Cholestasis of pregnancy

Background

• Caused by combination of hormonal, genetic, and environmental factors --> impaired bile flow --> deposition of bile salts in skin and placenta
• May predispose mothers to vitamin K deficiency and increase risk of preterm delivery, IUFD, and neonatal respiratory distress syndrome

Clinical Features

• Typically develops in late second and/or 3rd trimester
• Rapidly resolves after delivery
• Pruritus, starts and predominates on palms and soles
• RUQ pain
• Nausea
• Jaundice

Differential Diagnosis

• Liver disease in pregnancy:
  • Acute fatty liver of pregnancy
  • HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome
  • Hyperemesis gravidarum
• Pregnancy-specific pruritus (see also: Rashes of pregnancy)
  • Pruritus gravidarum
  • Atopic eruption of pregnancy
  • Polymorphic eruption of pregnancy
  • Pemphigoid gestationis
  • Prurigo of pregnancy
  • Pruritic folliculitis of pregnancy

Evaluation

• CBC (rule out thrombocytopenia)
• LFTs
  • Elevated total bile acid concentration
  • Aminotransferases usually <2x upper limit of normal
  • Alk phos and bili may be elevated
  • GGT normal or modestly elevated
  • RUQ US normal, no biliary duct dilation

Management

• Ursodeoxycholic acid (ursodiol) 300mg TID until delivery
• OBGYN follow-up

Disposition

• Discharge with OBGYN follow-up

References

https://www.uptodate.com/contents/intrahepatic-cholestasis-of-pregnancy