Intrahepatic Cholestasis of Pregnancy (ICP)

Intrahepatic Cholestasis of Pregnancy

• Accounts for 20% of obstetric jaundice
• Presents with
  • Generalized pruritus, +/- jaundice
  • Absence of primary lesions
  • Biochemical abnormalities consistent with cholestasis
  • No history of exposure to hepatitis or hepatotoxic drugs

Pathophysiology

• Thought to be due to increased levels of estrogen

• Estrogen Effects

  1. Promotes cholestasis
  2. Inhibits reuptake of bile acids into hepatocytes
  3. Inhibits bile transport proteins

Findings

elevation of

• Raised bilirubin
• Raised transaminases
• Raised alkaline phosphatase
• the hallmark of ICP is elevation of serum bile acids.

ICP: Complications

A- For the mother, risks associated with ICP include 1- Bleeding 2- Intestinal malabsorption 3- Cholelithiasis

B- For the fetus risks include 1- Prematurity 2- Fetal distress 3- Death.

Treatment

• Although ICP resolves after delivery, treatment is indicated.

• The goal of treatment is to decrease circulating bile acids.

• Vitamin K supplementation plays a role in management if bleeding parameters become abnormal.

Therapeutic Options

The goal of treatment is to reduce symptoms and to prevent maternal and fetal complications.

• early induction of labor, commonly at 37 to 38 weeks.

  • When cholestasis is severe, delivery is considered earlier if fetal lung maturity is established.

• Ursodeoxycholic acid

  • Considered 1st- line treatment

Case Three: History

• Wala presents with intense, non-remitting pruritus without skin lesions.
• She is G3P2. Both previous pregnancies were uncomplicated. She is in her 30th week of gestation.
• She says the itch is worse after a hot shower.
• She is healthy, except for a history of eczema as a child and well-controlled hypothyroidism.