Itching in pregnancy (intrahepatic cholestasis of pregnancy)
BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.
Itching in pregnancy: look for intrahepatic cholestasis of pregnancy
Fasting laboratory tests
- Total serum bile acids (fasting; not reimbursed in France)
- AST
- ALT
- FBC (platelets)if neededRaised transaminases with hypertension, epigastric or right upper quadrant pain: exclude pre-eclampsia or dissociated HELLP syndrome [1] (see the page Hypertension in pregnancy).
- Serum creatinineif neededRaised transaminases with hypertension, epigastric or right upper quadrant pain: exclude pre-eclampsia or dissociated HELLP syndrome [1] (see the page Hypertension in pregnancy).
- Urine protein:creatinine ratioif neededRaised transaminases with hypertension, epigastric or right upper quadrant pain: exclude pre-eclampsia or dissociated HELLP syndrome [1] (see the page Hypertension in pregnancy).
- PT, serology for HAV (IgM), HBV, HCV, HEV (IgM), CMV, EBV (if symptoms suggestive of another liver disease)if neededFever, jaundice, flu-like syndrome or marked cytolysis: viral hepatitis (A, B, C), primary CMV, HSV or EBV infections, drug-induced or autoimmune hepatitis are part of the differential diagnoses; these tests are not to be done in the absence of suggestive symptoms [1].
- Intense pruritus with urticarial plaques (especially abdominal), vesicles or blisters: refer to a dermatologist (biopsy with direct immunofluorescence, anti-BP180 antibodies) before any treatment.
- Liver and biliary tract ultrasound (not a laboratory test) only if pain, fever or jaundice.
Do not order
Confirmed intrahepatic cholestasis of pregnancy: monitoring
At the frequency set with the maternity unit
- Total serum bile acids (fasting)
- AST
- ALT
After delivery
8 to 12 weeks after delivery
- AST
- ALT
- GGT
- Alkaline phosphatase
- If the abnormalities persist 3 months after delivery: work-up for chronic liver disease (see the page Cholestasis).
Sources (11)
- Sentilhes L, Sénat MV, Bouchghoul H, et al. La cholestase gravidique : recommandations pour la pratique clinique du Collège national des gynécologues obstétriciens français. Gynecol Obstet Fertil Senol. 2023;51(11-12):493-510.
- Ovadia C, Seed PT, Sklavounos A, et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet. 2019;393(10174):899-909.
- Powell AM, Sakuma-Oyama Y, Oyama N, Albert S, Bhogal B, Kaneko F, et al. Usefulness of BP180 NC16a enzyme-linked immunosorbent assay in the serodiagnosis of pemphigoid gestationis and in differentiating between pemphigoid gestationis and pruritic urticarial papules and plaques of pregnancy. Arch Dermatol. 2005;141(6):705-10.
- Centre de référence des maladies bulleuses auto-immunes. Protocole national de diagnostic et de soins (PNDS) : Maladies bulleuses auto-immunes, pemphigoïde de la grossesse. Synthèse à destination du médecin traitant (HAS, 2016-2017).
- Society for Maternal-Fetal Medicine (SMFM), Lee RH, Greenberg M, Metz TD, Pettker CM. Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol. 2021;224(2):B2-B9.
- Nederlandse Vereniging voor Obstetrie en Gynaecologie (NVOG). Richtlijn Zwangerschapscholestase, module « Zwangerschapscholestase », 6 novembre 2024 (Pays-Bas).
- Hagenbeck C, Hamza A, Kehl S, et al. Management of Intrahepatic Cholestasis of Pregnancy: Recommendations of the Working Group on Obstetrics and Prenatal Medicine - Section on Maternal Disorders. Geburtshilfe Frauenheilkd. 2021;81(8):922-939 (Allemagne).
- Royal College of Obstetricians and Gynaecologists. Intrahepatic cholestasis of pregnancy. Green-top Guideline No. 43, juin 2022 (Girling J, et al. BJOG. 2022;129(13):e95-e114).
- Mitchell AL, Ovadia C, Syngelaki A, et al. Re-evaluating diagnostic thresholds for intrahepatic cholestasis of pregnancy: case-control and cohort study. BJOG. 2021;128(10):1635-1644.
- Cwm Taf Morgannwg University Health Board (pays de Galles). Intrahepatic Cholestasis of Pregnancy (ICP) Guideline, version 2, août 2024 (guide hospitalier reprenant le RCOG 2022).
- Collège national des gynécologues et obstétriciens français (CNGOF). Post-partum. Recommandations pour la pratique clinique, 2015 (texte court : Sénat MV, et al. J Gynecol Obstet Biol Reprod (Paris). 2015;44(10):1157-66).