Practice Easily missed?

Intrahepatic cholestasis of pregnancy

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1236 (Published 21 April 2016) Cite this as: BMJ 2016;353:i1236
  1. Sarah C Hillman, general practice specialist trainee year 11 2,
  2. Helen Stokes-Lampard, GP principal and primary care academic2,
  3. Mark D Kilby, professor of fetal medicine and therapy1 3
  1. 1Centre for Women’s and New-born Health, Institute of Metabolism and Systems Research, College of Medical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
  2. 2School of Health and Population Sciences, College of Medical and Dental Sciences University of Birmingham, Birmingham, UK
  3. 3Fetal Medicine Centre, Birmingham Women’s Foundation Trust, Birmingham, UK
  1. Correspondence to: S C Hillman sarahchillman{at}hotmail.com
  • Accepted 23 December 2015

What you need to know

  • Consider intrahepatic cholestasis of pregnancy in all women who have itching during pregnancy

  • Urgently request LFTs including serum bile acids (may require referral to local maternity unit)

  • If LFTs or bile acids are normal but distressing widespread itching persists, repeat testing at weekly intervals while symptoms persist

  • Delayed diagnosis is associated with an increased risk of stillbirth, and induction of labour (offered from 37 weeks’ gestation) reduces this risk

A 30 year old, 35 week pregnant, nulliparous woman visits her general practitioner because of itching but no rash. Fundal height measurements and fetal movements are normal. The GP arranges an urgent antenatal clinic review, where liver function tests (LFTs), including bile acids, are reported as normal. At a midwife appointment two weeks later, she still has intense itching. Repeat tests show raised total bile acids (100 µmol/L; reference range 0-14) and aspartate aminotransferase (150 U/L; 5-35). Intrahepatic cholestasis of pregnancy is diagnosed and she is offered induction of labour that day.

A brief description of the condition

Intrahepatic cholestasis of pregnancy, also called “obstetric cholestasis,” is a multifactorial condition of pregnancy characterised by pruritus in the absence of a skin …

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