Obstetric cholestasis (also known as Intrahepatic homeostasis of pregnancy (ICP), is the most common liver disease in pregnancy (Glatz, Marschall, Mattsson 2004) it is a multifactoral and pregnancy specific condition and is characterised by it is by puritus, elevated serum aminotransferases and bile acid levels, with the onset in the second or third trimester of pregnancy, with spontaneous relief of signs and symptoms within two to three weeks of delivery (Beuers and Pusl 2006).
ICP is a relatively benign but often significantly distressing condition maternally, the clinical importance of obstetric cholestatis lies in the potential fetal risk, which may include with ...view middle of the document...
Aetiology, and signs and symptoms of ICP
As previously highlighted despite intrahepatic homeostasis of pregnancy (ICP) being the most common pregnancy related liver disorder the cause of ICP remains elusive. Presently just 0.7% of pregnancies in England in multiethnic populations (Royal College of Obstetrics and Gynaecologists (RCOG) 2006). Comparable to a geographical variation range from 0.2% in France to 4% in Chile (Jon and Erin 2012). Current pathogenesis of ICP focuses upon a genetic or hormonal factors (Kondrackiene and Kupcinskas 2008). to Milkiewicz, Elias, Weaver and Williamson (2002) suggest the low quoted incidents of ICP in England may reflect an underestimation of the problem due to a failure of diagnosis.
Mrs X presented at the community midwife at 34 weeks gestation during her first pregnancy, with a history intensive itching (pruritus) of the palms of her hands and the soles of her feet increasing with intensity as the day progressed, without a visable rash.
Pruritus in pregnancy can be normal Causes of However despite the possible adverse outcomes to the fetus this condition is has a reported incidence of It could be suggested the failure of diagnosis may be related to a number of factors including non recognition of the characteristic presentation of ICP, as pruritus is deemed as not an uncommon feature of normal pregnancy. Prurigo of pregnancy effects 80% of pregnancies and occurs without a rash. Prurigo usually begins in the 3rd trimester and affects the trunks more than the limbs. ICP also without a rash, usually begins in the 3rd trimester, it usually involves limbs and trunk, but more specifically palms and soles distinguishing it from its benign counterpart. Seong and Valayatham (2013).
Diagnosis is suggested if a woman in the third trimester, (although earlier presentation has been suggested Saleh and Abdo 2006) develops itching without a rash and at least one biochemical liver abnormality (Walker, Nelson-Piercy and Williamson 2002), The RCOG (2006) recognise that ICP is a diagnosis of exclusion, therefore other more common causes of deranged Liver function test (LFT) must be excluded. This includes pre -eclampsia, acute fatty liver, infective and auto-immune hepatitis and choledocholithiasis (Seong and Valayatham 2013).
Raised liver enzymes (Alanine Transfinite (ALT) and increased Serum bile acids (SBA) usually confirms the diagnosis of ICP (Kenyon, Pier, Girling, Williamson, Tribe and Shennan 2002), with the measurement of SBA considered the most important biochemical marker for the both the diagnosis and monitoring of ICP.
The liver is the largest gland in the body, weighing about 1.4kg and occupies most of the right hypochodriac and epigastric regions. The liver has a dual vascular supply, the hepatic artery delivers oxygenated blood from the general circulation, and the hepatic portal vein delivering deoxygenated blood from the small intestine containing nutrients (Ross and...