Intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy is a disorder characterized by itching, with onset in the third trimester of pregnancy, without any primary skin lesions with relief of signs and symptoms within two to three weeks after delivery. It affects 0.7% of pregnancies in multiethnic populations and 1.2–1.5% of women of Indians. Prevalence is influenced by genetic and environmental factors and varies among populations worldwide. In Chile, 2.4% of all pregnancies are affected, with a 5% prevalence in women of Araucanian – Indian origin. Pruritus in pregnancy is common, affecting 23% of pregnancies, of which a small proportion will have obstetric cholestasis.

A higher incidence is seen in twin pregnancies, following IVF, women of age more than 35 years, with a history of itching in previous pregnancies and in women with a history of the biliary disease. Patients with IVF may present in the second trimester with ICP. The itching/pruritus of obstetric cholestasis is typically worse at night, like most other cholestasis, is often widespread and may involve the palms of the hands and/or the soles of the feet. Jaundice typically develops 1 to 4 weeks after the onset of pruritus but occasionally can be the initial symptom. Often there may be no overt jaundice. Typically, transaminases will range from just above the upper limit of normal to several hundred. It has been associated with increased risk of pre-term delivery (up to 19 to 60%), meconium staining of amniotic fluid (up to 27% cases), fetal bradycardia (up to 14%), fetal distress (22%-41%)and fetal loss (0.4 to 4.1%), particularly when serum bile acids level goes beyond 40 μmol / L. Maternal complications include bleeding from fat-soluble vitamin deficiency and a higher incidence of gallstones.

It has been seen that a higher proportion of these women (10-36%) undergo a caesarean section, the relative role of ICP is difficult to prove, though. Topical emollients like calamine lotion have been tried for pruritus, the efficacy though has not been proven by clinical trials but is still useful in some patients. Cholestyramine has not been subjected to randomised trials and antihistamines such as Chlorpheniramine may provide some welcome sedation at night but do not have a significant impact on pruritus. There is insufficient evidence to demonstrate whether S-adenosyl methionine (SAMe) is effective for either control of maternal symptoms or for improving fetal outcome.

Ursodeoxycholic acid (UDCA) improves pruritus and liver function by displacement of more hydrophobic endogenous bile salts from the bile acid pool. This may protect the hepatocyte membrane from the damaging toxicity of bile salts and enhance bile acid clearance across the placenta from the fetus. UDCA seems to be well tolerated by pregnant women and no adverse effects on mothers or newborn have been observed. Steroids should not be used. In order to reduce fetal complications, labour is induced at 37-38 weeks.