Pocket ObGyn – Intrahepatic Cholestasis of Pregnancy (ICP)
See Abbreviations
Definitions and Epidemiology
- Dz of intrahepatic biliary tree or hepatocellular secretory system resulting in elevated bilirubin & other solutes eliminated in bile (bile salts & cholesterol) that occurs during Preg
- 1–0.2% incid in North America
- Chronic hepatitis C a/w 20-fold in incid of cholestasis
Pathophysiology
- Unk but likely genetically susceptible alterations in steroid & bile acid metabolism
- HLA-B8 & HLA-BW16 & gene mutations in hepatocellular transport systems (MDR3)
- May be related to circulating estrogen levels (incid in twin pregnancies >
singletons)
- Bile acids incompletely cleared & accumulate in plasma w/ assoc dyslipidemia
- mec & intrapartum fetal distress (22–41%), preterm birth (19–60%), & fetal demise (0.75–1.6%); esp if bile acids >40 mmol/L (Glantz. Hepatology 2004;467)
Clinical Manifestations and Physical Exam
- Generalized pruritus in 2nd or 3rd trimester esp on palms & soles of feet
- Jaundice (20–75%)
- No assoc rash, but excoriations from scratching
Diagnostic Workup/Studies
- Pruritus precedes lab abnormalities by several weeks Hyperbilirubinemia (rarely exceeds 4–5 mg/dL)
serum bile acids (chenodeoxycholic acid, deoxycholic acid, cholic acid) > 10 mmol/L
alk phos more than nml Preg
Nml to moderately AST/ALT but seldom >250 U/L
- Liver bx shows mild cholestasis w/ centrilobular dilation w/ bile plugs (rare to bx)
- Rule out preeclampsia, not likely in setting of nml pressures & absence of proteinuria
- RUQ US to rule out cholelithiasis & biliary obst
Treatment and Medications
- Sx & labs nml 2–4 w after deliv but likely to recur in subseq pregnancies or w/ exogenous estrogen use
- Antihistamines & topical emollients for symptomatic relief of pruritus
- Ursodeoxycholic acid (probably superior rx), cholestyramine, naltrexone
- Consider antepartum testing after dx; consider deliv at 37–38 w