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Intrahepatic Cholestasis of Pregnancy
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Intrahepatic Cholestasis of Pregnancy
See Also
Pruritus in Pregnancy
Epidemiology
Most common liver disease in pregnancy
Incidence
: 1-1.5% of pregnancies
Pathophysiology
Related to increased serum
Estrogen
levels
Risk Factors
Third Trimester pregnancy
Multiple Gestation
pregnancy
Symptoms
Severe
Pruritus
in third trimester of pregnancy
Pruritus
localized to trunk and extremities, especially palms and soles, and especially at night
Abdominal Pain
and
Jaundice
are uncommon
Signs
No rash
No
Jaundice
in mild form (
Prurigo gravidarum
)
Differential Diagnosis
See
Acute Hepatitis
Hyperemesis Gravidarum
Liver
transaminases (AST, ALT) may be over 200 IU/L
Alkaline Phosphatase
may be increased up to twice normal
Serum Bilirubin
may be increased enough to cause visible
Jaundice
HELLP Syndrome
Often associated with
Preeclampsia
with
Severe Hypertension
and
Proteinuria
Most commonly occurs in third trimester and immediately postpartum
Acute Fatty Liver of Pregnancy
Associated with more severe liver failure and
Renal Insufficiency
May be difficult to distinguish with
HELLP Syndrome
Labs
Serum Bilirubin
>4 mg/dl (>16 confers adverse fetal outcome)
Serum transaminase (AST, ALT) levels may be >1000 IU/L
Management
Exclude other causes of liver disease (see differential diagnosis as above)
Ursodeoxycholic Acid
(
Ursodiol
)
Reduces symptoms, reduces
Serum Bilirubin
levels, and prolongs gestation
Brouwers (2015) Am J Obstet Gynecol 212(1): 100.e1 [PubMed]
Other symptomatic management
Oral
Antihistamine
s for
Pruritus
Cholestyramine
(Questran)
Consult maternal fetal medicine
Increased antepartum observation
Plan delivery by 35-37 weeks gestation
Course
Resolves with delivery
Complications
Bilirubin
is toxic to fetal cardiac cells, and causes
Vasocon
striction of chorionic veins
Adverse effects
Preterm delivery
Meconium-stained amniotic fluid
Intrauterine Fetal Demise
References
Swencki (2015) Crit Dec Emerg Med 29(11):2-10
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