Intrahepatic cholestasis of pregnancy in a chronic kidney disease patient: A case report

Authors

  • Sri Mariyani Department of Dermatology and Venereology Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada
  • Yulia Eka Irmawati Department of Dermatology and Venereology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/ 2RSUP Dr. Sardjito Hospital, Indonesia
  • Kristiana Etnawati Department of Dermatology and Venereology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/ 2RSUP Dr. Sardjito Hospital, Indonesia
  • Agnes Sri Siswati Department of Dermatology and Venereology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada/ 2RSUP Dr. Sardjito Hospital, Indonesia

Keywords:

ICP, CKD, pruritus, obstetric cholestasis, pruritus uremicum

Abstract

The pregnancy-specific liver condition known as intrahepatic cholestasis of pregnancy (ICP) is characterized by pruritus throughout the third trimester of pregnancy and elevated serum transaminases. ICP in patients with CKD can obscure the diagnosis. Fetal risks whose mothers suffer from ICP must be monitored. Case: 32-year-old woman 29 weeks pregnant with a history of CKD and routine hemodialysis, complaints of itching appeared on the palms and legs that extended into the abdomen and back in the final trimester of pregnancy. The serum transaminase results are within normal limits. Topical emollients are given as therapy. Babies are born prematurely with low birth weight and asphyxia. The baby dies at the age of 3 days. The patient's itching complaints are reduced after delivery. Discussion: The diagnosis of ICP is based on pruritus complaints on both palms and feet in late trimester pregnancy. Increased serum aminotransferase levels are a clue to the diagnosis. Normal serum aminotransferase is due to a deficiency in its coenzyme formation due to CKD. ICP therapy is non-specific and systemic. Increased levels of maternal bile acids cause the failure of pulmonary surfactant and increase oxytocin resulting in premature labor. Chorionic venous vasoconstriction and placental oxidative stress cause low birth weight in infants. Conclusion: Pruritus with or without skin changes in the last trimester of pregnancy should consider the possibility of ICP. CKD patients have normal or lower serum aminotransferase levels. Strict supervision of the fetus should carried out.  

References

Floreani A, Gervasi M. New Insights on Intrahepatic Cholestasis of Pregnancy. Clin Liver Dis. 2016;20(1):177-89.

Stulic M, Culafic D, Boricic I, Stojkovic Lalosevic M, Pejic N, et al. Intrahepatic Cholestasis of Pregnancy: A Case Study of the Rare Onset in the First Trimester. Medicina (B Aires). 2019;55(8):454.

Bartolone S, Mayrovitz H. Intrahepatic Cholestasis of Pregnancy: Role of Baby's Sex on Itch Severity and Bile Acid Levels. Cureus. 2021;13(3):e14089.

Keitel V, Dröge C, Stepanow S, Fehm T, Mayatepek E, et al. Intrahepatic cholestasis of pregnancy (ICP): case report and review of the literature. Z Gastroenterol. 2016;54(12):1327-33.

Estela Nogueira, Iolanda Godinho, Joana Dias, Inês Martins, Mónica Centeno, Luisa Pinto. FP126 Maternal, obstetric and fetal outcomes in CKD pregnant woman - 7 years experience of a renal pregnancy clinic at Lisbon. Nephrology Dialysis Transplantation. 2018;33(suppl_1):i19-i.

Tangren J, Nadel M, Hladunewich M. Pregnancy and End-Stage Renal Disease. Blood Purif. 2018;45:194-200.

Furaz-Czerpak K, Fernández-Juárez G, Moreno-de la Higuera M, Corchete-Prats E, Puente-García A, et al. Pregnancy in women on chronic dialysis: a review. Nefrologia. 2012;32(3):287-94.

Malhotra J, Hospitals R, Agrawal P, Garg R. Pruritus in Pregnancy. J South Asian Feder Obst Gynae. 2013;5(3):142-6.

Lammert F, Marschall H, Glantz A, Matern S. Intrahepatic cholestasis of pregnancy: molecular pathogenesis, diagnosis, and management. J Hepatol. 2000;33:1012–21.

Ghosh S, Chaudhuri S. Intra-hepatic Cholestasis of Pregnancy: A Comprehensive Review. Indian J Dermatol. 2013;58(4):327.

Baros A, Cirstoiu M, Bohiltea R, Bratila E, Navolan D, et al. Intrahepatic cholestasis of pregnancy. Case report. Ginecoeu. 2016;12(2):64-6.

Fabrizi F, Lunghi G, Finazzi S, Colucci P, Pagano A, et al. Decreased serum aminotransferase activity in patients with chronic renal failure: impact on the detection of viral hepatitis. Am J Kidney Dis. 2001;38(5):1009-15.

Marschall H. Management of intrahepatic cholestasis of pregnancy. Expert Rev Gastroenterol Hepatol. 2015;9(10):1273-9.

Downloads

Published

2023-03-05

How to Cite

1.
Sri Mariyani, Yulia Eka Irmawati, Kristiana Etnawati, Agnes Sri Siswati. Intrahepatic cholestasis of pregnancy in a chronic kidney disease patient: A case report. J Pak Assoc Dermatol [Internet]. 2023Mar.5 [cited 2024Jun.17];33(1):289-93. Available from: https://www.jpad.com.pk/index.php/jpad/article/view/2006

Issue

Section

Case Reports