Cholestasis of pregnancy: Difference between revisions
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*Caused by combination of hormonal, genetic, and environmental factors --> impaired bile flow --> deposition of bile salts in skin and placenta | *Caused by combination of hormonal, genetic, and environmental factors --> impaired bile flow --> deposition of bile salts in skin and placenta | ||
*May predispose mothers to [[vitamin K deficiency]] and increase risk of preterm delivery, [[IUFD]], and neonatal [[respiratory distress syndrome]]<ref>http://bestpractice.bmj.com/topics/en-us/800</ref> | *May predispose mothers to [[vitamin K deficiency]] and increase risk of preterm delivery, [[IUFD]], and neonatal [[respiratory distress syndrome]]<ref>http://bestpractice.bmj.com/topics/en-us/800</ref> | ||
{{Gallbladder disease types}} | |||
==Clinical Features== | ==Clinical Features== | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Jaundice DDX}} | |||
===Pregnancy-specific pruritus=== | |||
''see also: [[Rashes of pregnancy]]'' | |||
*Pruritus gravidarum | |||
*Atopic eruption of pregnancy | |||
*Polymorphic eruption of pregnancy | |||
*Pemphigoid gestationis | |||
*Prurigo of pregnancy | |||
*Pruritic folliculitis of pregnancy | |||
==Evaluation== | ==Evaluation== |
Latest revision as of 23:38, 28 February 2024
Background
- Caused by combination of hormonal, genetic, and environmental factors --> impaired bile flow --> deposition of bile salts in skin and placenta
- May predispose mothers to vitamin K deficiency and increase risk of preterm delivery, IUFD, and neonatal respiratory distress syndrome[1]
Gallbladder disease types
- Symptomatic cholelithiasis (biliary colic)
- Choledocholithiasis
- Acute calculous cholecystitis
- Ascending cholangitis
- Acalculous cholecystitis
- Biliary atresia
- Cholestasis of pregnancy
Clinical Features
- Typically develops in late second and/or 3rd trimester
- Rapidly resolves after delivery
- Pruritus, starts and predominates on palms and soles
- RUQ pain
- Nausea
- Jaundice
Differential Diagnosis
Jaundice
Indirect Hyperbilirubinemia
- Hemolytic
- G6PD
- Drug related
- Autoimmune hemolytic anemia
- Hematoma resorption
- Ineffective erythropoiesis
- Gilbert's
Direct (Conjugated) Hyperbilirubinemia
- Choledocholithiasis
- Cholecystitis
- Ascending cholangitis
- AIDS cholangiopathy
- Stricture
- Neoplasm
- Pancreatic head
- Gallbladder
- Primary liver (e.g. hepatocellular carcinoma)
- Metastatic
- Obstructing AAA
Hepatocellular damage
Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase
- Viral hepatitis
- Fulminant hepatic failure
- alcoholic hepatitis
- Ischemic hepatitis
- Toxins
- Isoniazid
- Phenytoin
- acetaminophen
- Ritonavir
- Halothane
- Sulfonamide
- Autoimmune hepatitis
- Primary biliary cirrhosis
- HELLP Syndrome
- Congestive Hepatopathy
Pregnancy Related
Transplant Related
Pediatric Related
- Inborn error of metabolism
- Neonatal jaundice (physiologic)
Additional Differential Diagnosis
- Reye syndrome
- TPN
- Heatstroke
- Budd-Chiari (with acute ascites)
- Wilson's disease
- Sarcoidosis
- Amyloidosis
Masqueraders
Only bilirubin stains the sclera
- Carotenemia
- Quinacrine ingestion
- Dinitrophenol, teryl (explosive chemicals)
Pregnancy-specific pruritus
see also: Rashes of pregnancy
- Pruritus gravidarum
- Atopic eruption of pregnancy
- Polymorphic eruption of pregnancy
- Pemphigoid gestationis
- Prurigo of pregnancy
- Pruritic folliculitis of pregnancy
Evaluation
- CBC (rule out thrombocytopenia)
- LFTs
- Elevated total bile acid concentration
- Aminotransferases usually <2x upper limit of normal
- Alk phos and bili may be elevated
- GGT normal or modestly elevated
- RUQ US normal, no biliary duct dilation
Management
- Ursodeoxycholic acid (ursodiol) 300mg TID until delivery
- OBGYN follow-up
Disposition
- Discharge with OBGYN follow-up
See Also
External Links
References
https://www.uptodate.com/contents/intrahepatic-cholestasis-of-pregnancy