Intrahepatic Cholestasis of Pregnancy
IHCP is typically seen in the second or third trimester and should be suspected when a pregnant patient has intense pruritus (mainly on the palms and soles) and abnormal liver tests in a cholestatic pattern (greater increase from normal values of ALP when compared with ALT)...
the diagnosis of IHCP is made when pruritus is present and the fasting bile acid concentration is elevated (typically >10 µmol/L). Importantly, other causes of liver disease do not typically raise bile acid levels. In IHCP, aminotransferase levels may also be elevated (1-5 times the upper limit of normal), with total bilirubin levels usually less than 5 mg/dL. Risk factors for IHCP include prior history of cholestasis secondary to oral contraceptive use, prior pregnancy complicated by IHCP, or a family history of IHCP.
First-line treatment for IHCP is initiation of ursodeoxycholic acid (UDCA) at 10 to 15 mg/kg maternal body weight. UDCA relieves pruritus, improves liver tests, and is safe and well tolerated by the mother and fetus. Maternal outcomes in IHCP are favorable; however, elevated bile acid levels are associated with unfavorable fetal outcomes such as preterm labor, prematurity, and perinatal death. Fetal distress correlates with rising bile acid concentrations and is more prevalent when bile acid levels exceed 40 µmol/L. Levels greater than 100 µmol/L are associated with stillbirth. Given the increased risk of fetal distress and negative outcomes, early delivery at 37 weeks is recommended, as intrauterine death is more common the last few weeks of pregnancy.
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