Soothing baths can help, ursodiol is most effective
Mild cholestasis responds to symptomatic treatment with soothing baths, topical antipruritics, emollients, and primrose oil, among others. Antihistamines are rarely effective. Anion exchange resins, such as cholestyramine, can be helpful, too; they bind bile acids and decrease their enterohepatic circulation.2
Patients who do not respond to cholestyramine, or who cannot tolerate it, may be treated with ursodeoxycholic acid (ursodiol). The research indicates that ursodiol works faster than cholestyramine, has a more sustained effect on pruritus, and is more effective in improving the biochemical abnormalities of ICP (strength of recommendation [SOR]: A, based on good-quality patient-oriented evidence). Ursodiol is considered safe for both mother and fetus.5 For all of these reasons, ursodiol has replaced cholestyramine as the first-line agent for ICP.
Doses range from 1 g/day to high doses of 1.5 to 2.0 g/d.6 The dose is maintained until delivery. Davies et al5 suggest that the use of ursodiol can reduce fetal mortality associated with ICP (SOR: C, based on consensus, usual practice, opinion, disease-oriented evidence, case series).
Weekly non-stress tests beginning at the 34th week of gestation are advisable (SOR: C).2 Labor may need to be induced in the 38th week in mild cases of ICP, and in the 36th week in severe cases (SOR: C).2
Ursodiol for our patient, labor was induced
We treated our patient with oral ursodiol and topical 1% hydrocortisone cream. Her bile acids and transaminase levels dropped and her pruritus improved—though it did not completely resolve until after delivery. Our obstetrics department recommended weekly non-stress tests starting at the 34th week of gestation. The non-stress tests were reactive. Due to the severity of her condition, labor was induced at 36 weeks.
Our patient had a healthy baby girl without complications. After delivery, the itching went away completely and her skin began to heal from all of those excoriations. Our patient is planning an elective cholecystectomy in the coming months because she doesn’t want to take a chance that she might have problems with her gallstones in the future.
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