विवरण
Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that occurs during pregnancy, characterized by impaired bile flow and elevated levels of bile acids in the bloodstream. The exact cause of ICP is not fully understood, but hormonal changes, genetic predisposition, and environmental factors are believed to play a role. Symptoms typically manifest in the third trimester and include intense itching, especially on the palms of the hands and soles of the feet. It is associated with an increased risk of adverse pregnancy outcomes, such as preterm birth, fetal distress, and stillbirth. Increased levels of bile acids can cause complications for the fetus, including respiratory distress syndrome and meconium staining. Regular monitoring of maternal and fetal well-being is crucial in managing ICP. This may involve frequent liver function tests, bile acid measurements, and fetal movement assessments. Women with ICP may require additional antenatal visits and closer surveillance during pregnancy. It usually resolves spontaneously after delivery, and symptoms improve within a few days or weeks postpartum.
सारांश
- Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder characterized by generalized pruritus without skin lesions, elevated serum bile acids, typically developing in the second or third trimester, and resolving rapidly postpartum. Incidence varies globally, with higher rates in certain ethnic groups. Obstetricians must understand ICP management to minimize stillbirth risk.
- Liver anatomy and physiology are critical. The liver performs over 500 vital functions including glucose metabolism, bile pigment excretion, and synthesis of albumin and coagulation factors. Bile acids, products of cholesterol metabolism, are secreted into the duodenum and undergo enterohepatic circulation, aiding in fat absorption and acting as signaling molecules.
- Cholestasis, a reduction or stoppage of bile flow, can be intrahepatic or extrahepatic. In pregnancy, high estrogen levels inhibit bile secretion, leading to bile buildup in the liver and increased bile acid levels in the bloodstream. Etiology includes genetic susceptibility, hormonal influences (estrogen, progesterone), and environmental factors (low selenium, vitamin D).
- Clinical presentation includes pruritus (often on palms and soles, worse at night), right upper quadrant pain, nausea, poor appetite, and sleep deprivation. Scratch marks may be present, but primary skin lesions are absent. Jaundice is rare. Risk factors include personal or family history of ICP, advanced maternal age, multiple pregnancy, and pre-existing hepatobiliary disease.
- Diagnosis is confirmed by elevated serum bile acids (thresholds vary by guideline, ACO and RCOG). Liver enzymes (AST, ALT) may be mildly elevated. Liver imaging is usually normal. Additional testing is only recommended if the presentation is atypical or suggests another underlying disease. Differential diagnoses include other causes of pruritus, liver disease, and systemic conditions.
- ICP is classified based on bile acid levels: gestational pruritus (100 micromol/L). Fetal risks include increased risk of stillbirth, meconium-stained amniotic fluid, preterm birth, and neonatal respiratory distress syndrome. Maternal risks include gestational diabetes, preeclampsia, and potential for hepatobiliary disease later in life.
- Management involves monitoring liver function tests and bile acids, with frequency determined by symptom severity, bile acid levels, gestational age, and comorbidities. Fetal monitoring (ultrasound, Doppler, CTG) doesn't prevent stillbirth, but women should monitor fetal movements. Ursodeoxycholic acid (UDCA) is the primary treatment, altering the bile acid pool, improving mitochondrial integrity, and having anti-apoptotic and choleretic actions.
- Timing of birth depends on disease severity and guidelines (ACO vs. RCOG). ACOG recommends delivery at 36 weeks for severe cases (>100 micromol/L) and 36-39 weeks for less severe cases, based on bile acid levels. Antenatal corticosteroids should be administered for deliveries before 37 weeks. Mode of delivery is determined by obstetric factors. Continuous fetal monitoring is recommended during labor for severe ICP cases.
- Postpartum follow-up at four weeks is essential to confirm resolution of ICP. If bile acids or liver enzymes remain abnormal, further investigation by a hepatologist is needed. Recurrence risk in subsequent pregnancies is high (60-90%). Baseline liver function tests and bile acids should be offered in future pregnancies. Contraceptive options must be considered, with certain methods preferred based on UK medical eligibility criteria.
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