Obstetric cholestasis (OC), also known as intrahepatic cholestasis of pregnancy (ICP), is a liver disorder that occurs during pregnancy characterized by severe pruritus and abnormal liver function tests. It is caused by genetic and environmental factors that inhibit bile salt transporters in the liver. Risk factors include a family history and multiple pregnancies. Symptoms include worsening pruritus, jaundice in 50% of cases, and elevated bile acids and liver enzymes. Management involves monitoring for preterm birth and fetal distress risks, discussing induction of labor after 37 weeks to prevent stillbirth, and treating pruritus symptoms. Prognosis is typically good with resolution of symptoms after delivery.
Intrahepatic Cholestasis of Pregnancy : Dr Sharda Jain & Dr Jyoti Agarwal Lifecare Centre
Intrahepatic Cholestasis of Pregnancy : Dr Sharda Jain & Dr Jyoti Agarwal
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.
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
Pruritus affects upto 20% of pregnant women.
There are conditions unique to pregnancy that involve pruritus as a leading symptom.
This is called dermotoses of pregnancy.
May produce risk to mother and foetus.
Approach to skin lesions in pregnancy: Pruritus related to pregnancy, Pruritus not related to pregnancy
Intrahepatic Cholestasis of Pregnancy : Dr Sharda Jain & Dr Jyoti Agarwal Lifecare Centre
Intrahepatic Cholestasis of Pregnancy : Dr Sharda Jain & Dr Jyoti Agarwal
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.
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
Pruritus affects upto 20% of pregnant women.
There are conditions unique to pregnancy that involve pruritus as a leading symptom.
This is called dermotoses of pregnancy.
May produce risk to mother and foetus.
Approach to skin lesions in pregnancy: Pruritus related to pregnancy, Pruritus not related to pregnancy
Obstetric cholestasis is a condition in which the functionality of liver get affect and the liver is unable to send out the waste product called bile acids which result in itching mainly on palms and soles during Pregnancy.
It can detect by LFT(liver function tests) and continuous treatment is needed.
It can have an effect on the baby if the levels are too high. Doctor's generally deliver the baby by 37 weeks to avoid this.
To know more details check out the doctors answer --> https://www.icliniq.com/qa/obstetric-cholestasis/i-am-pregnant-and-having-severe-body-itching-what-is-the-treatment
Dr Anil Arora address the liver diseases that are specific during pregnancy. The presentation contains case discussions on diagnosis, treatments & take home messages
Intrahepatic Cholestasis of Pregnancy - Prof Surekha TayadeSurekhaTayade4
This presentation is for undergraduates, postgraduates, consultants and nurses and describes incidence, etiology, pathophysiology, complications and management of intrahepatic cholestasis of pregnancy /obstetric cholestasis
Obs cholestasis also called IHCP/ICP
and etiology of IHCP ,pathogenesis in IHCP,bile acids as a investigation to detect and confirm it ,it's monitoring in pregnancy
It's adverse effects in pregnancy
Management of IHCP in pregnancy. Various drugs in management of IHCP. GUIDELINES on when to deliver and mode of delivery.Necessary information on obstetric cholestasis
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. Introduction
Obstetric cholestasis (Intrahepatic Cholestasis of Pregnancy ICP) is a
multifactorial condition of pregnancy characterized by pruritus in the
absence of a skin rash with abnormal liver function tests (LFTs), and
both of which resolve after birth.
Usually occurring in the last trimester of pregnancy. It can, however,
occur earlier in gestations.
Second most common cause of jaundice in pregnancy, first- viral
hepatitis
• RCOG, Guideline , 2011
3. Background
• Prevalence is influenced by genetic and environmental factors and
varies between populations worldwide .
• In England, obstetric cholestasis affects 0.7% of pregnancies in
multiethnic populations and 1.2–1.5% of women of Indian–Asian or
Pakistani–Asian origin.
• In Chile, 2.4% of all pregnancies are affected .
• In India:- 5% of all pregnancies are affected .
5. • Genetic mutations in the hepatocellular transport protein ABCB4
which controls secretion of phosphatidylcholine into bile.
• Genetic changes to bile salt transport molecules, high levels of
estrogen glucuronides have been shown to inhibit the bile salt export
pump (BSEP) ABCB11, and high levels of sulfated progesterone
metabolites to inhibit the ABCB4 (MDR3) phospholipid transporter.
• limited studies have shown the role of selenium deficiency. Selenium
acts as a cofactor of several enzymes in the oxidative metabolism in
the liver but the role of selenium in bile secretion has yet to be
defined.
• Seasonal variation is also noted, with more severe cases in the winter
months.
6. Risk Factors
1. Personal or family history of obstetric cholestasis.
2. Multiple pregnancy.
3. Carriage of hepatitis C.
4. Presence of gallstones.
7. Clinical Presentation
1. Unexplained pruritus and Abnormal (LFTs) and/or
2. Raised bile acids.
Other causes of itching and of liver dysfunction should be excluded.
Postnatal resolution of pruritus and abnormal LFTs should be confirmed.
• RCOG, Guideline , 2011
8. • Pruritus of Pregnancy - is common, affecting 23% of pregnancies, of
which a small proportion will have obstetric cholestasis.
Pruritus of Cholestasis is
1- worse at night
2- often widespread and may involve the palms of the hands and/or
the soles of the feet.
Other evidence of cholestasis should be sought, including pale stool,
dark urine and jaundice.
Other causes of pruritus must be excluded such as eczema or atopic
eruption of pregnancy.
9. • If a rash is present, polymorphic eruption of pregnancy or
pemphigoid gestations (blisters) should be considered.
10. Jaundice
• Approximately, 2 weeks later, clinical jaundice will develop in 50 % of
cases.
• The jaundice is usually mild, soon plateaus, and remains constant
until delivery.
• The pruritus worsens with the onset of jaundice, and the patient's
skin can become excoriated.
• The symptoms usually abate within 2 days after delivery.
11. Laboratory abnormalities
Unexplained abnormalities in
1- Transaminases,
2-Gamma-Glutamyl Transferase
3 Bile salts
are considered sufficient to support the diagnosis of obstetric cholestasis.
Alkaline phosphatase (non specific as it is placental in origin so, it is not reflect liver
disease).
Bilirubin is raised only infrequently.
The most specific and sensitive marker of ICP is total serum bile acid (BA) levels
greater than 10 micromol/L Pregnancy-specific reference
ranges for LFTs should be used
(20% of non pregnant value)
12. Other causes of pruritus and abnormal LFTs should be sought:-
1. viral screen for hepatitis A, B, and C, EBV, CMV.
2. primary biliary cirrhosis (for example, anti-smooth muscle and
antimitochondrial antibodies). (liver ultrasound)
3. Pre-eclampsia and acute fatty liver of pregnancy are pregnancy-
specific causes of abnormal LFTs that might form part of the
differential diagnosis in atypical or early cases.
13. Maternal morbidity
1. Intense pruritus and Consequent sleep deprivation.
2. Increase Rate Of CS. (10-36%)
3. Increase Risk Of PPH.
4. If cholestasis lasts for several wks, liver dysfunction may
result in:
i. Decreased vitamin K re-absorption or
ii. Decreased prothrombin production, leading to a
prolongation of the prothrombin time.
14. Fetal risks
1. Preterm Birth- Spontaneous 4-12 % vs iatrogenic 7-25 %
2. Meconium Passage- More common in cases with severe
cholestasis compared with mild (10% vs with 0 %)
3. Still Birth.
4. Perinatal Mortality.
15. Monitoring
• Measure LFTs weekly until delivery
• If LFTs return to normal, obstetric cholestasis is not likely to be the
correct diagnosis.
• If LFTs escalate very rapidly, additional diagnoses need to be
considered and the frequency of monitoring increased.
• A coagulation screen should be performed.
• blood pressure measurement and urine check, allow monitoring of
the condition and exclusion of other diagnoses.
RCOG, Guideline , 2011
16. Can fetal death be predicted and prevented?
• Poor outcome cannot currently be predicted by biochemical results
and delivery decisions should not be based on results alone.
• No specific method of antenatal fetal monitoring for the prediction of
fetal death can be recommended.
• Ultrasound and CTG are not reliable methods for preventing fetal
death in cholestasis.
• Continuous fetal monitoring in labour should be offered.
• Fetal death is usually sudden. There is no evidence of placental
insufficiency. Fetal growth restriction and oligohydramnios are not
features of the disease.
RCOG, Guideline , 2011
17. Management
• A discussion should take place with women regarding induction of
labour after 37+0 weeks of gestation.
• Women should be informed of the increased risk of perinatal morbidity
from early intervention (before 37+0 weeks of gestation).
• informed of the inability to predict stillbirth if the pregnancy continues.
• Informed that the case for intervention (after 37+0 weeks of gestation)
may be stronger in those with more severe biochemical abnormality
(transaminases and bile acids).
• IOL at 38 weeks, in those with hyperbilirubinemia and fetal lungs
mature delivery at 36 weeks
Progress in Obs/ Gyne- 16
RCOG, Guideline , 2011
18. Treatment
RCOG, Guideline , 2011
There is no evidence that any specific treatment improves fetal or
neonatal outcomes.
Topical emollients calamine lotion and aqueous cream with menthol).
Safe but their efficacy is unknown
19. Systemic treatments
• Aim:- relieve pruritus
1. Colestyramine.
2. Antihistamines such as chlorphenamine may provide some
but not significant impact on pruritus.
3. Activated charcoal and guar gum do not relieve pruritus.
20. Cholestyramine (Cholestran Pack 4 gm).
A total of 8 to 16 g/day in three to four divided doses
• an anion exchange resin which acts by binding bile acids in the gut, thereby
inhibiting the enterohepatic circulation and increasing fecal excretion of
bile acids.
• May improve pruritus in some women
• It may reduce the intestinal absorption of fat-soluble vitamins, thus
depleting the levels of vitamin K and increasing the risk of hemorrhage for
the mother and fetus
• No randomised trials and is not in clinical use .
21. S-adenosyl methionine
• There is insufficient evidence to demonstrate whether it is
effective for either control of maternal symptoms or for
improving fetal outcome
• It is not recommended
RCOG, Guideline , 2011
22. Ursodeoxycholic acid (UDCA)
• UDCA is a naturally occurring hydrophilic bile acid
• Improves pruritus and liver function.
• No robust data concerning protection against stillbirth and safety to the fetus or
neonate.
• It enhances bile acid clearance across the placenta, This may protect the
hepatocyte membrane from the damaging toxicity of bile salts.
• 600- 2000mg
RCOG, Guideline , 2011
23. Dexamethasone
• 10 mg orally for 7 days and then stopping over 3 days
• should not be first-line therapy for treatment of obstetric
cholestasis,
• The results are conflicting, with some improvement in symptoms
and biochemistry in some women.
RCOG, Guideline , 2011
24. Role of vitamin K
Obstetric cholestasis can result in:-
1. Reduced absorption of dietary fats due to failure of excretion of
bile salts into the GIT and reduced micelle formation.
2. Increased fat excretion affects the absorption of fat-soluble
vitamins including vitamin K
RCOG, Guideline , 2011
25. Vitamin K
• 5- 10 mg daily oral, aiming to improve both maternal and
neonatal levels, and therefore reduce postpartum haemorrhage
and fetal or neonatal bleeding
• The use of water-soluble vitamin K (menadiol sodium
phosphate) is indicated.
• Postnatal vitamin K must be offered to the babies in the usual
way
26. Recent updates- Use of Rifampicin
• Combined Ursodeoxycholic acid (UDCA) and rifampicin is 2nd line
treatment.
• Enhances bile acid detoxification as well as bilirubin concentration.
• Increase excretion of bilirubin glucuronides by increasing MRP2
expression.
• Phenobarbitone increases the excretion of bile salt.
27. Role of Progesterone Metabolites in diagnosis of
ICP
• Progesterone sulfate are prognostic indicator of ICP
• Sulfated progesterone metabolites (PM2DiS,PM3S and PM3DiS
are found to be increased in maternal serum during ICP.
• Furthermore, UDCA treatment reduces ICP associated elevation of
disulfated progesterone metabolites.
28. POSTNATAL
• LFTs should be deferred for at least 10 days postnatally (6-8 wks)
• In normal pregnancy, LFTs may increase in the first 10 days of the
puerperium.
• Postnatal resolution of symptoms and of biochemical abnormalities
is required to secure the diagnosis.
RCOG, Guideline , 2011
29. Recurrence
• Intrahepatic cholestasis tends to recur in subsequent
pregnancies, but the severity may vary from one pregnancy
to the next.
• In their Chilean study, Gonzalez et al. reported a recurrence
rate of 70 % in singleton pregnancies.
31. References
• Obstetric Cholestasis, Green–top Guideline No. 43 April 2011
• Intrahepatic cholestasis of pregnancy, Victoria Geenes and Catherine
Williamson World J Gastroenterol. 2009 May 7; 15(17): 2049–2066.
Published online 2009 May 7. doi: 10.3748/wjg.15.2049
• Hepatic, Biliary and Pancreatic Disorders of Pregnancy, Williams
Obstetrics, 24th Edition
• Progress in Obstetrics and Gynecology, 16
Aka intrahepatic cholestasis of pregnancy, is condition unique to pregnancy and is very important to diagnose because of the adverse outcomes it is associated with.
80% occur after 30 weeks,
Affected individuals have a defect involving the excretion of bile salts, which leads to increased serum bile acids. These are deposited within the skin, causing intense pruritus. [1] The cause of ICP is unknown but is thought to be multifactorial with genetic, hormonal, and environmental involvement.
Increase serum bile salt acids- taurocholate and taurodeoxycholate
These acids are deposited in the kin and probably cause the extreme pruritus.
Lft does not change in normal pregnancy The upper limit of the normal reference range for ALT and AST should be reduced by 20% and the γ-glutamyl transpeptidase (GGT) also Total and free bilirubin is also lower during all three trimesters, and conjugated bilirubin is lower in the second and third trimesters the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic/chenodeoxycholic acid level ratio.
PPH- Despite physiological reasons and a high caesarean section rate, which might suggest an increased risk of postpartum haemorrhage, evidence from current practice does not show this.
Still birth-
Possible explanations for this are taurocholate crossing into the fetal compartment and causing fetal arrhythmias and decreased contractility. This has been documented in the rat model. Other studies have noted an increased P-R interval in human fetuses affected by ICP. [33] Still others have found human chorionic vein constriction when exposed to the bile acid cholate. This is postulated as a possible cause of acute fetal asphyxia. Also a role for impaired fetal adrenal function
All such therapies should be discussed with the individual woman with this in mind
Dexamethasone inhibits placental estrogen synthesis by reducing secretion of the precursor, dehydroepiandrosterone sulfate, from the fetal adrenal glands
it enhances bile acid detoxification, an effect that is complementary to the up-regulation of bile acid export induced by UDCA