1、ICPINTRAHEPATIC INTRAHEPATIC CHOLESTASIS OF CHOLESTASIS OF PREGNANCYPREGNANCY Intrahepatic cholestasis of pregnancy(ICP)is a reversible condition of cholestasis that happens usually in the third trimester.Findings such as pruritus,high serum bile acids levels,and abnormal liver function tests usuall
2、y resolve after delivery.It is a liver disease of pregnancy associated with raised serum bile acids and increased rates of adverse fetal outcomesadverse fetal outcomes.Obstetric CholestasisWHAT IS ICPICP is more prevalent in Scandinavian and South American countries.Prevalence in Europe,United State
3、s,Canada and Australia is 0.1%to 1.5%.More prevalent in south China,Yangtze valley(14%)ICP was associated with an increase in the risk of developing hepatobiliary diseases later in life,such as hepatitis C,cirrhosis,and gallstones.EPIDEMIOLOGYGenetic predisposition:MDR3(ABCB4)?ABCB11?ATP8B1?-not sur
4、e.Hormones:ICP happens late in pregnancy and has a higher incidence in multiple gestation pregnancies,and that it resolves after delivery when sex hormones(estrogen)levels fall?Environment:seasonal variation、seleniumFamilial tendency.PATHOGENESISPATHOGENESIS-NOT CLEAR-NOT CLEARPruritus-marked dermat
5、itisPostpartum hemorrhageHepatic impairmentMATERNAL RISKIntrauterine death(5%of full-term stillbirth)Fetal distressPrematurityMeconium-stained amniotic fluid RDSFETAL RISKICP usually commences in the third trimester although earlier start in the second trimester has been reported.The most common sym
6、ptom is PRURITUS.Severity of pruritus increases at night and can involve the palms and soles.Other symptoms include steatorrhea,malabsorption of fat-soluble vitamins,and weight loss.ICP seems also to increase the incidence of gallstones and cholecystitis.CLINICAL PRESENTATIONCLINICAL PRESENTATIONFas
7、ting serum bile acids level 10 mol/L.Aminotransferases can be elevated as well up to 2-10 folds.Clinical jaundice is detected in 10%-15%of the cases only and bilirubin levels rarely exceed 100 mol/L.Liver biopsy can reveal bland cholestasis(intrahepatic cholestasis without parenchymal inflammation).
8、DIAGNOSISMILDSerum bile acids level 1039 mol/LBilirubin 12 mol/LPruritusSEVERESerum bile acids level 40 mol/Lbilirubin mol/LSevere pruritusOther complications：PE、TwinDEGREEDermatitisAcute fatty Liver of pregnancyHepatitisHELLP syndromeDEFERENTIAL DIAGNOSIS The aims of management are to reduce sympto
9、ms and biochemical abnormalities in the mother and to reduce the risk of fetal distress,preterm delivery and sudden fetal death.A.General:fetal monitorB.DrugsC.Obstetrical managementMANAGEMENTUrsodeoxycholic acid(UDCA,熊去氧胆酸):15mg/kg/DS-adenosyl-methionine（SAM,思美泰）:1g/DDexamethasoneDexamethasone:Vita
10、min K:Vitamin K:DRUGDRUGTERM:No evidence is strong enough to recommend early delivery(37wk)METHOD:Vaginal delivery:a)Mildb)40wk C-section:a)Severeb)Abnormal historyc)Fetal distressd)Other complicationsOBSTETRICAL TREATMENT Although ICP is a benign condition for the mother,poor fetal outcomes can occ
11、ur.Most women have no lasting hepatic damage,but ICP recurs in the majority of cases,with variations in intensity in subsequent pregnancies.Long-term follow-up studies have shown an increased risk of gallstones,non-alcoholic cirrhosis and pancreatitis,hepatitis C and autoimmune Hepatitis.PROGNOSISPROGNOSISTHE OUTCOMEISEVERYTHING
