Medicate, Observer, Understand, Self-help, Early delivery
Ursodeoxycholic Acid - UDCA (Actigall, Urso)
UDCA is one of the most important treatments for ICP. It's natural bile acid composition improves maternal liver funtion by replacing the more toxic bile acids in bloodstream. Studies have shown that it also improves bile acid transport across the placenta, which may greatly reduce the risk of stillbirth associated with ICP.
Vitamin K therapy is a suggested course of treatment for all ICP patients. Choleastasis reduces the absorption of fat-soluble vitamins which can lead to Vitamin K deficiency, possibly resulting in serious complications including hemmorhaging in the mother and intra-cranial hemmorhaging for the infant. Oral, water-soluble Vitamin K supplements are recommended for the mother and upon delivery, the newborn should recieve an injection of Vitamin K. Breast milk contains little to no amounts of Vitamin K and therefore should not be relied upon for treatment purposes.
Raised bile acids increase the risk of premature labor. This threat coupled with the fact that all ICP babies should be delivered by 36 weeks often prompts the usage of steroids to increase the probability of lung maturity at birth. Research is strong that steroids given before 32 weeks gestation have a profound impact on fetal lung maturity. In addition to improving fetal lung maturation, there is some indication that steriods may also curtail some of the itching associated with ICP by suppressing hormone production.
Cholestyramine (Questran, Colestipol)
In previous years, cholestyramine and other cholesterol lowering agents were the front-line medications for treating ICP. As more information and studies have become available, cholestyramine has been excluded by many doctors for ICP treatment due to it's lack of effectiveness in aggressively lowering bile acids and it's potentially dangerous side affects. Cholesterol lowering agents are known to also inhibit certain fat-soluble vitamins, including Vitamin K, which is essential for blood clotting. Due to the fact that ICP patients are aleady at risk for Vitamin K deficiency, prescribing cholestyramine should be avoided to prevent maternal hemmorrhage or intracranial hemmorhaging in the unborn child.
Serum Bile Acid Testing
The most sensitive indicator of ICP is a rise of serum bile acid levels (amounts above 12-14 umo/l). Therefore, the a Serum Bile Acid test should be used to determine a diagnosis of ICP and bile acids tests should be repeated at least weekly until delivery and again afterwards in order to rule out underlying liver problems. Bile acids, whether acting directly or indirectly, trigger the intense itching associated with ICP and are believed to be the catalyst. The increase of serum bile acids in combination with itching is highly suggestive of a diagnosis of ICP. Any pregnant woman with raised serum bile acids needs to be treated to reduce the bile acids even if the ICP is thought to be the result of an underlying disorder.
Liver Function Testing
A Liver Function Test that measures the levels of transaminases (AST, ALT & ALK) in the bloodsteam should also be carried out weekly or twice weekly. It is important to note that liver enzymes elevate in the bloodstream as a result of elevated serum bile acids, and therefore a normal result of a Liver Function Test means nothing when concluding a diagnosis of ICP. It is possible for an ICP patient with raised Serum Bile Acid levels to have perfectly normal Liver Function Test results and still be at risk.
CTG, Doppler & Ultrasound Surveillance
Although the above mentioned surveillance techniques will not totally elimiate the risk of stillbirth, aggressive surveillance is suggested. Most ICP experts suggest some or all of the following fetal monitoring techniques to be administered twice weekly upon diagnosis or start of the illness and be repeated until delivery: