A 33-year-old primigravida at 32 weeks gestation comes to the office due to severe generalized itching that is most intense on her hands and feet. Her pregnancy has been uncomplicated so far. The patient has no other medical conditions and her only medication is a daily prenatal vitamin. She does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 106/60 mm Hg, pulse is 56/min, and respirations are 12/min. Skin examination shows excoriations on her forearms and anterior shins. The abdomen is nontender and there is no hepatosplenomegaly. The remainder of the physical examination is within normal limits.
Laboratory results are as follows:
Viral hepatitis panel is negative. Abdominal ultrasound reveals normal liver echogenicity and no dilated bile ducts.
Which of the following is the most appropriate next step in management of this patient?

Question

A 33-year-old primigravida at 32 weeks gestation comes to the office due to severe generalized itching that is most intense on her hands and feet.  Her pregnancy has been uncomplicated so far.  The patient has no other medical conditions and her only medication is a daily prenatal vitamin.  She does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 106/60 mm Hg, pulse is 56/min, and respirations are 12/min.  Skin examination shows excoriations on her forearms and anterior shins.  The abdomen is nontender and there is no hepatosplenomegaly.  The remainder of the physical examination is within normal limits.
Laboratory results are as follows:
 Viral hepatitis panel is negative.  Abdominal ultrasound reveals normal liver echogenicity and no dilated bile ducts.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98a3_ec69_853d_4dfff7c659d7_MD0002_00 This patient has intrahepatic cholestasis of pregnancy (ICP), a pregnancy complication that typically occurs in the second or third trimester. Patients usually present with generalized, intolerable pruritus that is most intense on the palms and soles and at night. Jaundice occurs in <10% of patients and usually follows the onset of pruritus. Abdominal pain, encephalopathy, liver failure, or a lack of pruritus are uncommon with ICP and suggest an alternate diagnosis. Intolerable pruritus is a cardinal feature of ICP and is uncommon with other conditions that share similar clinical features in pregnancy (eg, preeclampsia, HELLP [Hemolysis, Elevated Liver enzymes, Low Platelet count] syndrome). Laboratory studies show elevated total bile acids; additional laboratory abnormalities include elevated bilirubin, alkaline phosphatase, AST, and ALT levels. Coagulation studies are normal. Although ICP is a cholestatic disease, gamma-glutamyl transpeptidase is normal or only mildly elevated in most patients. Patients with an AST and ALT >1000 U/L require testing to rule out viral hepatitis. Abdominal ultrasound is usually normal. ICP may recur in subsequent pregnancies but does not usually cause significant maternal complications or postpartum hepatic disease. However, ICP increases fetal risk of prematurity, fetal demise, and neonatal respiratory distress syndrome. Current guidelines recommend delivery at 37 weeks gestation to prevent fetal complications. Delivery prior to 36 weeks gestation is suggested only in cases of unremitting pruritus (not relieved by pharmacotherapy) or previous fetal demise due to ICP (Choice B). First-line treatment is with ursodeoxycholic acid to improve bile flow, reduce pruritus, and improve liver function tests. (Choice A) Cholestyramine is less effective than ursodeoxycholic acid in decreasing pruritus and is a second-line therapy for ICP. In addition, side effects of steatorrhea and vitamin K deficiency exacerbation can limit its usefulness. (Choice C) N-acetylcysteine is used as an antidote for acute acetaminophen poisoning to prevent liver toxicity and is administered within 8 hours of ingestion (or as soon as possible). (Choice D) Prednisolone has not been shown to improve pruritus, decrease serum bile acid levels, or decrease fetal risk in patients with ICP. Prednisolone can be used in treatment of severe alcoholic hepatitis (eg, Maddrey discriminant function >32). Educational objective: Intrahepatic cholestasis of pregnancy presents in the second and third trimesters with pruritus and elevated bile acids and is associated with an increased risk of fetal demise. Management includes administration of ursodeoxycholic acid to lower bile acid levels and delivery at 37 weeks gestation. __________ References: Evaluating the effectiveness and safety of ursodeoxycholic acid in treatment of intrahepatic cholestasis of pregnancy: a meta-analysis (a prisma-compliant study). (http://www.ncbi.nlm.nih.gov/pubmed/27749550) The active management of intrahepatic cholestasis of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/20124899) Perinatal outcomes associated with intrahepatic cholestasis of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/28581354)

A 33-Year-Old Primigravida at 32 Weeks Gestation Comes to the Office