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Rationale:
ICP has a 60%-70% recurrence rate, and therefore, this patient is at high risk of recurrence. Ursodeoxycholic acid (UDCA) has been shown to reduce pruritus and improve bile acid levels and liver-associated enzymes. There is also evidence that UDCA is safe late in pregnancy and likely improves fetal outcomes. Cholestyramine is not as effective as UCDA at reducing pruritus, reducing bile acid levels, or normalizing aminotransferase. In addition, babies are delivered closer to term with UDCA as opposed to cholestyramine. Hydroxyzine improves pruritus but can aggravate respiratory issues in preterm babies and is not recommended in ICP. Given these findings, UDCA is considered first-line therapy in treatment of ICP. A recent study showed that the perinatal mortality is decreased with delivery of the baby at 36 weeks gestation, or if ICP develops past 36 weeks, delivery with onset of symptoms. Thus, optimal management if her current pregnancy mimics the previous pregnancy if UDCA is given with development of symptoms with planned delivery at approximately 36-37 weeks gestation.
References
1. Bacq Y, Sentilhes L, Reyes HB, et al. Efficacy of ursodeoxycholic acid in treating intrahepatic cholestasis of pregnancy: a meta-analysis. Gastroenterology. 2012;143(6):1492-501.
2. Kondrackiene J, Beurers U, Kupcinskas L. Efficacy and safety of ursodeoxycholic acid versus cholestyramine in intrahepatic cholestasis of pregnancy. Gastroenterology. 2005;129(3):894-901.
3. Puljic A, Kim E, Page J, et al. The risk of fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age. Am J Obstet Gynecol. 2015;212(5):667e1-5.
Rationale:
ICP has a 60%-70% recurrence rate, and therefore, this patient is at high risk of recurrence. Ursodeoxycholic acid (UDCA) has been shown to reduce pruritus and improve bile acid levels and liver-associated enzymes. There is also evidence that UDCA is safe late in pregnancy and likely improves fetal outcomes. Cholestyramine is not as effective as UCDA at reducing pruritus, reducing bile acid levels, or normalizing aminotransferase. In addition, babies are delivered closer to term with UDCA as opposed to cholestyramine. Hydroxyzine improves pruritus but can aggravate respiratory issues in preterm babies and is not recommended in ICP. Given these findings, UDCA is considered first-line therapy in treatment of ICP. A recent study showed that the perinatal mortality is decreased with delivery of the baby at 36 weeks gestation, or if ICP develops past 36 weeks, delivery with onset of symptoms. Thus, optimal management if her current pregnancy mimics the previous pregnancy if UDCA is given with development of symptoms with planned delivery at approximately 36-37 weeks gestation.
References
1. Bacq Y, Sentilhes L, Reyes HB, et al. Efficacy of ursodeoxycholic acid in treating intrahepatic cholestasis of pregnancy: a meta-analysis. Gastroenterology. 2012;143(6):1492-501.
2. Kondrackiene J, Beurers U, Kupcinskas L. Efficacy and safety of ursodeoxycholic acid versus cholestyramine in intrahepatic cholestasis of pregnancy. Gastroenterology. 2005;129(3):894-901.
3. Puljic A, Kim E, Page J, et al. The risk of fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age. Am J Obstet Gynecol. 2015;212(5):667e1-5.
Rationale:
ICP has a 60%-70% recurrence rate, and therefore, this patient is at high risk of recurrence. Ursodeoxycholic acid (UDCA) has been shown to reduce pruritus and improve bile acid levels and liver-associated enzymes. There is also evidence that UDCA is safe late in pregnancy and likely improves fetal outcomes. Cholestyramine is not as effective as UCDA at reducing pruritus, reducing bile acid levels, or normalizing aminotransferase. In addition, babies are delivered closer to term with UDCA as opposed to cholestyramine. Hydroxyzine improves pruritus but can aggravate respiratory issues in preterm babies and is not recommended in ICP. Given these findings, UDCA is considered first-line therapy in treatment of ICP. A recent study showed that the perinatal mortality is decreased with delivery of the baby at 36 weeks gestation, or if ICP develops past 36 weeks, delivery with onset of symptoms. Thus, optimal management if her current pregnancy mimics the previous pregnancy if UDCA is given with development of symptoms with planned delivery at approximately 36-37 weeks gestation.
References
1. Bacq Y, Sentilhes L, Reyes HB, et al. Efficacy of ursodeoxycholic acid in treating intrahepatic cholestasis of pregnancy: a meta-analysis. Gastroenterology. 2012;143(6):1492-501.
2. Kondrackiene J, Beurers U, Kupcinskas L. Efficacy and safety of ursodeoxycholic acid versus cholestyramine in intrahepatic cholestasis of pregnancy. Gastroenterology. 2005;129(3):894-901.
3. Puljic A, Kim E, Page J, et al. The risk of fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age. Am J Obstet Gynecol. 2015;212(5):667e1-5.
A 31-year-old G2P1 woman presents to your clinic for pregnancy counseling. She is currently 12 weeks pregnant, and states that her first pregnancy was complicated by intrahepatic cholestasis of pregnancy (ICP) development at 29 weeks. She developed severe pruritus, and the baby was delivered prematurely. She is concerned about complications with her current pregnancy and is wondering about therapy if ICP recurred at the same point in her pregnancy.