Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disorder associated with adverse perinatal outcomes, including intrauterine fetal death (IUFD). We present a diagnostically and therapeutically challenging case involving a 26-year-old G2P1 woman (BMI 35, at 25+1 weeks' gestation) with a history of gestational hypertension and gestational diabetes, who was admitted with severe, recurrent ICP.
She developed intense pruritus, abdominal discomfort, and progressive biochemical deterioration: ALT rose from 74 to 758 U/L, AST from 36 to 411 U/L, and fasting bile acids escalated from 10 to 300 μmol/L. Bilirubin was 24 μmol/L, LDH 309, and platelets 287. Her previous pregnancy was complicated by pre-eclampsia and probable ICP.
In the current pregnancy, comprehensive evaluation—including haemolysis workup, autoimmune screening, liver ultrasound, and MRCP—revealed no alternate pathology. A stable hepatic hemangioma and mild hepatomegaly were noted. Despite treatment with high-dose ursodeoxycholic acid and a trial of rifampicin (later ceased due to concern for hepatotoxicity), liver function continued to worsen.
Following administration of betamethasone for fetal lung maturation, liver function and bile acid levels improved. This prompted a multidisciplinary team (MDT) discussion and the initiation of prednisolone 50 mg daily. The rationale included immunomodulatory and anti-inflammatory effects, support of bile acid transport, and reduced risk of metabolic side effects compared to other corticosteroids. Transplacental transfer of prednisone is also lower than that of other corticosteroids.
This highlights the importance of clinical judgment and an MDT approach in the setting of limited evidence. It also underscores the potential future role of corticosteroids in refractory ICP.