加拿大妇产科医师协会《妊娠期肝内胆汁淤积症的诊断和管理（2024）》解读

doi:10.12280/gjfckx.20250406

摘要/Abstract

摘要：

妊娠期肝内胆汁淤积症（intrahepatic cholestasis of pregnancy，ICP）是常发生于妊娠中晚期的肝脏疾病，主要表现是皮肤瘙痒、血清总胆汁酸水平升高，可导致不良妊娠结局。2024年加拿大妇产科医师协会（Society of Obstetricians and Gynaecologists of Canada，SOGC）指南指出ICP诊断标准为非空腹血清胆汁酸>19 μmol/L，每2~4周监测血清胆汁酸水平，根据妊娠期最高胆汁酸水平，结合高危因素个体化决定分娩时机，熊去氧胆酸（ursodeoxycholic acid，UDCA）是ICP的一线治疗药物。2022年英国皇家妇产科医师学会指南的ICP诊断标准为随机胆汁酸≥19 μmol/L且伴有无皮损的瘙痒症状，不推荐常规使用UDCA来降低ICP不良围产期结局风险。而2024年中国指南推荐将空腹血清胆汁酸≥10 μmol/L或餐后血清胆汁酸≥19 μmol/L作为ICP的诊断标准，且针对ICP的辅助检查、治疗方案、孕期监测频率、分娩时机也略有差异。通过解读2024年SOGC指南，并对3个指南进行对比分析，以期为临床医生诊治ICP提供更多依据。

关键词: 胆汁淤积，肝内, 妊娠并发症, 胆汁酸, 诊断, 治疗, 临床管理

Abstract:

Intrahepatic cholestasis of pregnancy (ICP) is a liver disease that commonly occurs in the second and third trimesters of pregnancy. Its main manifestations are skin pruritus and elevated serum total bile acid levels, which can lead to adverse pregnancy outcomes. The 2024 guideline of the Society of Obstetricians and Gynaecologists of Canada (SOGC) states that the diagnostic criterion for ICP is non-fasting serum bile acid>19 μmol/L. Serum bile acid levels should be monitored every 2-4 weeks. The timing of delivery is determined individually based on the highest bile acid level during pregnancy and combined with high-risk factors. Ursodeoxycholic acid (UDCA) is the first-line treatment for ICP. The 2022 guideline of the Royal College of Obstetricians and Gynaecologists (RCOG) in the UK stipulates that the diagnostic criterion for ICP is random bile acid≥19 μmol/L accompanied by pruritus without skin lesions, and it does not recommend the routine use of UDCA to reduce the risk of adverse perinatal outcomes in ICP. The 2024 Chinese guideline recommends using a fasting serum bile acid level≥10 μmol/L or a post-meal serum bile acid level≥19 μmol/L as the diagnostic criterion for ICP, and there are also slight differences in the auxiliary examinations, treatment regimens, frequency of prenatal monitoring, and timing of delivery for ICP. By interpreting the 2024 SOGC guideline and conducting a comparative analysis of the three guidelines, we hope to provide more evidence for clinicians in the diagnosis and treatment of ICP.

Key words: Cholestasis, intrahepatic, Pregnancy complications, Bile acid, Diagnosis, Therapy, Clinical governance

尹小青, 张健, 向雪芹, 李涛. 加拿大妇产科医师协会《妊娠期肝内胆汁淤积症的诊断和管理（2024）》解读[J]. 国际妇产科学杂志, 2025, 52(5): 596-600.

YIN Xiao-qing, ZHANG Jian, XIANG Xue-qin, LI Tao. Interpretation of the 'Diagnosis and Management of Intrahepatic Cholestasis in Pregnancy (2024)' by the Society of Obstetricians and Gynaecologists of Canada[J]. Journal of International Obstetrics and Gynecology, 2025, 52(5): 596-600.

参考文献 24

[1]	Hobson SR, Cohen ER, Gandhi S, et al. Guideline No. 452: Diagnosis and Management of Intrahepatic Cholestasis of Pregnancy[J]. J Obstet Gynaecol Can, 2024, 46(8):102618. doi: 10.1016/j.jogc.2024.102618.
[2]	Girling J, Knight CL, Chappell L. Intrahepatic cholestasis of pregnancy: Green-top Guideline No. 43 June 2022[J]. BJOG, 2022, 129(13):e95-e114. doi: 10.1111/1471-0528.17206.
[3]	中华医学会妇产科学分会产科学组, 中华医学会围产医学分会. 妊娠期肝内胆汁淤积症临床诊治和管理指南(2024版)[J]. 中华妇产科杂志, 2024, 59(2):97-107. doi: 10.3760/cma.j.cn112141-20230914-00099.
[4]	Allen AM, Kim WR, Larson JJ, et al. The Epidemiology of Liver Diseases Unique to Pregnancy in a US Community: A Population-Based Study[J]. Clin Gastroenterol Hepatol, 2016, 14(2):287-294.e1-2. doi: 10.1016/j.cgh.2015.08.022.
[5]	Williamson C, Geenes V. Intrahepatic cholestasis of pregnancy[J]. Obstet Gynecol, 2014, 124(1):120-133. doi: 10.1097/AOG.0000000000000346. pmid: 24901263
[6]	Corcoran A, Langan H. Obstetric Cholestasis: Investigation of a suspected high incidence in the West of Ireland[J]. Eur J Obstet Gynecol Reprod Biol, 2022, 269:114-117. doi: 10.1016/j.ejogrb.2021.12.009.
[7]	Gao XX, Ye MY, Liu Y, et al. Prevalence and risk factors of intrahepatic cholestasis of pregnancy in a Chinese population[J]. Sci Rep, 2020, 10(1):16307. doi: 10.1038/s41598-020-73378-5.
[8]	Geenes V, Chappell LC, Seed PT, et al. Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: a prospective population-based case-control study[J]. Hepatology, 2014, 59(4):1482-1491. doi: 10.1002/hep.26617. pmid: 23857305
[9]	Dixon PH, Williamson C. The pathophysiology of intrahepatic cholestasis of pregnancy[J]. Clin Res Hepatol Gastroenterol, 2016, 40(2):141-153. doi: 10.1016/j.clinre.2015.12.008.
[10]	Kenyon AP, Tribe RM, Nelson-Piercy C, et al. Pruritus in pregnancy: a study of anatomical distribution and prevalence in relation to the development of obstetric cholestasis[J]. Obstet Med, 2010, 3(1):25-29. doi: 10.1258/om.2010.090055.
[11]	Sarkar M, Brady CW, Fleckenstein J, et al. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases[J]. Hepatology, 2021, 73(1):318-365. doi: 10.1002/hep.31559.
[12]	Azer SA, Hasanato R. Use of bile acids as potential markers of liver dysfunction in humans: A systematic review[J]. Medicine(Baltimore), 2021, 100(41):e27464. doi: 10.1097/MD.0000000000027464.
[13]	Mitchell AL, Ovadia C, Syngelaki A, et al. Re-evaluating diagnostic thresholds for intrahepatic cholestasis of pregnancy: case-control and cohort study[J]. BJOG, 2021, 128(10):1635-1644. doi: 10.1111/1471-0528.16669.
[14]	Conti-Ramsden F, McEwan M, Hill R, et al. Detection of additional abnormalities or co-morbidities in women with suspected intrahepatic cholestasis of pregnancy[J]. Obstet Med, 2020, 13(4):185-191. doi: 10.1177/1753495X19868873.
[15]	Wikström Shemer E, Marschall HU, Ludvigsson JF, et al. Intrahepatic cholestasis of pregnancy and associated adverse pregnancy and fetal outcomes: a 12-year population-based cohort study[J]. BJOG, 2013, 120(6):717-723. doi: 10.1111/1471-0528.12174.
[16]	Mor M, Shmueli A, Krispin E, et al. Intrahepatic cholestasis of pregnancy as a risk factor for preeclampsia[J]. Arch Gynecol Obstet, 2020, 301(3):655-664. doi: 10.1007/s00404-020-05456-y. pmid: 32034507
[17]	Arafa A, Dong JY. Association between intrahepatic cholestasis of pregnancy and risk of gestational diabetes and preeclampsia: a systematic review and meta-analysis[J]. Hypertens Pregnancy, 2020, 39(3):354-360. doi: 10.1080/10641955.2020.1758939. pmid: 32326772
[18]	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[J]. Lancet, 2019, 393(10174):899-909. doi: 10.1016/S0140-6736(18)31877-4. pmid: 30773280
[19]	Chappell LC, Bell JL, Smith A, et al. Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial[J]. Lancet, 2019, 394(10201):849-860. doi: 10.1016/S0140-6736(19)31270-X. pmid: 31378395
[20]	Ovadia C, Sajous J, Seed PT, et al. Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis[J]. Lancet Gastroenterol Hepatol, 2021, 6(7):547-558. doi: 10.1016/S2468-1253(21)00074-1.
[21]	Walker KF, Chappell LC, Hague WM, et al. Pharmacological interventions for treating intrahepatic cholestasis of pregnancy[J]. Cochrane Database Syst Rev, 2020, 7(7):CD000493. doi: 10.1002/14651858.CD000493.pub3.
[22]	Kawakita T, Parikh LI, Ramsey PS, et al. Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy[J]. Am J Obstet Gynecol, 2015, 213(4):570.e1-e8. doi: 10.1016/j.ajog.2015.06.021.
[23]	Liauw J, Foggin H, Socha P, et al. Technical Update No. 439: Antenatal Corticosteroids at Late Preterm Gestation[J]. J Obstet Gynaecol Can, 2023, 45(6):445-457.e2. doi: 10.1016/j.jogc.2022.12.006.
[24]	Tamiru AT, Rade BK, Ali O. The Recurrent Liver Disorder of a Pregnant Mother: Intrahepatic Cholestasis of Pregnancy - A Case Report and Literature Review[J]. Int Med Case Rep J, 2021, 14:73-76. doi: 10.2147/IMCRJ.S299354.