Intrahepatic Cholestasis of Pregnancy Dr. Tkiak 2011.06.11 Part I
Intrahepatic Cholestasis of Pregnancy “ Delivery is the only solution to reduce Clinical symptoms and reduce abnormal Biochemical Results to normal to a nullipara”
What is ICP? <ul><li>Intrahepatic Cholestasis of Pregnancy (ICP) is a pregnancy Liver -related liver disorder and also known as Obstetrics Cholestasis (OCP). It is common towards 3rd trimester of pregnancy and associated with ascending extreme peripheries puritus (skin itchy) and elevated biochemical liver enzymes. </li></ul><ul><li>Benign to the mother but posed high fetal complications and perinantal mortality. </li></ul>
Pathogenesis: “UNKNOWN”?? <ul><li>Though the cause is still not clearly understood , however there are possibilities that it is due to the combination of the following factors: </li></ul><ul><ul><li>Genetics </li></ul></ul><ul><ul><li>Changes in Environment </li></ul></ul><ul><ul><li>Sex Hormones (Progesterone & Estrogen) </li></ul></ul><ul><ul><li>Immunological Immune balance </li></ul></ul>
Epidemiology <ul><li>ICP varies geographically world wide but high incidence has been reported in the following countries: </li></ul><ul><ul><li>Araucanian Indian descent in Chile and Boliva - 6%-27.6% </li></ul></ul><ul><ul><li>Sweden 1%-1.5% </li></ul></ul><ul><ul><li>Women of Indian-Asian/Pakistain-Asian Orign - 1-2-1.5% </li></ul></ul><ul><ul><li>Lower elsewhere in Europe -0.1%-1.5% & USA -0.7%. </li></ul></ul>
Signs and Symptoms <ul><li>ICP has been linked to adverse maternal and fetal outcomes </li></ul><ul><li>Main symptoms: </li></ul><ul><ul><li>Puritus - without evidence of skin lesions (Itching, particularly on the hands and feet (often is the only symptom noticed ) </li></ul></ul><ul><ul><li>Dark urine color,steatorrhoea,Fatigue or exhaustion,Loss of appetite,Depression </li></ul></ul><ul><li>Less common symptoms include: </li></ul><ul><ul><li>Jaundice (yellow coloring of skin, eyes, and mucous membranes), Upper-Right Quadrant Pain, Nausea </li></ul></ul>
Fetal Complications Note: Maternal consequences include severe puritus with increasing gestational weeks and rarely Post-Partum Hemorrhage (PPH). <0.1 Intra-crainal Hemorrhage (rare) Meconium Staining 1-2 Still Birth (IUFD) 22-33 Fetal Distress 19 -60 Premature Delivery Risks (%) Fetal complications
Still Birth (IUFD) Premature Delivery Meconium Staining
How is Cholestasis of pregnancy diagnosed? <ul><li>A diagnosis of cholestasis can be made by: </li></ul><ul><ul><li>doing a complete medical history, </li></ul></ul><ul><ul><li>physical examination, </li></ul></ul><ul><ul><li>blood tests that evaluate liver function, bile acids, and bilirubin. </li></ul></ul><ul><li>Note: The Hallmark of ICP is the high level of BILE ACIDS </li></ul>
Less Useful Mild-mod increase >10 fold in Ser.ICP Most sensitive Indicator 2-10xNR 2-10xNR comments 30-117u/L ALP 0.2-5.2mg/dL 0-1mg/dL Bilirubin 17mmol/L <3.1mmol/L Cholic Acids > 40mmo/L 6.6-11.00mmo/L Total Bile Acids 119+/-51u/L 0-40u/L AST 131+/-96u/L 0-37u/L ALT Ave Values in ICP Normal Range (NR) Tests Lab Diagnosis: Biochemical Tests for ICP
The treatment goals for cholestasis of pregnancy are to relieve itching. Some treatment options include <ul><li>Topical anti-itch medications or medication with corticosteroids </li></ul><ul><li>Medication to decrease the concentration of bile acids such as ursodeoxycholic acid </li></ul><ul><li>Cold baths and ice water slow down the flow of blood in the body by decreasing it’s temperature </li></ul><ul><li>Dexamethansone is a steroid that increases the maturity of the baby’s lungs </li></ul><ul><li>Vitamin K supplements administered to the mother before delivery and again once the baby is born to prevent intracranial hemorrhaging </li></ul><ul><li>Dandelion Root and Milk Thistle are natural substances that are beneficial to the liver </li></ul><ul><li>Bi-weekly non-stress tests which involve fetal heart monitoring and contraction recordings </li></ul><ul><li>Regular blood tests monitoring both bile serum levels and liver function </li></ul>
Puritus after 20 wks gestation of pregnancy in absence of othe medical or dermatological condition SBA level <10mmol/L SBA level >11mmol/L <ul><li>R/O possible ICP </li></ul><ul><li>Comfort measures </li></ul><ul><li>Reassses @ each visit </li></ul><ul><li>Encourage Fetal Kick Counts </li></ul>Mild ICP-SBA level 11-39 Expectant Management Severe ICP->40mmol/L Active management <ul><li>Weekly SBA level </li></ul><ul><li>Biweekly BPP/NST </li></ul><ul><li>UDCA </li></ul><ul><li>Fetal Kick Count </li></ul>37 <weeks Gestation 37 >weeks Gestation Rising SBA >40mmol/l Increase in Symptoms 40 weeks gestation <34 weeks gestation Administer Beta or Dexamethasone per protocol Admission to hospital Cont . Monitoring Cont.UCDA Additional Comfort measures Non -Reasuring fetal status Considered Induction of Labor Draw SBA levels LFTs Baseline Fetal Monitoring (NST/BPP ) ICP management Protocol : BPP-Biophysical Profile;LFTs= Liver Function Test;NST=Non-Stress Test;SBA=Serum Bile Acids;UCDA=Ursodeoxycholic Acid
Women treated with chlestyramine should be given supplemental fat soluble vitamines & Vit K (10mg/day) Glucocorticord anti-inflammatory effect 12 mg/day comes in 2,4,6 mg tabs Dexamthasone (Decadrone) Natural water soluble Bas that injure cell membranes ; reduce relase of puritic agents 900 mg-2mg/day Comes in 300mg tabs Ursodeoxyxholic Acid (Actigall) Bile acid sequestran that binds Bile Acids in the gut to facililiate excretion 4mg BID Cholestyramine (Questran) Antihistamine 25-50mg/day comes in 25mg 0r 50 mg Hydroxyzine (Vistaril) Antihistamine 4mg tid;comes in 4mg or 8mg tabletes Chlorpheniramine (Chlor-Trimeton) Mechanism of Action Dose Medication Pharmacologic Treatment of ICP
NOTE <ul><li>For all the Pharmacological Drugs mentioned for the treatment of ICP, numerous Randomized Clinical Trial (RCT) has proven Ursodeoxycholic is the most effective drug with no clinical evidence of side Effects. URDC reduces the ICP symptoms and improves the fetal outcome </li></ul><ul><li>However, the actual mechanism is still debatable an still under researched. </li></ul>
<ul><li>Whether or not a woman will get cholestasis in future pregnancies is debatable. However, some sources claim that women who have had cholestasis of pregnancy have up to a 90% chance of having this repeat in future pregnancies </li></ul>What are the chances of the mother getting Cholestasis in another pregnancy?
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