Review Note

Intra-hepatic Cholestasis of Pregnancy (IHCP)

• The second most frequent cause of cholestasis and jaundice during pregnancy (after viral hepatitis).
• Many cases are subclinical, and recurrence in subsequent pregnancies is common.
• Genetic predisposition increases the risk of cholestasis during pregnancy or while using oral contraceptive pills (OCP).

Pathophysiology:

• Dysfunction of bile secretion by hepatocellular transporters, leading to intracellular accumulation of toxic bile acids, which causes liver cell injury.
• Liver biopsy shows:
  • Dilated bile canaliculi.
  • Minimal inflammatory response.
  • Non-specific cholestasis.
• Pruritus results from a reduction in bile flow and bile salt excretion, typically starting in the extremities before extending to the trunk and face.

Obstetric Implications:

• Maternal complications are generally limited, but fetal outcomes may be significantly impacted.
  • Transfer of toxic bile acids from mother to fetus can result in:
    • Intrauterine fetal death (IUFD).
    • Small for gestational age (SGA) infants.
    • Prematurity.
• Close maternal-fetal surveillance is essential.
• Ursodeoxycholic acid (UDCA) is the main treatment:
  • Displaces toxic bile acids from hepatic membranes, reducing maternal and fetal levels.
  • Results in improvement of pruritus, bile acids, and ALT levels.
• Delivery should occur near term after confirmation of fetal lung maturity or earlier if fetal compromise is noted.
• IHCP resolves within 24 hours of delivery, though jaundice and abnormal liver function tests may persist for several months.

Anaesthetic Implications:

• Coagulopathy may develop due to impaired absorption of fat-soluble vitamins (K, A, D, E).
• Increased risk of postpartum hemorrhage (PPH) due to potential coagulopathy.
• Ondansetron may be effective in treating pruritus associated with IHCP.