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Cholestasis of Pregnancy

Recurrent Jaundice of Pregnancy


Presentation

  • Signs and symptoms [ edit ] Most women with this condition present in the third trimester (although it can present as early as seven weeks) with itching without a rash.[en.wikipedia.org]
  • COMPLICATION ICP presents risk to the fetus than to the mother (Fetal outcome ).[flipper.diff.org]
  • Earlier presentations of Intrahepatic Cholestasis of Pregnancy (ICP) seem to carry an even greater risk of preterm labor, as well as twin or triplet pregnancies.[liverfoundation.org]
  • When present, it increases the incidence of acute hepatic failure.[patient.info]
  • However, there is no research at present to confirm that taking oral vitamin K will do this, but neither is it thought to harm your baby.[britishlivertrust.org.uk]
Liver Disorder in Pregnancy
  • Vigilance in recognizing liver disorders in pregnancy and early coordinated management among the primary care physician, obstetrician, liver specialist, and transplant surgeon are essential for promoting good maternal and fetal outcomes.[clevelandclinicmeded.com]
Falling
  • The facts that ICP happens late in pregnancy and has a higher incidence in multiple gestation pregnancies, and that it resolves after delivery when sex hormones levels fall, make a logical connection between sex hormones and ICP.[wjgnet.com]
Diarrhea
  • METABOLISM 301 DISORDERS OF CONNECTIVE TISSUE 308 DISEASES CAUSED BY CHEMICAL AND PHYSICAL AGENTS 352 A General Aspects of Infectious Diseases 381 HOSPITALACQUIRED INFECTIONS 392 BACTEREMIA AND SEPTIC SHOCK 400 CHEMOTHERAPY OF INFECTION 406 ACUTE BACTERIAL DIARRHEA[books.google.com]
Food Poisoning
  • POISONING 420 Infections Caused by GramPositive Cocci 433 STREPTOCOCCAL INFECTIONS 441 Infections Caused by GramNegative Cocci 447 Aerobic Bacterial Infections 459 ANTHRAX 465 CHOLERA 472 BARTONELLOSIS 475 E Anaerobic Bacterial Infections in Pregnancy[books.google.com]
Jaundice
  • JAUNDICE DURING PREGNANCY ... - - 17 1) Incidence of jaundice durip. g pregnancy 17 2) Classification of jaundice during pregnancy 17 3) Frequency distribution of different diseases causing jaundice during pregnancy ... ... '. 20 4) Review of literature[books.google.de]
  • , because of jaundice of 2 weeks' . . .[nejm.org]
  • Intrahepatic cholestasis of pregnancy Also known as recurrent cholestasis of pregnancy, obstetric cholestasis, cholestasis of pregnancy, recurrent jaundice of pregnancy, cholestatic jaundice of pregnancy, idiopathic jaundice of pregnancy, prurigo gravidarum[dermcoll.edu.au]
  • […] of unknown cause but associated with high estrogen levels. intrahepatic cholestasis of pregnancy a type of intrahepatic cholestasis sometimes seen during the third trimester of pregnancy, characterized by severe itching, hepatomegaly, and sometimes jaundice[medical-dictionary.thefreedictionary.com]
  • Jaundice is detected clinically when there is yellowing of whites of eyes and skin.[news-medical.net]
Recurrent Jaundice
  • ALTHOUGH there have been numerous reports in the European literature on a syndrome of recurrent jaundice in late pregnancy we have found only sparse reference to it in the American literature.[nejm.org]
  • Synonym(s): cholestasis of pregnancy , recurrent jaundice of pregnancy . intrahepatic cholestasis of pregnancy Abbreviation: ICP A complication of approx. 1% of pregnancies in which elevated levels of pregnancy hormones cause obstruction to bile flow[medical-dictionary.thefreedictionary.com]
  • Intrahepatic cholestasis of pregnancy Also known as recurrent cholestasis of pregnancy, obstetric cholestasis, cholestasis of pregnancy, recurrent jaundice of pregnancy, cholestatic jaundice of pregnancy, idiopathic jaundice of pregnancy, prurigo gravidarum[dermcoll.edu.au]
  • Description DEFINITION Intrahepatic cholestasis of pregnancy ICP also known as Obstretic cholestasis or recurrent jaundice of pregnancy or Pruritus gravidarum, is a cholestatic disorder characterized by pruritus,elevated serum aminotransferases and bile[flipper.diff.org]
  • Recurrent jaundice caused by recurrent hyperemesis gravidarum. Abstract The existence of jaundice induced by hyperemesis gravidarum is controversial.[gut.bmj.com]
Pruritus
  • […] intrahepatic cholestasis of pregnancy intrahepatic cholestasis with centrilobular bile staining without inflammatory cells or proliferation of mesenchymal cells; clinically characterized by pruritus and icterus; of unknown cause but associated with high[medical-dictionary.thefreedictionary.com]
  • These are deposited within the skin, causing intense pruritus.[flipper.diff.org]
  • […] on pruritus as compared to UDCA monotherapy [ 42 ].[ojrd.biomedcentral.com]
  • Pruritus (itching) is a common symptom of pregnancy, affecting around 20% of women. [3] The majority of times, itching is a minor annoyance caused by changes to the skin, especially that of the abdomen.[en.wikipedia.org]
  • 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.[emedicine.medscape.com]
Excoriation
  • There is no rash but the skin may show scratch marks (excoriations) or become yellow (jaundiced). This condition typically develops late in pregnancy and resolves within days after the baby is born.[dermcoll.edu.au]
Excoriation
  • There is no rash but the skin may show scratch marks (excoriations) or become yellow (jaundiced). This condition typically develops late in pregnancy and resolves within days after the baby is born.[dermcoll.edu.au]
Eczema
  • It is also important to exclude all other possible causes of your itching, such as allergies or eczema (but it is possible to have a skin condition and OC/ICP).[britishlivertrust.org.uk]
Dark Urine
  • The following signs and symptoms may be present in cases of cholestasis of pregnancy: intense itching, especially on the palms of the hands and soles of the feet dark urine light-colored feces jaundice, giving the whites of the eyes, skin and tongue a[medicalnewstoday.com]
  • Other signs such as pale stools or dark urine may indicate a problem with your liver, including OC/ICP. Your doctor can diagnose OC/ICP from blood tests called liver function tests (LFTs) and a serum bile salt test.[britishlivertrust.org.uk]
  • Other symptoms include dark urine, steatorrhea and, less commonly, jaundice. Itching can be intense or mild and there appears to be no correlation between intensity of itch with increased fetal risk.[rcm.org.uk]

Workup

  • The underlying disorder can have a significant effect on morbidity and mortality in both mother and fetus, and a diagnostic workup should be initiated promptly.[clevelandclinicmeded.com]
Vitamin K Increased
  • Patients with cholestasis will have low levels of vitamin K, increasing the chance of hemorrhage, so a mother will often need Vitamin K supplements before and after delivery.[medicalnewstoday.com]

Treatment

  • What is the treatment for ICP? Despite the possible outcomes of ICP, proper treatment provides a great degree of reduction in both fetal risk and maternal symptoms.[liverfoundation.org]
  • Treatment Treatment may not be necessary if cholestasis is mild and occurs late in pregnancy. Treatment normally aims to relieve symptoms, mainly the itching, and to prevent potential complications.[medicalnewstoday.com]
  • Thus, early recognition, treatment, and timely delivery are imperative.[emedicine.medscape.com]
  • TREATMENT The primary objective of pharmacologic treatment in ICP is to alleviate maternal symptoms and improve fetal outcome. Many drug agents have been used in the treatment of ICP.[flipper.diff.org]
  • Usually a lotion (e.g. calamine lotion) with soothing elements is prescribed for this itching and no pills or other drug treatments are needed. Mild itching is common in pregnancy because of the increased blood supply to the skin.[news-medical.net]

Prognosis

  • Maternal prognosis is good and symptoms resolve rapidly after delivery,accompanied by normalization of serum liver test. ICP recurs during subsequent pregnancies in 45-70% with varying severity of recurrent episodes.[flipper.diff.org]
  • Jaundice in pregnancy carries a grave prognosis for both the fetus and the mother, and is responsible for 10% of maternal deaths. The present study analyzes the causes and the fetomaternal outcome in pregnancies affected with jaundice.[ijrcog.org]
  • Prognosis Hyperemesis gravidarum is usually a reversible condition with no permanent damage to the liver and almost never fatal.[wjgnet.com]
  • View Article PubMed Google Scholar Laatikainen T, Ikonen E: Fetal prognosis in obstetric hepatosis. Ann Chir Gynaecol Fenn. 1975, 64: 155-164.[ojrd.biomedcentral.com]
  • There is generally a favourable prognosis for both mother and baby. Pre-eclamptic liver disease and HELLP See the separate HELLP Syndrome article for further details.[patient.info]

Etiology

  • The etiology of this syndrome is unknown, but the clinical and laboratory findings are sufficiently distinctive to separate it from other causes of jaundice.[nejm.org]
  • The cause of ICP is unknown but is thought to be multifactorial with genetic,hormonal and environmental involvement.Family clustering and varying incidence in different geographic regions speaks strongly for a genetic etiology of ICP.[flipper.diff.org]
  • Etiology and pathogenesis The etiology of ICP is not completely understood and is still under discussion. Genetic and hormonal factors, but also environmental factors may contribute to the pathogenesis of ICP [ 1 ].[ojrd.biomedcentral.com]
  • ICP has no clear etiology, and it is believed to be a multifactorial disorder with environmental, hormonal, and genetic contributions.[emedicine.medscape.com]
  • Etiology of cirrhosis in pregnancy is similar to that in the nonpregnant state and commonly includes alcohol and viral hepatitis C and B. Cirrhosis can affect ovulation and cause infertility.[clevelandclinicmeded.com]

Epidemiology

  • EPIDEMIOLOGY The incidence of ICP varies widely with geographical location and ethnicity. 1 to 2 pregnancies in 1000 are affected by cholestasis. it is most common in South America, particularly in Chile, where the early reports described an overall incidence[flipper.diff.org]
  • Acute fatty liver of pregnancy Epidemiology It is a rare condition with an incidence of 5 in 100,000 pregnancies. [ 8 ] Acute fatty liver of pregnancy (AFLP) tends to occur in late pregnancy. [ 3 ] Risk factors include first pregnancies, pre-eclampsia[patient.info]
  • […] findings remains to be fully elucidated. [17, 18] A study by Abu-Hayyeh et al found that sulfated progesterone metabolites are a prognostic indicator for ICP and can help predict onset of ICP and distinguish it from benign pruritus gravidarum. [19] Epidemiology[emedicine.medscape.com]
  • Epidemiology ICP has been observed in almost all ethnic groups, but there is relevant geographical variation in the incidence of ICP [ 1, 4 ].[ojrd.biomedcentral.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Affected individuals have a defect involving the excretion of bile salts, which leads to increased serum bile acids.[emedicine.medscape.com]
  • It typically arises in the third trimester of pregnancy, although it has been reported as early as 13 weeks' gestation. 18 – 20 The pathophysiology of intrahepatic cholestasis of pregnancy remains poorly understood. 19 Pruritus alone occurs in 80 percent[aafp.org]
  • […] microvesicular steatosis cannot be detected as well as the more common macrovesicular fatty change, in which imaging is very sensitive. 123 Although the exact mechanism of liver injury still is unknown, great advances have been made in understanding the pathophysiology[glowm.com]
  • There are no clinical markers that predict the course of a pregnancy and the pathophysiologic mechanisms are not always understood, but knowledge and management of the preconception liver disease and efficacious pre-pregnancy and prenatal care are essential[clevelandclinicmeded.com]

Prevention

  • Treatment normally aims to relieve symptoms, mainly the itching, and to prevent potential complications.[medicalnewstoday.com]
  • The gallbladder or its bile ducts can become blocked, preventing excretion of bilirubin into the intestine. Bilirubin will then back up into the liver and then into the bloodstream.[medbroadcast.com]
  • This could be mediated by enhanced expression of plasma membrane transporters involved in the excretory role of the placenta and would prevent structural alterations of the trophoblast induced by maternal cholestasis.[flipper.diff.org]
  • Many of these women are sexually active and do not take effective measures to prevent pregnancy.[clevelandclinicmeded.com]

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