Intrahepatic Cholestasis of Pregnancy

1. See Also
   1. Pruritus in Pregnancy
2. Epidemiology
   1. Most common liver disease in pregnancy
   2. Incidence: 1-1.5% of pregnancies
3. Pathophysiology
   1. Related to increased serum Estrogen levels
4. Risk Factors
   1. Third Trimester pregnancy
   2. Multiple Gestation pregnancy
5. 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
6. Signs
   1. No rash
   2. No Jaundice in mild form (Prurigo gravidarum)
7. 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
8. Labs
   1. Serum Bilirubin >4 mg/dl (>16 confers adverse fetal outcome)
   2. Serum transaminase (AST, ALT) levels may be >1000 IU/L
9. 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
10. Course
    1. Resolves with delivery
11. 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
12. References
    1. Swencki (2015) Crit Dec Emerg Med 29(11):2-10