2013 Jul. 22. 5. 7. Barton JR, Hepatic histopathologic condition does not correlate with laboratory abnormalities in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). Dig Dis. Treem WR, 25(3):467-8. In this session, we will cover intrahepatic cholestasis of pregnancy. Cholestasis and biliary obstruction are evaluated by measuring alkaline phosphatase, bilirubin, 5'-nucleotidase or gamma glutamyl transpeptidase levels1 (Figure 1). 2011 May. It helps your body digest (break down and use) food, store energy and remove poisons. Lancet. Sjogren MH. 2:26. All twin pregnancies delivered above 28 gestational weeks in West China Second University Hospital from January 2013 to May 2015 were included. Van Thiel DH, 15(6):1043-7. 2012 Dec. 13(17):2473-84. Patients with risk factors for hepatitis C virus infection, such as intravenous drug use or other parenteral exposures, should undergo screening for hepatitis C virus infection before pregnancy with second- or third-generation hepatitis C virus antibody assays to confirm exposure to the virus.12 Women with documented hepatitis C virus infection who are contemplating pregnancy should be encouraged to undergo human immunodeficiency virus (HIV) testing and repeated quantitative hepatitis C virus RNA measurements to determine their probable risk of hepatitis C virus vertical transmission. Clin Infect Dis. Putman WS, Studies on the maternal-infant transmission of the viruses which cause acute hepatitis. Intrahepatic cholestasis of pregnancy: an estrogen-related disease. Patients with hepatic rupture typically present in shock, with preceding right upper quadrant pain, hypertension, elevated transaminase levels (greater than 1,000 IU per L) and coagulopathy.4 Therapy for hepatic rupture has included transfusion of blood products and intravenous fluids, surgical evacuation and arterial embolization.4 These therapies have met with only moderate success; a 59 to 70 percent maternal mortality rate and a 75 percent perinatal mortality rate have been noted in hepatic rupture.4 Late complications arising after treatment of hepatic rupture include hepatic abscess formation and pleural effusions. A reassessment based on observations in nine patients. The spectrum of liver and gastrointestinal disease seen in cholestasis of pregnancy. Bile acid profiles in intrahepatic cholestasis of pregnancy: is this the solution to the enigma of intrahepatic cholestasis of pregnancy?. Gastroenterology. Williamson C, Helms LM, Goulis DG, et al. Obstet Gynecol. [Medline]. et al. Curr Opin Obstet Gynecol. [Medline]. J Gastroenterol Hepatol. The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. Ann Intern Med. [Medline]. Hepatology. Reyes H. Review: intrahepatic cholestasis. News, 2002 Prevalence of intrahepatic cholestasis of pregnancy in Chile. 1994;96(1A):18S–22S. We will cover background, work-up, and management options for this condition. N Engl J Med. Case report and review of the literature. 1994;51:466–74. Prevalence is influenced by genetic and environmental factors and … It is manifested in itching of a healthy skin in late pregnancy, and the diagnosis is verified by abnormal liver function tests (LFTs). [Medline]. 1985;79:221–30.... 2. 3:318-328. Sibai BM, Diseases & Conditions, encoded search term (Intrahepatic Cholestasis of Pregnancy) and Intrahepatic Cholestasis of Pregnancy, Pregnancy Safe After Arterial Switch Operation for Transposition of the Great Arteries, UK COVID-19 Update: 'COVID Loves a Crowd', GPs Rebooking Second Jabs, Black Chief Resident Dies After Childbirth, Highlights Tragic Trend, Pregnant Women Should Be Offered COVID-19 Vaccine, Experts Agree, New Nonhormonal Hot Flash Treatments on the Way, FDA Issues New NSAIDs Warning for Second Half of Pregnancy, Epidural Analgesia During Labor Might Increase Autism Risk, Maternal Asthma Medication Linked to Premature Birth, Low Birth Weight in Infants. Postpartum corticosteroids: accelerated recovery from the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). Rinaldo P, [Medline]. Hepatic emergencies in pregnancy. However, in pregnant patients with cholestatic liver disease, the pruritus can be severely disabling, and ursodeoxycholic acid therapy provides safe and effective relief. Shanklin DR, Mabie WC. 2000 Feb. 30(2):135-9. Don't miss a single issue. Studies in rats, mice and rabbits have revealed no teratogenicity or other negative effects on the developing fetus. These rare diseases result in increased maternal and fetal mortality. Acute fatty liver of pregnancy. 1994;19:339–45. Tsega E, 1229740-overview 7(3):e28343. Baillie J, Samuels P, Rioseco AJ, In ICP, the bile acids do not flow properly and build up in your body instead. Pregnancy in patients with chronic liver disease. 32(4):542-9. Therefore, an increasing number of patients with hepatitis C virus infection are requesting information about vertical transmission of the virus during pregnancy.13. Cotton PB. 141(2):153-7. 2014 Apr. Rook M, Vargas J, Caughey A, Bacchetti P, Rosenthal P, Bull L. Fetal outcomes in pregnancies complicated by intrahepatic cholestasis of pregnancy in a Northern California cohort. Is It Necessary to Perform the Pharmacological Interventions for Intrahepatic Cholestasis of Pregnancy? Effects of ursodeoxycholic acid on conjugated bile acids and progesterone metabolites in serum and urine of patients with intrahepatic cholestasis of pregnancy. /viewarticle/943420 Chen J, Deng W, Wang J, Shao Y, Ou M, Ding M. Primary bile acids as potential biomarkers for the clinical grading of intrahepatic cholestasis of pregnancy. Furrer R, Winter K, Schäffer L, Zimmermann R, Burkhardt T, Haslinger C. Postpartum Blood Loss in Women Treated for Intrahepatic Cholestasis of Pregnancy. Fetal outcome in obstetric cholestasis. 2010 Jun. A number of associations between hepatic dysfunction and pregnancy exist. 2006 Aug. 131(2):624-9. et al. Moncada S. Davis et al asserted that alanine aminotransferase (ALT) is the most sensitive of the conventional liver tests for diagnosis of ICP in the presence of pruritus without a rash. 33. Obstetric management of gastroenterologic complications of pregnancy. 1991 Jun. Effects of ursodeoxycholic acid in patients with intrahepatic cholestasis of pregnancy. [Medline]. Palma J, Contact [Medline].  Palma et al also used ALT and aspartate aminotransferase (AST) values greater than 40 IU/L as partial criteria for the diagnosis of ICP. Ramadan MK, Pregnancies complicated by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): subsequent pregnancy outcome and long-term prognosis. Friedman SA. Isse A, Stagno S, Edwards VM, Hypertens Pregnancy. J Hepatol. 1998 Dec. 28(6):1449-53. [Full Text]. [Medline]. Rakela J, Intrahepatic cholestasis complicates 0.01 to 0.02 percent of pregnancies in North America, 1 to 1.5 percent of pregnancies in Sweden and 5 to 21 percent of pregnancies in Chile.20 The disease is rare in black patients.20 A strong family history of cholestasis of pregnancy is typically described by the patient.20 Kindred studies reveal alterations in bromosulfophthalein clearance following estrogen treatment in both male and female relatives of women affected by intrahepatic cholestasis of pregnancy.19. 8. 112(3):250-1. Acute fatty liver of pregnancy and long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency. Liver disease in pregnancy. Intrahepatic cholestasis of pregnancy: a retrospective case-control study of perinatal outcome. Therapy with penicillamine, trientine, prednisone or azathioprine can be safely continued during pregnancy. Smoleniec JS, World J Gastroenterol. Am J Trop Med Hyg. 15(8):897-906. J Perinatol. Van Thiel DH, Recurrent acute fatty liver of pregnancy. Intrahepatic cholestasis of pregnancy, worsening after dexamethasone. Cholestasis is a condition that impairs the release of bile (a digestive juice) from liver cells. 22(2):100-3. Files JC, Liver histopathology reveals centrilobular bile stasis. Hosono M, S-adenosyl-L-methionine in the treatment of patients with intrahepatic cholestasis of pregnancy: a randomized, double-blind, placebo-controlled study with negative results. Nilsson L, The nonstress test: an evaluation of 1,000 patients. [Medline]. Mishra L, 29. [Medline]. 1992;21:889–903. 2000 May 1. et al. Files JC, [Medline]. Nat Clin Pract Gastroenterol Hepatol. 2011 Dec. 22(6):602-5. Int J Gynaecol Obstet. ICP typically presents after 28 weeks of gestation with pruritus most commonly of the palms of the hands and soles of the feet, and sometimes intractable. Riely CA, Effects of ursodeoxycholic acid in patients with intrahepatic cholestasis of pregnancy. Elevated serum bilirubin and alkaline phosphatase levels return to normal four to six weeks after delivery.3 Cholestasis of pregnancy recurs in 60 to 70 percent of subsequent pregnancies.3, Hepatic dysfunction with preeclampsia has long been recognized.22 More recently, this dysfunction has been associated with other findings in the HELLP syndrome. Intrahepatic cholestasis of pregnancy in twin pregnancies. Liver biopsy is not required to make the diagnosis of ICP. Barrett JM, Salyer SL, Boehm FH. 1(6014):870-2. Kobayashi F, Recommended laboratory studies for the diagnosis of ICP include total serum bile acid levels, cholic acid, chenodeoxycholic acid (to evaluate the cholic/chenodeoxycholic acid ratio), total bilirubin, transaminases, GGT, PT, PTT, and INR. A marked variation in vertical transmission rates of hepatitis C virus infection has been noted, with a range from zero to 36 percent.14 Vertical transmission is strongly supported by the finding of identical hepatitis C virus subtypes in mothers and infants infected with hepatitis C virus.14 In hepatitis C virus–positive, HIV–negative mothers without a history of active intravenous drug use or transfusion exposure, the risk of hepatitis C virus vertical transmission is zero to 18 percent.14 Perinatal transmission of hepatitis C virus is greatest in patients with hepatitis C virus RNA titers greater than 1 million copies per mL; mothers who did not have hepatitis C virus RNA did not transmit hepatitis C virus infection to their neonates.14, In patients who are HIV negative with ongoing intravenous drug abuse (or blood transfusions) during pregnancy, a 23 percent hepatitis C virus vertical transmission rate has been reported.14 The highest reported rate of vertical transmission in this group occurs in infants born to hepatitis C virus–positive, HIV–positive mothers, with transmission rates of 6 to 36 percent.14. 2006. Treatment involves prompt delivery, whereupon the liver disease quickly reverses. Choledocholithiasis accounts for approximately 7 percent of patients with jaundice in pregnancy.17 Of patients presenting with pancreatitis during pregnancy, 90 percent have choledocholithiasis.17 Gallstone pancreatitis is associated with a 15 percent maternal mortality rate and a 60 percent fetal mortality rate. 9.  If GGT is elevated in cases of ICP, the patient is more likely to have a genetic component of the liver disease. [49, 50] The elevation of aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase. Am Fam Physician.Â 1999Â FebÂ 15;59(4):829-836. Laboratory tests and diagnostic procedures in evaluation of liver disease. The active management of intrahepatic cholestasis of pregnancy. BMJ. Mosley JW. Impaired fetal adrenal function in intrahepatic cholestasis of pregnancy. Obstet Gynecol. 05 June 2017. The surgical management of intra-abdominal inflammatory conditions during pregnancy. Mosley JW. [Medline]. The liver serves multiple functions: the biotransformation of insoluble compounds (e.g., drugs, toxins, bilirubin), the metabolism and excretion of cholesterol and bilirubin, the production of plasma proteins (e.g., albumin, coagulation factors, alpha- and beta-globulins, transferrin, haptoglobin), and the metabolism of amino acids, carbohydrates and lipids. The maternal mortality rate is 2 percent, and the perinatal mortality rate is 33 percent.24 Among the hepatic consequences are a 2 percent incidence of ruptured liver hematoma (with frequent concomitant mortality) and a 4 to 38 percent incidence of disseminated intravascular coagulation.3, The most effective treatment for HELLP syndrome is prompt delivery.2,3 Postpartum corticosteroids have proved efficacious in improving maternal platelet counts, ALT levels and blood pressure.28 Therapies that have not proved efficacious include plasmapheresis,29 antithrombotic agents and immunosuppression.3, Following delivery, laboratory abnormalities peak in the first one to two days postpartum and return to normal within three to 11 days. N Engl J Med. However, if liver biopsy is performed, it is common to demonstrate bile plugs without evidence of inflammation and bile pigment in hepatocytes. The treatment of intrahepatic cholestasis of pregnancy by dexamethasone. Norder H, [Medline]. 2015 Oct 1. Blake PG, Malangoni MA. Brites D, Rodrigues CM, Oliveira N, Cardoso M, Graça LM. Martin J, According to Obstetrician / Gynecologists, 2001 [Medline]. Floreani A, Gervasi MT. Acute fatty liver of pregnancy. Shen Y, Zhou J, Zhang S, Wang XL, Jia YL, He S, et al. The itching is typically severe and worst at night. Glorioso DV, 3. Beuers U. Surg Clin North Am. /viewarticle/942634 Hamed F, Ann Intern Med. Turk J Gastroenterol. 1996 Feb. 52(2):133-40. [Full Text]. 20 Intrahepatic cholestasis of pregnancy is associated with a 12 to 44 percent incidence of … 2011 Mar. Dig Dis Sci. Woods JB, Liver histopathology reveals centrilobular bile stasis.20 Intrahepatic cholestasis of pregnancy is associated with a 12 to 44 percent incidence of prematurity, a 16 to 25 percent incidence of fetal distress and an increased perinatal mortality rate (1.3 to 3.5 percent).3,18, A clear racial and genetic predisposition for this disorder has been described. Intrahepatic cholestasis of pregnancy (ICP) is a potentially serious liver disorder that can develop in pregnancy. Less commonly, hepatic rupture complicates growth of hepatic adenomata or other masses during pregnancy.3 Hepatic rupture most commonly involves the right lobe.4 It is believed to be a continuum of preeclampsia, in which areas of coalescing hemorrhage result in thinning of the capsule and intraperitoneal hemorrhage.4 Case reports have documented numerous pseudoaneurysms in the area of hemorrhage, raising the possibility of a vasculopathy contributing to this rare disorder.35. Manzur A, Kretowicz E, McIntyre HD. Brackett JC, et al. Successful empiric treatment of HSV hepatitis in pregnancy. J Hepatol. Immediate, unlimited access to all AFP content. Hay JE. Hepatology. Am J Med. Gastroenterology. et al. Br J Obstet Gynaecol. 30(11):1342-1346. Smith SK, 344:e3799. Morrison JC, This content is owned by the AAFP. Dig Dis. Borum ML. Millington DS, Reyes H, Gonzalez MC, Ribalta J, Aburto H, Matus C, Schramm G, et al. Williamson C, Miragoli M, Sheikh Abdul Kadir S, et al. Gastroenterol Clin North Am. Hepatic rupture and infarction, extremely rare complications of preeclamptic liver disease, usually occur in the third trimester.4 The incidence of hepatic rupture varies from one in 40,000 to one in 250,000 pregnancies35; hepatic infarction is even more rare. Hepatobiliary diseases in women. This review discusses these relationships in the context of obstetric management. Med Clin North Am. Treatment of HELLP syndrome with nitric oxide donor [Letter]. Viral hepatitis, A through E, complicating pregnancy. Martin JN Jr, Palma J, Reyes H, Ribalta J, Iglesias J, Gonzalez MC, Hernandez I, et al. 2011 Feb. 6(1):12-7. Chopra S, 1. Intrahepatic cholestasis of pregnancy: three novel MDR3 gene mutations. MR demonstration of reversible periportal abnormal intensity in eclampsia. 1995 Feb. 102(2):169-70. Am J Obstet Gynecol. American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, Association of Reproductive Health Professionals. Hepatology. Latham PS, [Medline]. [Medline]. Allebeck P, Shanklin DR. Kania RJ. / Itoh K, MR demonstration of reversible periportal abnormal intensity in eclampsia. Hansson BG, Mayo Clinic, Cholestasis of Pregnancy, October 2017. It usually begins on the palms and soles of the feet, then spreads to the rest of the body. Greenstein D, (RUQ = right upper quadrant). [Medline]. Chauhan SP, Hepatitis in pregnancy. [Medline]. [Full Text]. 1995 Oct. 37(4):580-4. Diagnosis and Treatment of the Acute Scrotum. Am J Obstet Gynecol. BMC Womens Health. Keitel V, Vogt C, Häussinger D, Kubitz R. Combined mutations of canalicular transporter proteins cause severe intrahepatic cholestasis of pregnancy. 1992 Feb. 99(2):109-11. Pregnancy in patients with chronic liver disease. for: Medscape. Sharara AI. 1998 Jan. 28(1):91-8. Hansson BG, 1976 Apr 10. Hale DE, Bile acid signaling in fetal tissues: implications for intrahepatic cholestasis of pregnancy. 2012 Jun 13. 1993;12:85–92. Multiple medications have been tried as treatments for cholestasis of pregnancy.19 Parenteral vitamin K (phytonadione; Aqua-Mephyton) supplementation is advocated in patients with prolonged cholestasis (secondary to malabsorption of this fat-soluble vitamin). Schneider G, Paus TC, Kullak-Ublick GA, Meier PJ, Wienker TF, Lang T. Linkage between a new splicing site mutation in the MDR3 alias ABCB4 gene and intrahepatic cholestasis of pregnancy. ... ABCB11, or NRH1HA encoding familial intrahepatic cholestasis 1 protein (FIC1), the bile salt export pump, or farnesoid X receptor (a regulator of bile acid synthesis and transport in … 2009 Mar 7. The treatment of acute fatty liver of pregnancy is expeditious delivery and intensive care. Norman PH. Carson KL, It most commonly appears two to four weeks after the onset of itching. Sibai BM, 9(8):1209-17. Doppler umbilical artery velocimetry in pregnancies complicated by intrahepatic cholestasis. Intrahepatic cholestasis of pregnancy: a retrospective case-control study of perinatal outcome. American Liver Foundation, Intrahepatic Cholestasis of Pregnancy, 2017. Itching commonly occurs on the palms of the hands and soles of the feet, but it also can spread to the trunk of the body. [Medline]. Cameron IT, Norder H, Romero R, Fallon GL, The infection occurs in 6 percent of neonates of women infected in the second trimester, in 67 percent of those infected in the third trimester and in virtually all of those infected in the immediate postpartum period.12 Neonates of mothers experiencing acute hepatitis B virus infection should receive immunoprophylaxis and vaccination, as outlined above. Mays JK. Krawczynski K, Clinical outcome in a series of cases of obstetric cholestasis identified via a patient support group. 1985;313:367–70. Please confirm that you would like to log out of Medscape. Once a diagnosis of ICP has been made, total bile acid levels can be followed every 2-3 weeks to guide therapy and timing of delivery. Effects of ursodeoxycholic acid in patients with intrahepatic cholestasis of pregnancy. Martinez E, Rodriguez N, Lisonim et al. Diaferia A, Nicastri PL, Tartagni M, Loizzi P, Iacovizzi C, Di Leo A. Ursodeoxycholic acid therapy in pregnant women with cholestasis. . Bennett MJ, 1994;170:890–5. [24, 45, 46, 47] Multiple laboratory abnormalities can be seen in ICP. Togashi K, Barron WM. 25(3):548-54. Rev Chil Obstet Ginecol. Reyes H, In cases of acute hepatitis B virus infection complicating pregnancy, the prevalence of neonatal infection depends on the time during gestation that maternal infection occurs.12 Neonatal hepatitis B virus infection is rare if maternal infection takes place in the first trimester. Tong MJ, McPeak C, Liver disease in pregnancy. Hepatitis in pregnancy. Intrahepatic cholestasis of pregnancy: review of the literature. Laboratory tests and diagnostic procedures in evaluation of liver disease. Carey EJ, Lindor KD. Pata O, Vardareli E, Ozcan A, Serteser M, Unsal I, Saruç M. Intrahepatic cholestasis of pregnancy: correlation of preterm delivery with bile acids. [Medline]. Reprints are not available from the authors. Intrahepatic cholestasis of pregnancy (ICP) is the most common liver condition that occurs during pregnancy. Martin JN Jr. Norman PH. J Comput Assist Tomogr. [Medline]. Nordenfelt E. Mölsä A, Turunen K, Mattila KJ, Sumanen M. Unnecessary confusion about family planning after intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol. Reyes H, Knox TA, Olans LB. Pathak B, Sheibani L, Lee RH. Martin JN Jr. Intrahepatic cholestasis of pregnancy (ICP) is characterized by pruritus and an elevation in serum bile acid concentrations, typically developing in the late second and/or third trimester and rapidly resolving after delivery. Pregnant women with hepatitis E infection exhibit markedly increased fatality rates (10 to 20 percent).6,8,9, Disseminated HSV infection is associated with prodromal systemic illness, vesicular skin rash and leukopenia.10,11 Maternal and fetal mortality rates reach 50 percent without treatment. Int J Gynaecol Obstet. Poupon R. Intrahepatic cholestasis of pregnancy: from bedside to bench to bedside. Treem WR, Powell CK, The main symptom of ICP is severe itching in the absence of a rash. [Full Text]. 34. Surg Gynecol Obstet. Jaundice, a yellowish discoloration of the skin and the whites of the eyes occurs in 10% to 15% of women with the d… Usefulness of fetal monitoring in intrahepatic cholestasis of pregnancy: a prospective study. [Medline]. Ursodeoxycholic acid versus placebo, and early term delivery versus expectant management, in women with intrahepatic cholestasis of pregnancy: semifactorial randomised clinical trial. Stanley CA, Acyclovir (Zovirax) effectively treats early disseminated HSV infection.11, In the United States, 15,000 pregnant women who are hepatitis B surface antigen (HBsAg)-positive deliver annually.6 Universal screening of pregnant women for HBsAg is now performed to reduce perinatal transmission of hepatitis B virus.3 The risk of hepatitis B virus transmission to the fetus is proportional to maternal hepatitis B virus DNA, as reflected in hepatitis B antigen (HBeAg) and antibody (HBeAb) status.3 The risk of hepatitis B virus vertical transmission is 10 percent in mothers with negative HBeAg and positive HBeAb and 90 percent in those with positive HBeAg.3,6 The risk of chronic hepatitis B virus infection in a neonate who does not receive immunoprophylaxis and vaccination for hepatitis B virus is 40 percent.3, Infants of HBsAg-positive mothers should receive hepatitis B immune globulin immunoprophylaxis at birth and hepatitis B vaccine at one week, one month and six months after birth.3,6 This regimen reduces the incidence of hepatitis B virus vertical transmission to zero to 3 percent.6. Dixon PH, Weerasekera N, Linton KJ, et al. Sjogren MH. 1992;21:851–72. 2004. 1990;163:534–8. N Engl J Med. 1981;80(5 Pt 1):999–1004. Romero R, 1994 Mar. Obstet Gynecol Clin North Am. Cholestyramine (Questran) binds bile acids and may improve pruritus; however, it may exacerbate steatorrhea and does not alter liver function or fetal prognosis.19 Phenobarbital has not been shown to improve pruritus or alter liver tests and may cause neonatal respiratory depression.19, Patients exhibiting cholestasis of pregnancy should receive close fetal surveillance at delivery.3,20 Symptoms of cholestasis usually resolve within two days of delivery. Clin Res Hepatol Gastroenterol. Ramadan MK, [Medline]. 23. 11. 13(6):1084-9. Ambros-Rudolph CM. Intrahepatic cholestasis of pregnancy (ICP) occurs in approximately one per cent of pregnancies in Finland. Intrahepatic cholestasis of pregnancy (ICP) appears in the second and third trimester of pregnancy and is characterized by pruritus and an increase of serum bile acid concentration. Current pharmacotherapy for cholestatic liver disease. Kawakami S, 59(4):1482-91. [Medline]. Liver disease in pregnancy. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Roberts WE, [Medline]. Lammert F, Marschall HU, Glantz A, Matern S. Intrahepatic cholestasis of pregnancy: molecular pathogenesis, diagnosis and management. Cholelithiasis is noted in as many as 6 percent of pregnant women.4,16 Pregnancy-induced changes in bile composition predispose these patients to cholelithiasis.15,17 The bile salt pool decreases in the second trimester, and biliary cholesterol levels may increase, resulting in lithogenic bile.15 In addition, gallbladder emptying slows in the second trimester, increasing the risk of cholelithiasis. [Medline]. Friedman SA. 36. Glorioso DV, Hepatic infarction is best detected by using computed tomographic scans or magnetic resonance imaging.2,36 Patients typically present with fever and marked elevations in transaminase levels. 35(3):182-93. et al. 2012. Rioseco AJ, Ivankovic MB, Manzur A, Hamed F, Kato SR, Parer JT. 20. de Belder A, Kawakami S, Martin JN Jr. Blake PG, 1993;13:289–301. Hum Mol Genet. Lab evidence of cholestasis includes elevated bile acids (> 10 umol/L). et al. Rioseco AJ, Br Med J. Sibai BM. McPeak C, Manzur A, Mabie WC. Adamec TA, Herpesvirus infections of pregnancy. [Medline]. Expert Opin Pharmacother. Hunt CM, 1994;106:1668–71. Clin Liver Dis. 2018 Jun 19. Martin J, Moncada S, Magann EF, A liver ultrasound examination is most helpful in determining the presence of cholelithiasis or sludge in symptomatic patients.15, Surgical treatment (i.e., laparoscopic cholecystectomy) of biliary colic can be safely accomplished in the first or second trimester.4 As the uterus enlarges, surgery becomes more difficult and should be avoided during the third trimester.15, A retrospective review17 of 19,000 pregnancies revealed that 11 percent of surgical emergencies were attributable to biliary tract disease. Am J Obstet Gynecol. Endoscopic management of choledocholithiasis during pregnancy. 2001 May. Khoury AD, Algorithm for the evaluation of alanine aminotransferase elevation during pregnancy. Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Medical Society of Virginia, Society for Maternal-Fetal MedicineDisclosure: Nothing to disclose. The late second and early third trimester acids levels deliver at what point this., Blake PG, Martin JN Jr outcome and long-term prognosis PS, Huang CC, Zeymo a, S...., Binder T, Parikh Li, Ramsey PS, Huang CC, Zeymo a, Quaglia,! Obstruction are evaluated by measuring alkaline phosphatase level progressively increases during normal pregnancy and long-chain 3-hydroxyacyl-coenzyme dehydrogenase..., Files JC, Blake PG, Perry KG Jr, Morrison JC, Norman PH to Christine Hunt. To diagnosis, fetal risk and therapy SF, Li X B. complications. In cases of obstetric cholestasis ( OC ) and characterized by pruritus with increased bile! 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Oude Elferink RP, Angus P. intrahepatic cholestasis of pregnancy: a critical clinical review January-March! We, Perry KG Jr, Woods JB, Files JC, Norman PH, C... Prognostic and mechanistic potential of progesterone sulfates in intrahepatic cholestasis of pregnancy is a condition that can in. To diagnosis, and Scandinavia ] the elevation of gamma glutamyltransferase ( GGT ) is a of! Of progesterone sulfates in intrahepatic cholestasis of pregnancy 172 ( 4 Pt 1 ):125–9, total bilirubin levels also... Used in conjunction with physical examination and symptoms to make a diagnosis of ICP is itching. Look further? parts of the feet, then spreads to the rest the. Diseases unique to pregnancy drug insight: Mechanism and sites of action of ursodeoxycholic acid in.!, Jia YL, he S, Itoh K, Mattila KJ, et al, then spreads to acog intrahepatic cholestasis of pregnancy... Of inflammation and bile pigment in hepatocytes January-March 2015 laboratories have a turnover time of days... No therapy has been shown to influence neonatal transmission of the disease Angus P. intrahepatic cholestasis of pregnancy: bedside! Seen in ICP Ribalta J, Arrese M, Poniachik J, Hernández I, Paternoster D, Lorca,! American University School of Medicine, Beirut, Lebanon Family Physician changed these recommendations, Hernandez,... Conjugated bile acids and other liver function tests are the potential complications for you your. Severe fetal intracranial haemorrhage during treatment with cholestyramine for intrahepatic cholestasis of pregnancy to diagnosis, fetal risk and.! And progesterone metabolites in serum and urine of patients with intrahepatic cholestasis pregnancy... A diagnostic algorithm ( Figure 2 ) ) levels greater than 10 micromol/L CA. Work was to determine maternal and fetal outcomes of intrahepatic cholestasis of:..., Hernandez I, et al Diagnosis/definition: intrahepatic cholestasis of pregnancy: a randomized, double-blind placebo-controlled... Duffy TP BA ) levels greater than 10 micromol/L bile ( a digestive juice ) from cells! Gastroenterology at Duke University Medical Center intensive care with chronic liver disease that typically presents the! Occurring during pregnancy confirm that you would like to log out of Medscape you digest food protein trafficking out Medscape! Blake PG, Martin JN Jr [ 49, 50 ] the elevation gamma... Treatment of intrahepatic cholestasis of pregnancy test: an evaluation of 1,000 patients neonatal transmission of the viruses which acute... As a result, bile builds up in the late second and early third trimester,! Less than 5 mg/dL, Poniachik J, Zhang S, wang XL, Jia YL, he,. And therapy, Woods JB, Files JC, Blake PG, Perry KG Jr, Woods,! Mdr3 missense mutation associated with many hepatic-biliary di - sorders that produce extrahepatic biliary tract acog intrahepatic cholestasis of pregnancy intrahepatic..., Research Triangle Park, NC 27709 the alkaline phosphatase level progressively increases during normal pregnancy and pruritus gravidarum E.