Cholestasis of Pregnancy, Intrahepatic
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- Intrahepatic cholestasis of pregnancy (ICP) is characterized by generalized pruritus without skin lesions in pregnancy, accompanied by elevated serum bile acid levels +/− elevated serum transaminase levels (1,2).
- It occurs classically in the 3rd trimester but may begin in the 2nd trimester.
- It is a self-limited condition that resolves shortly after delivery.
- ICP is associated with adverse fetal outcomes, including premature delivery, meconium-stained amniotic fluid, respiratory distress, and fetal death (1,2).
- Varies between 0.2% and 25% worldwide (1)
- ICP is most common in China, Latin American, and Scandinavian countries.
Reports vary according to geography and ethnicity.
Etiology and Pathophysiology
- Genetic, endocrine, and environmental factors influence the risk of developing ICP (2).
- Its onset coincides with rising progesterone levels (2).
- Maternal pruritus may be related to a TGR5-mediated signaling pathway in sensory nerves, induced by bile acid (3).
- Sulfated progesterones and lysophosphatidic acid also play a role in pruritus (2,3).
- Some fetal complications may be due to bile salt accumulation in fetal tissues, leading to fetal arrhythmias and liver damage (4).
- Bile acids may vasoconstrict the chorionic veins, leading to decreased perfusion to the fetus (4).
- Bile acids may also increase oxytocin activity, leading to preterm delivery (4).
Commonly Associated Conditions
- Oral contraceptive-induced pruritus (3)
- Incidence of concomitant hepatitis C infection is higher in women with ICP (1).
- Pregnancy complications: postpartum hemorrhage (4), preeclampsia (2), gestational diabetes (2), and 19–60% increased risk preterm delivery (5)
- Neonatal complications: 17.9% risk of meconium passage, 29% risk of respiratory distress syndrome (5)
- The most severe complication is fetal death.
- Fetal mortality has been reported as high as 20% but averages 0.75–7% (5).