Introduction: Intrahepatic cholestasis of pregnancy (ICP), also described as obstetric cholestasis is the second most common cause of icterus in pregnancy. Although not fully understood, proposed theories indicate it could be due to decreased bile flow through the liver and its poor excretion, leading to increased levels of colic and chenodeoxycholic acid. It is known to be associated with adverse maternal and fetal outcomes.
Materials and methods: The data were collected by retrospective record review for the past 2 years and the information collected included obstetrical outcomes and complications in mothers with ICP admitted in a tertiary care hospital.
Results: Among the 64 pregnant women admitted with ICP, 56.2% of women were booked pregnancies and 47 (73.4%) were in the age groups of 21–30 years. Most women presented with ICP at gestational ages of >37 weeks 51 (79.9%), with the onset of symptom around 33–36 weeks of gestation 21 (32.8%). Common complications encountered were severe preeclampsia and gestational diabetes mellitus 6 (9.3%). Among neonates, meconium-stained liquor (MSL) and low appearance pulse rate grimace activity respiration (APGAR) at 1 minute were common complications. Mothers with ICP were induced with PGE2 (dinoprostone) and 54.7% delivered vaginally. Pregnancies induced with PGE2 and PGE1 (misoprostol) had a higher chance of undergoing lower segment cesarean section (LSCS) 19 (29.6%).
Conclusion: Mothers with ICP should be screened antenatally for preeclampsia. The delivery team should be prepared to manage meconium aspiration in the newborn, although most patients deliver vaginally.
Key message: Newer modalities of treatment with better pregnancy outcomes in mothers with ICP.
Menżyk T, Bator M, Derra A, et al. The role of metabolic disorders in the pathogenesis of intrahepatic cholestasis of pregnancy. Clin Exp Hepatol 2018;4(4):217–223. DOI: 10.5114/ceh.2018.80122.
Glantz A, Marschall HU, Mattsson LÅ. Intrahepatic cholestasis of pregnancy: Relationships between bile acid levels and fetal complication rates. Hepatology 2004;40(2):467–474. DOI: 10.1002/hep.20336.
Ozkan S, Ceylan Y, Ozkan OV, et al. Review of a challenging clinical issue: Intrahepatic cholestasis of pregnancy. World J Gastroenterol 2015;21(23):7134–7141. DOI: 10.3748/wjg.v21.i23.7134.
Ataalla WM, Ziada DH, Gaber R, et al. The impact of total bile acid levels on fetal cardiac function in intrahepatic cholestasis of pregnancy using fetal echocardiography: a tissue Doppler imaging study. J Matern Fetal Neonatal Med 2016;29(9):1445–1450. DOI: 10.3109/14767058.2015.1051020.
Feng C, Li WJ, He RH, et al. Impacts of different methods of conception on the perinatal outcome of intrahepatic cholestasis of pregnancy in twin pregnancies. Sci Rep 2018;8(1):2–9. DOI: 10.1038/s41598-018-22387-6.
Dixon PH, Williamson C. The molecular genetics of intrahepatic cholestasis of pregnancy. Obstet Med 2008;1(2):65–71. DOI: 10.1258/om.2008.080010.
Piechota J, Jelski W. Intrahepatic cholestasis in pregnancy: review of the literature. J Clin Med 2020;9(5):1361. DOI: 10.3390/jcm9051361.
Lammert F, Marschall HU, Glantz A, et al. Intrahepatic cholestasis of pregnancy: molecular pathogenesis, diagnosis and management. J Hepatol 2000;33(6):1012–1021. DOI: 10.1016/S0168-8278(00) 80139-7.
Larson SP, Kovilam O, Agrawal DK. Immunological basis in the pathogenesis of Intrahepatic cholestasis of pregnancy. Expert Rev Clin Immunol 2016;12(1):39–48. DOI: 10.1586/1744666X.2016.1101344.
Ambros-Rudolph CM, Glatz M, Trauner M, et al. The importance of serum bile acid level analysis and treatment with ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a case series from central Europe. Arch Dermatol 2007;143(6):757–762. DOI: 10.1001/archderm.143.6.757.
Kawakita T, Parikh LI, Ramsey PS, et al. Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol 2015;213(4):570-e1. DOI: 10.1016/j.ajog.2015.06.021.
Baucom AM, Kuller JA, Dotters-Katz S. Immune thrombocytopenic purpura in pregnancy. Obstetric Gynecol Surv 2019;74(8):490–496.
Geenes V, Williamson C. Intrahepatic cholestasis of pregnancy. World J Gastroenterol 2009;15(17):2049–2066. DOI: 10.3748/wjg.15. 2049.
Geenes V, Williamson C, Lucy CC. Intrahepatic cholestasis of pregnancy. Obstetric Gynaecolog 2016;18(4):273–281. DOI: 10.1111/tog.12308.
Estiú MC, Frailuna MA, Otero C, et al. Relationship between early onset severe intrahepatic cholestasis of pregnancy and higher risk of meconium-stained fluid. PLoS ONE 2017;12(4):1–15. DOI: 10.1371/journal.pone.0176504.
Stulic M, Culafic D, Boricic I, et al. Intrahepatic cholestasis of pregnancy: a case study of the rare onset in the first trimester. Med 2019;55(8):1–8.
Pusl T, Beuers U. Intrahepatic cholestasis of pregnancy. Orphanet J Rare Dis 2007;2(1):1–6. DOI: 10.1186/1750-1172-2-26.
Ovadia C, Seed PT, Sklavounos A, et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet 2019;393(10174):899–909. DOI: 10.1016/S0140-6736(18)31877-4.
Jebbink J, Tabbers M, Afink G, et al. HELLP syndrome preceded by intrahepatic cholestasis of pregnancy: one serious itch. BMJ Case Rep 2014(apr07 1):2–6. DOI: 10.1136/bcr-2013-203208.
Yang J, Chen C, Liu M, et al. Women successfully treated for severe intrahepatic cholestasis of pregnancy do not have increased risks for adverse perinatal outcomes. Medicine (Baltimore) 2019;98(27):e16214. DOI: 10.1097/MD.0000000000016214.
Chappell LC, Chambers J, Dixon PH, et al. Ursodeoxycholic acid versus placebo in the treatment of women with intrahepatic cholestasis of pregnancy (ICP) to improve perinatal outcomes: protocol for a randomised controlled trial (PITCHES). Trials 2018;19(1):1–10. DOI: 10.1186/s13063-018-3018-4.
Chappell LC, Bell JL, Smith A, et al. Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial. Lancet 2019;394(10201):849–860. DOI: 10.1016/S0140-6736(19)31270-X.
Arthuis C, Diguisto C, Lorphelin H, et al. Perinatal outcomes of intrahepatic cholestasis during pregnancy: an 8-year case-control study. PLoS ONE 2020;15(2):1–9. DOI: 10.1371/journal.pone.0228213.
Mohan M, Antonios A, Konje J, et al. Stillbirth and associated perinatal outcomes in obstetric cholestasis: a systematic review and meta-analysis of observational studies. Eur J Obstet Gynecol Reprod Biol X [Internet] 2019;3:100026. Available from: https://doi.org/10.1016/j.eurox.2019.100026.
Kong X, Kong Y, Zhang F, et al. Evaluating the effectiveness and safety of ursodeoxycholic acid in treatment of intrahepatic cholestasis of pregnancy: a meta-analysis (a prisma-compliant study). Med (United States) 2016;95(40):e4949. DOI: 10.1097/MD.0000000000004949.
Geenes V, Chappell LC, Seed PT, et al. Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: a prospective population-based case-control study. Hepatology 2014;59(4):1482–1491. DOI: 10.1002/hep.26617.
Li L, Chen YH, Yang YY, et al. Effect of intrahepatic cholestasis of pregnancy on neonatal birth weight: a meta-analysis. JCRPE J Clin Res Pediatr Endocrinol 2018;10(1):38–43. DOI: 10.4274/jcrpe.4930.
Gurung V, Stokes M, Middleton P, et al. Interventions for treating cholestasis in pregnancy. Cochrane Database Syst Rev 2013;2013(6):CD000493. DOI: 10.1002/14651858.CD000493.pub2.
Ali MK, Abdelbadee AY, Shazly SA, et al. Intrahepatic cholestasis of pregnancy. J Eviden Based Women's Health J Soc 2013;3(1):1–4. DOI: 10.1097/01.EBX.0000422793.57061.6b.
Malhotra J, Agrawal P, Garg R, et al. Pruritus in pregnancy. J SAFOG 2013;5(3):142–146. DOI: 10.5005/jp-journals-10006-1248.