Intrahepatic Cholestasis in Pregnancy
Patient presentation:
Patient MJE, a 32 year old G1P0 (first pregnancy) presents to labor and delivery at 38 weeks gestation with total body itching. She explains that “nothing works” and “I’m itching so bad I can’t sleep at night”. Vitals signs were BP 141/86, P 80, RR 18 and temp 37.1c. The patient reports positive fetal movement and denies vaginal bleeding or rupture of membranes. The EFM shows a category I tracing (fetal well being) with occasional contractions. The clinical technician collected a urine sample from the patient and reported her urine as a “dark dandelion” color.
Differential Diagnosis:
HELLP syndrome and Pre-Eclampsia, but due to MJE’s pruritus a diagnosis of Intrahepatic Cholestasis of Pregnancy (ICP) was stronlgy suspected.
Diagnosis:
Serial blood pressures were done to assess if the patient’s initial elevated BP was a true assessment. Two BPs of 140/80 30 minutes apart will raise awareness for the possibility of Pre-Eclampsia. HELPP/Pre-eclamptic labs were sent (CBC, AST, ALT, LDH, Uric Acid, UA) as well as a total/direct bilirubin and bile acids. The results were as follows CBC: Hct – 33% (norm 34-44%), Platelets 117 k/uL (norm 145-400) all other values within the CBC were WNL. Liver Enzymes were as follows: ALT-94 (normal 15-41), AST- 49 (norm 3-34). Bile Acids were extremely elevated at 31 (normal are under 10umole/L). The Total and Direct Bilirubin, Uric Acid, LDH and UA were all within normal limits. The patient’s next 3 blood pressures were 130/74, 121/70 and 118/68. The patient was ruled out for HELLP and pre-eclampsia due to her normotensive blood pressures and lack of proteinuria. Due to her extreme itching, elevated liver enzymes and elevated bile acids, a diagnosis of Cholestasis was given.
Treatment:
MJE’s diagnosis of ICP at 38 weeks (term pregnancy) puts her at an increased risk for Intra-uterine fetal demise. Most patients will be diagnosed with ICP before term gestation, and scheduled for labor induction between 36 and 37 weeks. Early induction is indicated with patients with a diagnosis of ICP because most intra-uterine demises associated with this condition occur after that time and antenatal testing cannot predict occurrence of fetal demise. MJE was admitted as an inpatient for an Induction of Labor (IOL). She was started on IV fluids and Pitocin. Cool cloths were offered to the patient to place under the bands holding the fetal monitors in place to decrease skin irritation. Due to MJE’s low platelets, she was encouraged to get an epidural sooner than later in case her platelets were trending downwards.
Outcome:
MJE delivered a healthy 7 pound 9oz baby girl via Cesarean Section due to prolonged second stage of labor. Mom and baby are both doing well. The patient was educated on the increased risk of ICP in future pregnancies and the testing that can be done during pre-natal visits.
Case created by Monica Elston, 2011.