The family physician made the diagnosis of intrahepatic cholestasis of pregnancy, a condition that is usually diagnosed based on clinical history and presentation. Patients demonstrate pruritus (with or without jaundice) and no primary skin lesions. Laboratory findings consistent with cholestasis (elevated serum bile acid levels and alkaline phosphatase levels) confirm the diagnosis. Elevated bilirubin levels may or may not be found. The etiology remains controversial.
Intrahepatic cholestasis of pregnancy usually resolves postpartum without specific treatment. It often recurs in subsequent pregnancies and patients have a higher risk of gallstones or a family history of gallstones. It is associated with a higher risk of premature delivery, meconium-stained amniotic fluid, and intrauterine demise. The pruritus of intrahepatic cholestasis of pregnancy may be treated with oral antihistamines. More severe cases require ursodeoxycholic acid (ursodiol [Actigall]) to relieve the pruritus and improve cholestasis while reducing adverse fetal outcomes.
This patient was treated with oral ursodiol and topical 1% hydrocortisone cream. The bile salts and transaminases were reduced and the patient’s pruritus improved—but did not resolve—until after delivery of a normal healthy child.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Skin findings in pregnancy. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:462.466.
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