LIVER DISEASE

INTRAHEPATIC CHOLESTASIS OF

PREGNANCY

A   31-year-old primigravida    woman   with    a   history of  infertility underwent

ovulation   induction.  She is  now at  20  weeks’  gestation   with    dizygotic   twins

of  different   genders.    She is  of  Swedish descent and complains   of  intense

skin-itching.   She has not experienced these   symptoms    previously. Her sister

experienced similar complaints  when    she was pregnant,   and delivered   her

baby    prematurely.    No  identifiable    rash    is  noted   on  physical    examination.

She states  that    her urine   appears dark-colored.

Intrahepatic cholestasis is stimulated by estrogen in genetically predisposed
women in the second half of pregnancy. Bile acids are incompletely cleared by
the liver and accumulate in the plasma. There is a high recurrence rate with
subsequent pregnancies.

The overall prevalence is 0.5% in North America and Europe. Risk is increased
in Chile, Finland, and Sweden, (as is twin pregnancy).

Clinical Findings. The most significant symptom is intractable pruritus on the
palms and soles of the feet—worse at night—without specific skin findings. Lab
tests show a mild elevation of bilirubin but diagnostic findings are serum bile
acids increased 10- to 100-fold.