Book of Medical Disorders in Pregnancy - Tintash

women (in the second and third
trimesters) with choledocholithiasis
using minimal fluoroscopy and lead
aprons to shield the abdomen. All of the
women delivered healthy babies at term.
Pregnancy specific liver disease:
Intrahepatic cholestasis of pregnancy:
Intrahepatic cholestasis of pregnancy
occurs in 0.01 percent of pregnancies in
the United States. It typically arises in
the third trimester of pregnancy,
although it has been reported as early as
13 weeks' gestation. The
pathophysiology of intrahepatic
cholestasis of pregnancy remains poorly
understood. 19 Pruritus alone occurs in 80
percent of patients; pruritus and jaundice
develop in 20 percent of patients.
Laboratory abnormalities include a
bilirubin level less than 5 mg per dL
(85.5 µmol per L), minimal or no
elevation in transaminase, cholesterol
and triglyceride levels, and infrequent,
mild to moderate steatorrhea. Liver
histopathology reveals centrilobular bile
stasis. 20 Intrahepatic cholestasis of
pregnancy is associated with a 12 to 44
percent incidence of prematurity, a 16 to
25 percent incidence of fetal distress and
an increased perinatal mortality rate (1.3
to 3.5 percent). A clear racial and
genetic predisposition for this disorder
has been described. Intrahepatic
cholestasis complicates 0.01 to 0.02
percent of pregnancies in North
America, 1 to 1.5 percent of pregnancies
in Sweden and 5 to 21 percent of pregnancies
in Chile. 20 The disease is rare in
black patients. 20 A strong family history
of cholestasis of pregnancy is typically
described by the patient. 20 Kindred
studies reveal alterations in
bromosulfophthalein clearance following
estrogen treatment in both male and
118
female relatives of women affected by
intrahepatic cholestasis of pregnancy. 19
Multiple medications have been tried as
treatments for cholestasis of pregnancy. 19
parenteral vitamin K (phytonadione;
Aqua MEPHYTON) supplementation is
advocated in patients with prolonged
cholestasis (secondary to malabsorption
of this fat-soluble vitamin). Ursodeoxycholic
acid (Actigall), given at dosages
of 15 mg per kg per day, has been the
most successful therapy for cholestasis
of pregnancy, as it ameliorates both the
pruritus and liver function abnormalities
and is well-tolerated by both mother and
fetus. 21 Ursodeoxycholic acid has been
proved safe in trials of cholestatic liver
disease in infants, children and adults.
Studies in rats, mice and rabbits have
revealed no teratogenicity or other negative
effects on the developing fetus. Studies
in humans examining the use of
ursodeoxycholic acid in pregnancy have
been uncontrolled and limited by small
patient numbers. However, in pregnant
patients with cholestatic liver disease,
the pruritus can be severely disabling,
and ursodeoxycholic acid therapy
provides safe and effective relief.
Cholestyramine (Questran) binds bile
acids and may improve pruritus; how
ever, it may exacerbate steatorrhea and
does not alter liver function or fetal
prognosis. 19 Phenobarbital has not been
shown to improve pruritus or alter liver
tests and may cause neonatal respiratory
depression. Patients exhibiting cholestasis
of pre-gnancy should receive close
fetal surveillance at delivery. Symptoms
of cholestasis usually resolve within two
days of delivery. Elevated serum
bilirubin and alkaline phosphatase levels
re-turn to normal four to six weeks after
delivery. 3 Cholestasis of pregnancy re-