II. Epidemiology

  1. Most common liver disease in pregnancy
  2. Incidence: 1-1.5% of pregnancies

III. Pathophysiology

  1. Related to increased serum Estrogen levels

IV. Risk Factors

  1. Third Trimester pregnancy
  2. Multiple Gestation pregnancy

V. Symptoms

  1. Severe Pruritus in third trimester of pregnancy
  2. Pruritus localized to trunk and extremities, especially palms and soles, and especially at night
  3. Abdominal Pain and Jaundice are uncommon

VI. Signs

  1. No rash
  2. No Jaundice in mild form (Prurigo gravidarum)

VII. Differential Diagnosis

  1. See Acute Hepatitis
  2. Hyperemesis Gravidarum
    1. Liver transaminases (AST, ALT) may be over 200 IU/L
    2. Alkaline Phosphatase may be increased up to twice normal
    3. Serum Bilirubin may be increased enough to cause visible Jaundice
  3. HELLP Syndrome
    1. Often associated with Preeclampsia with Severe Hypertension and Proteinuria
    2. Most commonly occurs in third trimester and immediately postpartum
  4. Acute Fatty Liver of Pregnancy
    1. Associated with more severe liver failure and Renal Insufficiency
    2. May be difficult to distinguish with HELLP Syndrome

VIII. Labs

  1. Serum Bilirubin >4 mg/dl (>16 confers adverse fetal outcome)
  2. Serum transaminase (AST, ALT) levels may be >1000 IU/L

IX. Management

  1. Exclude other causes of liver disease (see differential diagnosis as above)
  2. Ursodeoxycholic Acid (Ursodiol)
    1. Reduces symptoms, reduces Serum Bilirubin levels, and prolongs gestation
    2. Brouwers (2015) Am J Obstet Gynecol 212(1): 100.e1 [PubMed]
  3. Other symptomatic management
    1. Oral Antihistamines for Pruritus
    2. Cholestyramine (Questran)
  4. Consult maternal fetal medicine
    1. Increased antepartum observation
    2. Plan delivery by 35-37 weeks gestation

X. Course

  1. Resolves with delivery

XI. Complications

  1. Bilirubin is toxic to fetal cardiac cells, and causes Vasoconstriction of chorionic veins
  2. Adverse effects
    1. Preterm delivery
    2. Meconium-stained amniotic fluid
    3. Intrauterine Fetal Demise

XII. References

  1. Swencki (2015) Crit Dec Emerg Med 29(11):2-10

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Related Studies

Ontology: Cholestasis of pregnancy (C0268318)

Concepts Disease or Syndrome (T047)
MSH C535932
SnomedCT 950004, 235888006
English CHOLESTASIS OF PREGNANCY, Cholestasis of pregnancy, recurrent jaundice of pregnancy, recurrent jaundice of pregnancy (diagnosis), Pregnancy related cholestasis, cholestasis of pregnancy, ricp, cholestasis pregnancy, pregnancy cholestasis, Cholestasis, Pregnancy-Related, Cholestasis, Intrahepatic, Of Pregnancy, Intrahepatic cholestasis of pregnancy (disorder), Cholestasis, intrahepatic of pregnancy, Pregnancy-Related Cholestasis, Obstetric Cholestasis, Intrahepatic Cholestasis of Pregnancy, Intrahepatic cholestasis of pregnancy, RICP, Recurrent intrahepatic cholestasis of pregnancy, Recurrent jaundice of pregnancy, Cholestasis of pregnancy (disorder), Intrahepatic cholestasis of pregnancy (disorder) [Ambiguous]
Italian Colestasi gravidica
Japanese 妊娠時胆汁うっ滞, ニンシンジタンジュウウッタイ
Czech Těhotenská cholestáza
Hungarian Terhességi cholestasis
Spanish colestasis intrahepática recurrente del embarazo, colestasis intrahepática del embarazo, CIRE, colestasis del embarazo, colestasis intrahepática del embarazo (trastorno), colestasia del embarazo (trastorno), colestasia del embarazo, colestasia intrahepática del embarazo, colestasis intrahepática del embarazo (concepto no activo), ictericia recurrente del embarazo, Colestasis del embarazo
Portuguese Colestase da gravidez
Dutch cholestase van zwangerschap
French Cholestase gravidique
German Schwangerschaftscholestase