COMMENTARY

Liver Disease in Pregnancy

Rowen K. Zetterman, MD

Disclosures

April 08, 2013

In This Article

Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy causes pruritus and elevated serum bile acid levels; these resolve following delivery.[14] This condition is more common in women from Scandinavia, South Asia, and South America, especially Chile.[14,15] The cause of intrahepatic cholestasis during pregnancy is unclear, but it is likely to be associated with genetic factors and increased hormone levels resulting in impaired canalicular transport of bile acids.[16] Symptoms will also occur in susceptible women taking oral contraceptives. Other causes of pruritus in these patients include medications or underlying biliary tract diseases such as primary biliary cirrhosis and primary sclerosing cholangitis.

Symptoms usually develop in the late second trimester or third trimester and include generalized pruritus, especially of the palms and soles. Jaundice is uncommon. Diarrhea and steatorrhea can develop, and supplementation with fat-soluble vitamins should be considered. If intrahepatic cholestasis is likely, bile acid levels should be measured as fasting serum bile acid levels, and levels > 10 µM/L are indicative of cholestasis.[17] Bilirubin levels are usually normal but can be mildly elevated. Aminotransferase levels range from normal to < 10 times normal.

Maternal mortality is low, although fetal complications related to placental insufficiency can result in anoxia, fetal distress, prematurity, and occasionally fetal death.[17,18] Fetal complications correlate with maternal serum bile acid levels and are uncommon when maternal serum bile acid levels are < 40 µM/L.[17,19] Symptoms typically resolve with the end of pregnancy, although persistence occurs in some familial forms of cholestasis. Patients with intrahepatic cholestasis of pregnancy have an increased risk for hepatic fibrosis[20] and a 22% likelihood of future gallbladder disease.[20,21]

Patients who develop intrahepatic cholestasis of pregnancy should be referred to a perinatologist for care of their high-risk pregnancy. Ursodeoxycholic acid, 10-15 mg/kg maternal body weight, will improve maternal pruritus and liver tests,[22,23] result in better fetal outcomes,[23] and is more effective than cholestyramine or S-adenosyl-methionine. Vitamin K may be needed in the presence of steatorrhea and fat-soluble vitamin malabsorption.

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