This letter has been printed by your patient out of concern that she may have an uncommon pregnancy condition called Intrahepatic Cholestasis of Pregnancy, also referred to as Obstetric Cholestasis.

This uncommon condition of pregnancy may be overlooked because the main presenting symptom, pruritus, is often considered to be a normal side effect of pregnancy. Although itching is common during pregnancy, it is important to consider ICP as a possible diagnosis as it carries an increased risk of fetal distress, premature labour, maternal and fetal hemorrhaging, and most importantly, stillbirth.

The following guidelines have been provided by Mrs. Jenny Chambers, http://www.ocsupport.org.uk/, who works as a research assistant with an ICP team in London. Mrs. Chambers has lost two babies due to cholestasis of pregnancy and is now working with some of the best specialists in the world to provide more information to the doctors and the general public. Current research includes trying to identify the gene(s) involved in the condition (it is known to be familial) and looking at the role of bile acids.

Please keep in mind, these are only guidelines to assist you with a possible diagnosis of this rare condition. Also, please keep in mind that anti-histamines are of no clinical value for the elimination of excess bile salts, as you are probably already aware.

Here are the current guidelines as set forth by the team in London:

Diagnosis:

The mother will normally complain of generalised pruritus (itching) from around 28 weeks (although we have had presentations as early as 6 weeks pregnant) and she will generally report that it is more noticeable on extremities (particularly hands and feet) and is worse at night. Urine can be quite dark. If cholestasis is suspected the following tests would be performed:

Serum Bile Acid Test:

This is considered the definitive test for ICP because it can confirm the condition before AST or ALT levels become elevated (we have experienced false negative results with liver function tests). Tests in the USA typically take a week or longer to return. Normal range values for bile acids may differ depending on the lab where the results are evaluated. If the above tests are normal but the mother continues to itch they should be repeated. A PT should also be performed to check vitamin K absorption.

Liver Function Test:

The AST or ALT is the key indicator here, anything above 30 U/L is outside normal range for pregnancy (Girling et al: 104 pp246 1997) although this can depend on what reference values each laboratory uses. If your local laboratory uses a different reference range to that quoted by Girling et al. it is suggested that 80% of the upper limit is used i.e. a laboratory using 60 as an upper limit would be adjusted to 48. The mother does not have to be jaundiced as it thought that around only 20% of women with ICP will develop jaundice, usually a few weeks after the pruritus starts. It should also be noted that although Alkaline Phosphatase is elevated in ICP it is also elevated in pregnancy and is therefore of little clinical value in the diagnosis.

Treatment & Management:

This can vary depending on the unit but in the two specialist centres in the UK it will usually involve regular monitoring by way of CTG’s and weekly dopplar scans, the use of medication and early delivery. Once ICP has been confirmed, women will be offered Ursodeoxycholic Acid (Actigall in the USA - Urso/Ursofalk in other countries). Prescribing is usually based on 300 mgs three times daily but again this can also vary. Some units also prescribe oral Vitamin K for the mother - 10mgs daily. Cholestyramine is not considered to be a suitable drug to use in the treatment of the condition because of it effect on vitamin absorption, which is already at risk during ICP. It is thought vital that delivery of the baby is carried out by no later than 36-37 weeks even if the condition has been ‘controlled’ by the use of drugs and all biochemical results have been brought back to normal. Consideration should be given to an even earlier delivery if the condition cannot be managed i.e. serum bile acids/LFT’s continue to remain elevated or if the pruritus is becoming increasingly difficult for the mother to tolerate.

If a mother has had the condition liver function tests should be performed at about six weeks after the birth to check that all levels are back to normal and repeated if they remain elevated. If these raised levels continue for too long consideration should be given to an alternative diagnosis because in ICP liver function should return to normal relatively quickly.

To view the website this information was printed from as well as a list of medical journals that may be of some clinical value, please visit us on the web at www.itchymoms.com