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INTRODUCTION AND BACKGROUND

KEY QUESTIONS

  • What is intrahepatic cholestasis of pregnancy (ICP)?

  • What are the risks associated with ICP?

  • What does the management of ICP entail?

  • How is the timing of delivery determined for patients with ICP?

CASE 32-1

A 31 y.o. G1P0 who is at 32 weeks gestation complains of diffuse itching. When further questioned, she complains mostly of itching of the palms and the soles of her feet. She denies having a rash. She is otherwise healthy and has had an uncomplicated pregnancy thus far. Total bile acids were drawn and found to be elevated, at 30 umol/L. Liver transaminases were also noted to be mildly elevated.

Intrahepatic cholestasis of pregnancy (ICP) is a reversible liver disease that occurs in the second and third trimesters of pregnancy.1 The presenting symptom is pruritus (severe itching), primarily of the palms of hands and the soles of feet associated with elevated bile acids (≥10 umol/L).1 In addition, 60% of women with ICP have elevated transaminases, and 25% have increased bilirubin, both of which normalize quickly after delivery.2 As reports range widely, the incidence of ICP is variable, ranging from 0.1 to 6% worldwide.35 In North America and Western Europe, the incidence is 0.1% to 1.5%.1 Patients with ICP are monitored closely, as it is associated with increased risk of preterm delivery (19%–60%),4,6,7 intrapartum fetal distress (22%–41%), meconium-stained fluid at time of delivery,1 respiratory distress syndrome (RDS),8 and intrauterine fetal demise (IUFD) (0.75%–1.6%).1,6,9,10 However, standard antepartum testing (nonstress tests, biophysical profiles) are not predictive of ICP-related morbidity and mortality.11,12

Although ICP is still thought of as a disease process specific to pregnancy, with resolution occurring shortly after delivery, it has recently been found that mothers with ICP may have increased risk of gallstone formation, nonalcoholic liver cirrhosis, nonalcoholic pancreatitis, and hepatitis C, suggesting that these patients may need more follow-up than initially assumed.13 Certainly, patients with persistent symptoms, laboratory abnormalities, or both after delivery should undergo further workup for underlying causes. Patients should also be counseled that there is a risk of recurrence (as high as 60%) of developing ICP in future pregnancies, which may be suggestive of a genetic component to the condition in some women.9,14

PRACTICE POINTS

  • ICP is a condition of pregnancy characterized by pruritus of the palms and soles and diagnosed by the finding of elevated bile acids.

  • ICP is associated with increased risk of pregnancy complications, most notably preterm birth and IUFD.

  • ICP generally resolves after delivery, but it also may signify underlying liver disease.

  • ICP has a high recurrence risk in subsequent pregnancies and may suggest a genetic component such as HPV.

EPIDEMIOLOGY

Multiple small studies have shown geographic variation in the ...

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