A 31-year-old G2P1A0L1 presented to our clinic for follow up at 20 weeks of gestation with the diagnosis of ICP. The patient reported that her symptoms started as early as 10 weeks of gestation of her spontaneously conceived pregnancy. Initially the patient used topical steroids in an attempt to relieve her symptoms to no avail. She later sought medical attention from several dermatologists who prescribed creams for eczema and dermatitis that included lotions, antihistamines and oral steroids reaching 40 mg daily also to no avail. Despite two weeks of treatment the pruritis increased in severity and at this point ICP was suspected for which total bile acid salts TBAS as well as liver function tests were ordered. The patient discontinued her previous medications and was started prophylactically on ursodeoxycholic acid (UDCA) at a dose of 250 mg TID. At 18 weeks of gestation the results of her laboratory tests showed an increase in TBAS of 9.1. At this point the patient was referred to a maternal fetal medicine specialist at our center.
At our clinic, the patient was followed every 3 weeks with out-patient clinic visits until 33 weeks of gestation and then weekly afterwards. Nonstress tests were performed twice weekly as of 28 WG and follow up growth scans at 2-3 week intervals. The estimated fetal weight was within 50th percentile range at all times. The levels of TBAS were measured every 3 weeks. Her UDCA doses were modified depending on her serum bile salt values. The patients' TBAS values are presented in Figure 1.
By the end of her pregnancy she was receiving 2000 mg daily of UDCA with mild tolerable symptoms. Her liver function tests were within the normal limits at all times during pregnancy. SGOT values ranged between 13 and 20 U/L, SGPT values ranged between 8 and 14 U/L, while bilirubin was less than 0.1 mg/dl.
The patient was induced at 37+1 weeks of gestation using misoprostol and then followed by oxytocin for labor augmentation. The patient progressed smoothly to full dilation within 12 hours of induction. She delivered a live born male of weight 3340 grams and Apagr score of 8 and 9 at 1 and 5 minutes respectively. The patient and her child were discharged home on the day 1 post vaginal delivery in a stable condition. Follow up TBAS 1-week post-partum revealed a value of 5.9 micro-mol/L, with complete resolution of symptoms. The patient provided an informed consent with which we were given permission to access her medical chart.