Intrahepatic cholestasis

Intrahepatic cholestasis of pregnancy

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Key recommendations

  • The diagnosis of intrahepatic cholestasis of pregnancy (ICP) should be considered in pregnant women who have itching in skin of normal appearance and raised peak random total bile acid concentration of 19 micromol/L or more. [Grade D]
  • Additional laboratory and/or imaging investigations are not recommended unless itch is associated with atypical clinical symptoms, the presence of relevant comorbidities, or in early onset severe ICP. Consider additional postnatal investigations in women in whom resolution of abnormal liver function tests is delayed or does not occur. [Grade C]
  • Consider discussing the care of women with severe, very early or atypical presentation of what appears to be ICP with a hepatologist. [Grade D]
  • Confirm the diagnosis of ICP in the postnatal period at least 4 weeks after birth, with resolution of itching and liver function tests returning to normal (including bile acids). [Grade D]
  • Advise women with isolated ICP and a singleton pregnancy that the risk of stillbirth only increases above population rate once their serum bile acid concentration is 100 micromol/L or more.
    • In women with peak bile acids 19–39 micromol/L (mild ICP) and no other risk factors, advise them that the risk of stillbirth is similar to the background risk. Consider options of planned birth by 40 weeks’ gestation or ongoing antenatal care according to national guidance.
    • In women with peak bile acids 40–99 micromol/L (moderate ICP) and no other risk factors, advise them that the known risk of stillbirth is similar to the background risk until 38–39 weeks’ gestation. Consider planned birth at 38–39 weeks’ gestation.
    • In women with peak bile acids 100 micromol/L or more (severe ICP), advise them that the risk of stillbirth is higher than the background risk. Consider planned birth at 35–36 weeks’ gestation. [Grade A]
  • Advise women with ICP and a twin pregnancy that the risk of stillbirth is higher compared with a twin pregnancy without ICP. [Grade D]
  • Clinicians should be aware that fetal ultrasound and/or cardiotocography (CTG) do not predict or prevent stillbirth in ICP. [Grade D]
  • Advise women with ICP that the presence of risk factors or co-morbidities (such as gestational diabetes and/or pre-eclampsia and/or multifetal pregnancy) appear to increase the risk of stillbirth and may influence decision-making around timing of planned birth. [Grade D]
  • Advise women that there are no treatments that improve pregnancy outcome (or raised bile acid concentrations) and treatments to improve maternal itching are of limited benefit. [Grade A]
  • Do not routinely offer ursodeoxycholic acid for the purpose of reducing adverse perinatal outcomes in women with ICP. [Grade A]

Read more : https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.17206

Intrahepatic cholestasis in pregnant women raises risk of multiple diseases later in life

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Women with intrahepatic cholestasis of pregnancy (ICP) face a higher risk of hepatobiliary cancer and immune-mediated and cardiovascular diseases later in life, shows a study conducted in Sweden.

The new study involving more than 125,000 pregnant women was conducted to determine the risks of ICP in expectant mothers. ICP is found in 0.4 to 1.5 percent of pregnancies. Symptoms include unexplained itching with increased levels of serum bile acids and/or liver enzymes in the second and third trimester. Although ICP may lead to preterm delivery and stillbirth, it was previously not regarded as a serious condition in mothers because it spontaneously resolves after delivery. [J Hepatol 2015 Mar 12. doi: 10.1016/j.jhep.2015.03.010]

“This large population-based study in women with ICP found increased risks of later hepatobiliary cancer and immune-mediated diseases and a small increased risk of later cardiovascular disease,” said principal investigator Dr. Hanns-Ulrich Marschall, of Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden.

Investigators identified 11,388 women with ICP and 113,893 matched women without ICP from the Swedish Medical Birth Register and the Swedish Patient Register. These women delivered between 1973 and 2009. The Patient Register provided information on diagnoses of cancer and immune-mediated and cardiovascular diseases both before and after delivery.

The study showed that women who had experienced ICP were at a 2.5-times higher risk of cancer in the biliary tree and at 3.5-times increased risk of liver cancer later in life compared with matched controls. Even after adjusting for a diagnosis of hepatitis C, which is very strongly associated with liver cancer, women with ICP were still at 2.5-times increased risk of liver cancer.

The data indicates that patients with ICP have an increased risk of a variety of immune-mediated diseases, such as thyroid disease (30 percent higher than pregnant controls), diabetes (47 percent), psoriasis (27 percent), and Crohn’s disease (55 percent). Investigators also found a slightly increased risk of future cardiovascular disease, but only in women with both ICP and pre-eclampsia during pregnancy.

“We strongly recommend a follow-up of serum liver tests 6 to 12 weeks after delivery in all women with ICP, with and without persisting pruritus, and if serum liver test results are elevated, further evaluation by a hepatologist,” said Marschall and his co-investigators.