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.