Intrahepatic cholestasis of pregnancy is characterized by pruritus, raised maternal liver enzymes and bile acids. It usually presents in the third trimester and rarely before 25 weeks. Ursodeoxycholic acid is the most promising therapy to alleviate symptoms and prevent fetal risk. However, its administration has been restricted for the last trimester as its embryotoxic effect is undetermined. We report here a case of an extremely rare, severe obstetric cholestasis with early onset treated by ursodeoxycholic acid from the 9th week of pregnancy, the earliest ever reported in the literature. The treatment was well tolerated. At the 32nd week urgent caesarean section was performed due to intolerable symptoms, worsening laboratory results and signs of fetal distress. A healthy newborn was delivered. It is concluded that ursodeoxycholic acid in case of a severe early-onset intrahepatic cholestasis may be started in the early pregnancy to improve maternal condition and prevent fetal complications.
[1]. B. A. Mullally W. F. Hansen 2002 Intrahepatic cholestasis of pregnancy: review of the literature Obstet. Gynecol. Surv. 57 47–52.
[2]. V. Keitel C. Vogt D. Häussinger et al.2006 Combined mutations of canalicular transporter proteins cause severe intrahepatic cholestasis of pregnancy Gastroenterology 131 624–629.
[3]. H. Reyes 1997 Review: intrahepatic cholestasis. A puzzling disorder of pregnancy J. Gastroenterol. Hepatol. 12 211–216.
[4]. A. P. Kenyon C. N. Piercy J. Girling et al.2002 Obstetric cholestasis, outcome with active management: a series of 70 cases BJOG 109 282–288.
[5]. T. A. Knox L. B. Olans 1996 Liver disease in pregnancy N. Engl. J. Med. 335 569–576.
[6]. J. Palma H. Reyes J. Ribalta et al.1997 Ursodeoxycholic acid in the treatment of cholestasis of pregnancy: a randomized, double-blind study controlled with placebo J. Hepatol. 27 1022–1028.
[7]. A. J. Rioseco M. B. Ivankovic A. Manzur et al.1994 Intrahepatic cholestasis of pregnancy: a retrospective case-control study of perinatal outcome Am. J. Obstet. Gynecol. 170 890–895.
[8]. S. Heinonen P. Kirkinen 1999 Pregnancy outcome with intrahepatic cholestasis Obstet. Gynecol. 94 189–193.
[9]. Y. Bacq T. Sapey M. C. Bréchot et al.1997 Intrahepatic cholestasis of pregnancy: a French prospective study Hepatology 26 358–364.
[10]. N. M. Fisk G. N. Storey 1988 Fetal outcome in obstetric cholestasis Br. J. Obstet. Gynaecol. 95 1137–1143.
[11]. O. M. Alsulyman J. G. Ouzounian M. Ames-Castro et al.1996 Intrahepatic cholestasis of pregnancy: perinatal outcome associated with expectant management Am. J. Obstet. Gynecol. 175 957–960.
[12]. M. M. Saleh K. R. Abdo 2007 Consensus on the management of obstetric cholestasis: National UK survey BJOG 114 99–103.
[13]. M. A. Serrano D. Brites M. G. Larena et al.1998 Beneficial effect of ursodeoxycholic acid on alterations induced by cholestasis of pregnancy in bile acid transport across the human placenta J. Hepatol. 28 829–839.
[14]. D. Brites C. M. Rodrigues N. Oliveira et al.1998 Correction of maternal serum bile acid profile during ursodeoxycholic acid therapy in cholestasis of pregnancy J. Hepatol. 28 91–98.
[15]. J. Palma H. Reyes J. Ribalta et al.1992 Effects of ursodeoxycholic acid in patients with intrahepatic cholestasis of pregnancy Hepatology 15 1043–1047.
[16]. J. Rudi T. Schönig W. Stremmel 1996 Therapy with ursodeoxycholic acid in primary biliary cirrhosis in pregnancy Z. Gastroenterol. 34 188–191.
[17]. K. L. Christensen B. N. Andersen H. Vilstrup 1997 Primary sclerosing cholangitis with itching treated during pregnancy with ursodeoxycholic acid Ugeskr. Laeger. 159 7151–7153.
[18]. S. Cabrita A. Areia M. Areia et al.2007 Intrahepatic cholestasis of pregnancy-atypical case J. Perinat. Med. 35S 128.
[19]. K. M. Davidson 1998 Intrahepatic cholestasis of pregnancy Semin. Perinatol. 22 104–111.
[20]. O. Braun-Falco G. Plewing H. H. Wolf et al.2000 Dermatology 2nd ed. Springer-Verlag New York 1229–1235.
[21]. S. Kenngott P. Lohse U. Beuers 2002 Intrahepatic cholestasis in pregnancy. What to consider in jaundice and pruritus MMW Fortschr. Med. 144 41–44.
[22]. M. Arrese H. Reyes 2006 Intrahepatic cholestasis of pregnancy: a past and present riddle Ann. Hepatol. 5 202–205.
[23]. J. E. Hay 2008 Liver disease in pregnancy Hepatology 47 1067–1076.
[24]. A. Floreani D. Paternoster A. Melis et al.1996 S-adenosylmethionine versus ursodeoxycholic acid in the treatment of intrahepatic cholestasis of pregnancy: preliminary results of a controlled trial Eur. J. Obstet. Gynecol. Reprod. Biol. 67 109–113.
[25]. G. Celle M. Cavanna R. Bocchini et al.1980 Chenodeoxycholic acid (CDCA) versus ursodeoxycholic acid (UDCA): a comparison of their effects in pregnant rats Arch. Int. Pharmacodyn. Ther. 246 149–158.