acute-fatty-liver-of-pregnancy.v1
- Markedly elevated PT/INR despite vitamin K → admission for PPH preparedness

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] New HTN + proteinuria + thrombocytopenia + marked transaminitis (HELLP) OR hypoglycemia + coagulopathy + encephalopathy (AFLP) on top of ICP-pattern pruritus → reroute to ob.hellp-syndrome.v1 or ob.acute-fatty-liver-of-pregnancy.v1; ICP is NOT the primary driver.
- [SEVERE] Severe ICP — total bile acids ≥ 100 µmol/L; stillbirth HR 30.5 vs lowest tier (Ovadia 2019 PMID 30773280); deliver at 36+0 wk per SMFM 2021 GRADE 1B (PMID 33197417).
- [MODERATE] Intermediate ICP — total bile acids 40-99 µmol/L; stillbirth risk ~ 0.28% (Ovadia 2019 PMID 30773280). UDCA + delivery 36+0 to 39+0 wk individualised per SMFM 2021 GRADE 1C.

Citations

- SMFM Consult Series #53 (2021) Intrahepatic Cholestasis of Pregnancy + Ovadia 2019 IPD meta-analysis (Lancet) + PITCHES 2019 RCT (Lancet) + Glantz 2004 Hepatology + Ch'ng 2002 Gut + LactMed for ursodiol / diphenhydramine / hydroxyzine / phytonadione [PMID:33197417](https://pubmed.ncbi.nlm.nih.gov/33197417/)
- Cited evidence (PMID 30773280) [PMID:30773280](https://pubmed.ncbi.nlm.nih.gov/30773280/)
- Cited evidence (PMID 31378395) [PMID:31378395](https://pubmed.ncbi.nlm.nih.gov/31378395/)
- Cited evidence (PMID 15368452) [PMID:15368452](https://pubmed.ncbi.nlm.nih.gov/15368452/)
- Cited evidence (PMID 12427793) [PMID:12427793](https://pubmed.ncbi.nlm.nih.gov/12427793/)

Last reconciled with current guidelines: 2026-05-26.

References

SMFM Consult Series #53 (2021) Intrahepatic Cholestasis of Pregnancy + Ovadia 2019 IPD meta-analysis (Lancet) + PITCHES 2019 RCT (Lancet) + Glantz 2004 Hepatology + Ch'ng 2002 Gut + LactMed for ursodiol / diphenhydramine / hydroxyzine / phytonadione — PMID:33197417
Cited evidence (PMID 30773280) — PMID:30773280
Cited evidence (PMID 31378395) — PMID:31378395
Cited evidence (PMID 15368452) — PMID:15368452
Cited evidence (PMID 12427793) — PMID:12427793