Pregnant intrahepatic cholestasis (ICP) is the most common pregnancy-specific liver disease. Symptoms include pruritus throughout the body, including the palms and soles, and elevated bile acid levels, but may not be accompanied by changes in liver function test (LFT) results. The etiology of cholestasis of pregnancy is influenced by a combination of genetic, endocrine, and environmental factors. Risk factors include multiple pregnancies, in vitro fertilization, advanced childbirth, pregnancy history, family history, and hepatitis C infection.(1)
How To Diagnose Cholestasis Of Pregnancy?
Determination Of Serum Bile Acid Concentration: It is the most valuable method for diagnosing cholestasis of pregnancy and the glycolic specific evidence of cholestasis of pregnancy. The bile acid in the bile is mainly glycolic acid (CG) and taurine with a ratio of 3: 1. The determination of the serum glycolic acid in pregnant women is the most sensitive method for the early diagnosis of cholestasis of pregnancy.
Liver Function Measurement: Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are mild to moderately elevated in most cholestasis of pregnancy patients (2 to 10 times the normal level). ALT is more sensitive than AST; some patients have lower serum bilirubin or moderately elevated.
Pathological Examination: Postpartum pathological examination showed that the placenta and amniotic membrane showed different degrees of yellow and gray plaque, chorionic plate and amniotic membrane deposited bile salts, trophoblasts swelled and increased in number, chorionic matrix edema, and narrow spaces; liver tissue biopsy of cholestasis of pregnancy patients showed liver cells.
There was no glycolic inflammation or degeneration. Only the bilirubin in the central region of the hepatic lobules was mild, and cholestasis of the bile ducts and bile thrombosis were usually observed. Electron microscopy can reveal dilated capillary bile ducts with microvilli edema or disappeared.
Differential Diagnosis: The diagnosis for cholestasis of pregnancy should exclude other diseases that can cause itching, jaundice, and abnormal liver function. If patients with severe vomiting, psychiatric symptoms or high blood pressure, your doctor may consider pregnancy, acute fatty liver, and preeclampsia; mild transaminase levels, moderately elevated should consider pregnancy with hepatitis, especially pregnant merger chronic hepatitis.(3) (4)
What Is The Best Medicine For Cholestasis Of Pregnancy?
Treatment aims to relieve pruritus symptoms, restore liver function, lower blood acid levels, with emphasis on fetal monitoring intrauterine conditions, to detect fetal hypoxia and take appropriate action.
Proper bed rest, take the left side-lying position to increase the placental blood flow, give intermittent oxygen inhalation, hypertonic glucose, vitamins, and energy mixtures, both to protect the liver and improve the fetus’s tolerance to hypoxia. Checking the liver function, blood bile acid level, and bilirubin regularly is essential.
The medicines that can reduce the clinical symptoms of pregnant women, the biochemical indicators of cholestasis and the improvement of the perinatal prognosis are:
Adenosylmethionine is the drug of choice for cholestasis of pregnancy. The drug can prevent cholestasis caused by elevated estrogen and protect the liver of estrogen-sensitive mothers. Clinically, it can improve the symptoms of cholestasis of pregnancy and delay the further development of the disease.
Ursodeoxycholic Acid inhibition after parenteral administration of hydrophobic bile acid promotes reabsorption of bile acids to reduce, improve the fetal environment, thus extending the gestational age. Pruritus symptoms and biochemical indicators can be improved significantly.
Dexamethasone inducible activity through the placenta to reduce the fetal secretion of adrenal DHEA reduced estrogen production, reduce cholestasis; promote fetal lung maturity, to avoid premature respiratory distress syndrome of the baby; reduce pruritus symptoms.
Phenobarbital drug inducible cytokine activity and P450 generated, thereby increasing bile flow, improve pruritus symptoms.(5)
The Common Cause Of Cholestasis During Pregnancy
Cholestasis in pregnant women is provoked due to an increase in the production of estrogen. This increases the production of bile acids that cause itching when it comes to the skin. In most cases, this disease does not pose a risk to the development of the endocrine fetus. Violation of liver functions, enlargement of the urinary tract organs and gallbladder and accordingly, put pressure on these organs by the uterus. Itching is often a symptom that indicates a malfunction in the work of these organs. In extreme cases, future mothers may be required to be hospitalized.(2) (3)
Genetic And Environmental Factors: Epidemiological studies found that the incidence of cholestasis of pregnancy is related to the season, the incidence is higher in winter than in summer, and it is significantly higher in women with a history of cholestasis of pregnancy in their family (mothers or sisters), indicating that genetic and environmental factors play a role in the cholestasis of pregnancy manifestation.
Drugs: Some drugs that reduce bile duct transportation, such as azathioprine taken after kidney transplantation, can cause cholestasis of pregnancy.(2) (3)
- Diken Z, Usta IM, Nassar AH. A clinical approach to intrahepatic of pregnancy. American journal of perinatology. 2014;31(01):001-008.
- Gabzdyl EM, Schlaeger JM. Intrahepatic cholestasis of pregnancy. The Journal of perinatal & neonatal nursing. 2015;29(1):41-50.
- Dixon PH, Williamson C. The pathophysiology of intrahepatic cholestasis of pregnancy. Clinics and research in hepatology and gastroenterology. 2016;40(2):141-153.
- Williamson C, Geenes V. Intrahepatic cholestasis of pregnancy. Obstetrics & Gynecology. 2014;124(1):120-133.
- Ozkan S, Ceylan Y, Ozkan OV, Yildirim S. Review of a challenging clinical issue: Intrahepatic cholestasis of pregnancy. World Journal of Gastroenterology: WJG. 2015;21(23):7134.