Green Top guideline Flashcards
What is the incidence of ICP in pregnancy in UK?
0.7% in multi ethnic group
1.2 - 1.5 % in Indian Asian or Pakistani asian origin
What percentage of women develop itching in pregnancy?
25%
How is ICP characterised?
1- pruritus
2- normal skin
3- abnormal bile acid concentration
When is symptoms of ICP usually started?
Third trimester
Can be earlier
How is ICP categorized?
Gestational pruritus: itching + bile acid < 19
Mild ICP : itching + bile acid 19-39
Moderate ICP: itching + bile 40-99
Severe ICP: itching + bile > 100
How is ICP diagnosed?
Itching +normal skin + bile acid concentration > 19 (non-fasting)
📌resolve after birth
📌 normalization of bile acid & LFTs during pregnancy 👉 reconsider the diagnosis
When should specialist hepatology advice to sought in women with ICP?
1-Severe
2- early in pregnancy
3- atypical presentation
What is the role of other investigations in the care of women with suspected ICP?
Additional antenatal imaging / lab are NOT recommended unless :
1- severe 2- early onset
3- atypical symptoms ( fever- jaundice)
4- presence of relevant comorbidity
( GDM - PET - MF pregnancies)
What is the usual postnatal resolution?
Confirm the diagnosis:
LFTs return to normal ( including bile acid)
4 WEEKS
Itching will stop very soon after birth
What is the maternal morbidity in Women with ICP?
1- affect sleep
2- higher risk of PET 12.2%
3- higher risk of GDM 13.2%
👉👉monitor BP+ urine + glucose
4- may be diagnosed later with: *hepatobiliary disease
* Hepatitis C 👉 DON’T SCREEN
What is the usual presentation of a woman with ICP?
1- itching: generalized & may affect
palms &soles ( ES: at night)
2- dark urine & pale stool
3- steatorrhoea ( ⬇️vitK)
4- jaundice ( rare) 1%
What are the risk factors for stillbirth in women with ICP?
1- bile acid concentration >100
2- twin ( stillbirth occurs earlier (33-35 in twin/ 36-38in singleton)
3- comorbidity: diabetes/ PET
What is the pathophysiology of stillbirth in ICP?
Uncertain : bile acids may cause fetal arrhythmia OR acute placental vessel spasm
What is the association between bile acids concentration & prevalence of stillbirth?
🚩19-39 👉same as background risk
🚩 40-99👉 same as background UNTIL 38-39 W
🚩> 100👉the risk is higher than the background
What are the perinatal morbidity in women with ICP?
ONLY SEVERE &MODERATE:
1- preterm birth
Mild 16%
Moderate 19%
Severe 30 %
2- meconium stained amniotic fluid during labour
3- more likely to receive neonatal care
How should women with ICP be monitored? [ pretest Q]
Consultant led unit
* LFTs & bile acid after 1 week then determin the frequency
19-39👉weekly until 38w ( inform timing of birth)
40-99👉weekly until 35w
>100 👉 routine weekly testing may not be required
What is the role of fetal monitoring in preventing stillbirth?
📌CTG or ultrasound DON’T predict or prevent stillbirth
🚩Recommended maternal monitoring of fetal movements
What impact of treatment on maternal itching/ maternal biochemistry/ fetal outcomes can be expected?
📌NO treatmentd that improve pregnancy outcomes or raised bile acid concentrations
📌Limited benefit in improving maternal itching
What are the treatment options in women with ICP?
🚩topical emollients: ameliorate skin symptoms
🚩antihistamines CHLORPHENAMINE
[ loratadine/ cetirizine DON’T have sedative effect]
🚩 DON’T routinely offer UDDC ( ursodeoxycholic) for reducing the adverse outcomes ( 15mg/kg)
📌SECOND LINE:RIFAMPICIN 1amp/d
( in severe early onset disease)
🚩Vit k : ( water soluble formulation)
10mg / d in the presence of steatorrhoea or ⬆️pt
What is the effect of UDCA on bile acid concentrations & transaminas ?
UDCA 👉 ⬆️ bile acid concentrations
👉⬇️ alanine transaminase
How should women be advised on timing of birth?
📌 mild (19-39) 👉 40 W
📌moderate (40-99) 👉38-39 W
📌severe >100 👉 35-36 W
What is the effect of ICP on the mode of birth?
DON’T affect the mode of birth
* women with ICP don’t have increased rates of assisted or operative delivery compared with control.
What are the indications of CEFM ( continuous electronic fetal monitoring) in women with ICP?
1- BILE ACID > 100
…………….
2- meconium stained amniotic fluid
3- presence of risk factors ( GDM- PET - MF pregnancy)
What follow up should be offered to women who have had ICP?
4 weeks after birth to confirm the resolution of ICP
If itching or biochemical abnormalities persist beyond 6 weeks 👉 hepatologist
What advice should be offered for future contraceptive or HRT?
ICP dosen’t influence taking OC or HRT
📌 women with previous ICP secondary to OC 👉 progesterone only pills
How should women be cared for in future pregnancies ?
LFTs + bile acid concentrations at booking as a baseline
Recurrence rate of ICP in future pregnancies?
Up to 90 % in old guidelines
In new::: no number just increase
What is the risk of stillbirth in women with ICP compared with general population ( 0.18-0.7) ?
Mild unchanged 0.13%
Moderate unchanged until 39w
0.28%
Severe raised 3.44 %
