Intraheptic Cholestasis Of Pregnancy Flashcards
What is ICP
Multi factorial condition characterised by
Itching without a rash (pruritus)
And
Abnormal liver blood test
Symptom resolve after birth
Pyruritis in pregnancy affects 25% of women but ICP affects around 0.7% of pregnancies
Rate of ICP varies according to ethnicity
Higher rates seems in women with Indian, Pakistani and Chilean heritage
How does it develop
In late 2nd or 3rd trimester, then resolves quickly after birth of the placenta
It’s more common
- during winter months
- for women with a multiple pregnancy
- older maternal ages
Family history of obstretric cholestasis
- personal history of obstretric cholestaisis
Causes of ICP
Not well understood
Genetics, environmental and hormonal factors
Usually occurs when level of oestrogen peak in pregnancy
What are the symptoms
Essential symptoms 0 tens itching without the rah, usually hand and feet. Itching is often worse at night
Possible symptoms - jaundice, pale stools, dark urine, right upper quadrant pain, tiredness
What is the pathiophysiology
Chloe’s - related to bile or bile duc
Stasis- period of inactivity
In normal preg - there is a progressive rise in serum bile acids as pregnancy progresses, it lie acids remain in the upper normal range of 10-14
In ICP, the livery cannot export bile acids done the bile ducts into the gall bladder so bile acids build up and leak into the bloodstream m
Levels of enzymes as Leo sho how wel the liver is functioning (LFT): transaminases (ALT and AST) often ride before bile acid rises with ICP.
Antenatal care - screening
Ask woman about the presence of itching
If they are experiencing itching, assess: location , presence of a rash and risk factors and symptoms associated with ICP
Offer blood test serum bile acids and LFTs
If results are normal and still severely itching, test again in 12 weeks
Itching and consistently normal bile acids - gestational pruritus (pregnancy itching)
Diagnosis of ICP
Diagnosis of ICP is by excluding all other possible conditions
Diagnosis - itching and bile acids 19+
Mild ICP 19-49 bile acids
Moderate ICP 50-99 bile acids
Severe ICP >100 bile acids
Risk associated with ICP
Preterm birth - around 1:10 women with IC will give birth before 37 weeks some of which id due o labour bring induced
Meconium stained liquor and NICU admission are higher in pregnancies affected by ICP. Rates of meconium staining are twice as high for women with ICP
The incidence of pre eclampsia was higher in women with ICP - 12.2% of women with ICP had pre eclampsia compared with 3.4% of women without ICP
Rates of gestational diabetes were higher in women with ICP - 13.2% of women with ICP had already been diagnosed with gestational diabetes compared with 5.9% of women without ICP. However increased testing is not currently recommended
Stillbirth and ICP
For ingleton pregnancies, the risk of stillbirth is only higher than the general population when bile acids exceed 100micromol/L i.e severe ICP is
Stillbirth rate from 28 weeks 2015 - 0.29%
Mild ICP - 0.13%
Moderate 0.28%
Severe ICP - 3.44%
Antenatal care for women with ICP
If LFT and/or bile acids raised
- refer to consultant led care
- vigilance in fetal movement monitoring
- repeat LFT and biles cids on individualised basis, up to weekly until birth
Considerations if atypical preseantaion or early onset
- arranging liver ultrasound
- involving heptologst
- screening for other conditions - hep A, B, C, Epstein Barr and cytomegalovirus
Treatments for ICP.
No eveidence that any specific treatment improves fetal or neonatal outcomes
All such therapies should be discussed with the individual woman with this is mind
Ursodeoxycholc acid is not routinely recommended. It may improve pruritis and liver function in women with obstretric cholestatis but show no impacts in primary outcome : still birth. It may reduce chance of preterm birth. Unclear dosing regime and not licensed for use in pregnancy
Topical emollients - treatment of the symptom, not cause. Safe, but may or may not work . Options - diprobase, calamine lotion, aqueous cream with menthol
Antihistamines - may help with rest at night, but wont help with pruritis
Vit k - if eveidence of deranged prothrombin time
Timing of birth for women with mild icp
Mild icp - women with this and no other risks factors, advise the, that the risk of stillbirth is similar to the background risk. Consider options of planned by 40 weeks or ongoing antenatl care according to national guidance
Timing of birth for women with moderate
With this and no other risk factors , advise hem that the known risk of stillbirth is similar to the background risk until 38-39 weeks or ongoing. Consider planned at 38-9 weeks
Timing of birth for women with severe ICP
Advise that the the risk of stillbirth is higher than the background risk factors
Consider planned birth at 35-36 weeks
Intrapartum care
Decision making should involve a consultant be personalised to the woman and involve her in the decision.
Obstretric unit for consultant led care is recommended
Continous electronic fetal monitoring is recommended for women with severe OC ( bile acids >100), uncertain evidence for fetal monitoring for mild or moderate OC - hard decision making
Risk assess - women with ICP and the presence of risk factors or co- morbidities (such ass gestational diabetes and/or pre eclampsia an/or multi fetal pregnancy) appear to have an increased risk of stilllbirth which may influence decision making around timing of planned birth
Postnatal care
Repeat bloods - LFTs and bile acids 4+ weeks post birth to heck that they have resolved
If LFTs and bile acids remain high, refer for follow up as condition may not be icp
Counsel about further risks of icp (45-90% recurrence rate) = baseline LFTS and bile acids with subsequent booking bloods
Contraception - avoid oestrogen based products if contraception related cholestatis is in the past
Postnatal care
Repeat bloods - LFTs and bile acids 4+ weeks post birth to heck that they have resolved
If LFTs and bile acids remain high, refer for follow up as condition may not be icp
Counsel about further risks of icp (45-90% recurrence rate) = baseline LFTS and bile acids with subsequent booking bloods
Contraception - avoid oestrogen based products if contraception related cholestatis is in the past
