Abstract
Intrahepatic cholestasis of pregnancy (ICP), the most common liver disorder of pregnancy, is associated with complications for both a pregnant person and their fetus. The underlying cause is not well understood. The pruritus associated with ICP is uncomfortable for pregnant people; however, the primary concern is the fetal risk. Fetal risks include preterm labor and birth and intrauterine fetal demise. This is particularly significant for certain populations because of the disparities in incidence of ICP; in the United States, it disproportionately affects Latinx people, the largest and fastest-growing minority population. Diagnosis, monitoring, and treatment of ICP are vital to reduce discomfort from pruritis and avoid potential fetal demise. However, diagnosis and treatment are complicated by the lack of definitive diagnostic criteria, the frequent delay in laboratory analysis, and the cost of treatment. This case report aims to improve midwives' familiarity with ICP and discusses the epidemiology, risk factors, presentation, diagnostic criteria, and available management strategies for this disease as well as the importance of anticipatory guidance regarding increased lifetime risk of ICP in future pregnancies and hepatobiliary disease. Additionally, it discusses the challenges involved in diagnosis and access to treatment. Prompt diagnosis and initiation of treatment may reduce fetal morbidity and mortality. J Midwifery Womens Health ;:– c by the American College of Nurse-Midwives. CASE SUMMARY M.C. is a-year-old gravida , para K'iche' woman from Guatemala who presented for her first prenatal visit at weeks' gestation. Her history includes prior term pregnancies, the third of which in was complicated by intrahepatic cholesta-sis of pregnancy (ICP). She had a history of a cholecystectomy in. The remainder of her health history and review of systems was noncontributory. At her routine prenatal visit at weeks' gestation M.C. reported to the midwife that she was intermittently itchy and attributed it to dry skin. She was using an oatmeal salve with good relief. Upon examination she had no rash. Because of her prior pregnancy history and her itching the midwife recommended fasting total bile acids, alanine transaminase (ALT) and aspar-tate transaminase (AST) to check M.C. for possible ICP. The laboratory results were as follows: ALT U/L, AST U/L, and total bile acids. µmol/L. These were reported as normal by the laboratory. The midwife provided reassurance and recommended continuing with routine prenatal care. At a later visit at weeks and days' gestation, M.C. reported increased itching, particularly at night. On examination, her legs were excoriated from scratching. Because of her worsening itching, her midwife recommended repeating the fasting total bile acids, ALT, and AST to again rule out ICP. A high suspicion of ICP was discussed with M.C., and a plan was made to reassess once the laboratory results were available.