Green Top guideline

Question 1

What is the incidence of ICP in pregnancy in UK?

Answer 1

0.7% in multi ethnic group
1.2 - 1.5 % in Indian Asian or Pakistani asian origin

Question 2

What percentage of women develop itching in pregnancy?

Answer 2

25%

Question 3

How is ICP characterised?

Answer 3

1- pruritus
2- normal skin
3- abnormal bile acid concentration

Question 4

When is symptoms of ICP usually started?

Answer 4

Third trimester
Can be earlier

Question 5

How is ICP categorized?

Answer 5

Gestational pruritus: itching + bile acid < 19
Mild ICP : itching + bile acid 19-39
Moderate ICP: itching + bile 40-99
Severe ICP: itching + bile > 100

Question 6

How is ICP diagnosed?

Answer 6

Itching +normal skin + bile acid concentration > 19 (non-fasting)
📌resolve after birth
📌 normalization of bile acid & LFTs during pregnancy 👉 reconsider the diagnosis

Question 7

When should specialist hepatology advice to sought in women with ICP?

Answer 7

1-Severe
2- early in pregnancy
3- atypical presentation

Question 8

What is the role of other investigations in the care of women with suspected ICP?

Answer 8

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)

Question 9

What is the usual postnatal resolution?

Answer 9

Confirm the diagnosis:
LFTs return to normal ( including bile acid)
4 WEEKS
Itching will stop very soon after birth

Question 10

What is the maternal morbidity in Women with ICP?

Answer 10

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

Question 11

What is the usual presentation of a woman with ICP?

Answer 11

1- itching: generalized & may affect
palms &soles ( ES: at night)
2- dark urine & pale stool
3- steatorrhoea ( ⬇️vitK)
4- jaundice ( rare) 1%

Question 12

What are the risk factors for stillbirth in women with ICP?

Answer 12

1- bile acid concentration >100
2- twin ( stillbirth occurs earlier (33-35 in twin/ 36-38in singleton)
3- comorbidity: diabetes/ PET

Question 13

What is the pathophysiology of stillbirth in ICP?

Answer 13

Uncertain : bile acids may cause fetal arrhythmia OR acute placental vessel spasm

Question 14

What is the association between bile acids concentration & prevalence of stillbirth?

Answer 14

🚩19-39 👉same as background risk
🚩 40-99👉 same as background UNTIL 38-39 W
🚩> 100👉the risk is higher than the background

Question 15

What are the perinatal morbidity in women with ICP?

Answer 15

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

Question 16

How should women with ICP be monitored? [ pretest Q]

Answer 16

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

Question 17

What is the role of fetal monitoring in preventing stillbirth?

Answer 17

📌CTG or ultrasound DON’T predict or prevent stillbirth
🚩Recommended maternal monitoring of fetal movements

Question 18

What impact of treatment on maternal itching/ maternal biochemistry/ fetal outcomes can be expected?

Answer 18

📌NO treatmentd that improve pregnancy outcomes or raised bile acid concentrations
📌Limited benefit in improving maternal itching

Question 19

What are the treatment options in women with ICP?

Answer 19

🚩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

Question 20

What is the effect of UDCA on bile acid concentrations & transaminas ?

Answer 20

UDCA 👉 ⬆️ bile acid concentrations
👉⬇️ alanine transaminase

Question 21

How should women be advised on timing of birth?

Answer 21

📌 mild (19-39) 👉 40 W
📌moderate (40-99) 👉38-39 W
📌severe >100 👉 35-36 W

Question 22

What is the effect of ICP on the mode of birth?

Answer 22

DON’T affect the mode of birth
* women with ICP don’t have increased rates of assisted or operative delivery compared with control.

Question 23

What are the indications of CEFM ( continuous electronic fetal monitoring) in women with ICP?

Answer 23

1- BILE ACID > 100
…………….
2- meconium stained amniotic fluid
3- presence of risk factors ( GDM- PET - MF pregnancy)

Question 24

What follow up should be offered to women who have had ICP?

Answer 24

4 weeks after birth to confirm the resolution of ICP
If itching or biochemical abnormalities persist beyond 6 weeks 👉 hepatologist

Question 25

What advice should be offered for future contraceptive or HRT?

Answer 25

ICP dosen’t influence taking OC or HRT
📌 women with previous ICP secondary to OC 👉 progesterone only pills

Question 26

How should women be cared for in future pregnancies ?

Answer 26

LFTs + bile acid concentrations at booking as a baseline

Question 27

Recurrence rate of ICP in future pregnancies?

Answer 27

Up to 90 % in old guidelines
In new::: no number just increase

Question 28

What is the risk of stillbirth in women with ICP compared with general population ( 0.18-0.7) ?

Answer 28

Mild unchanged 0.13%
Moderate unchanged until 39w
0.28%
Severe raised 3.44 %