The Bile Dam: Care of the Patient with Intrahepatic Cholestasis of Pregnancy

Background: Intrahepatic cholestasis of pregnancy (ICP) may affect women from the 28th week of pregnancy to 2-3 weeks after delivery. Researchers have discovered many factors responsible for ICP, such as genetics, environment, and hormones. Since delivery is the cure for ICP, clinicians must weigh the risk of induction vs the risk of fetal death, a consequence of ICP. Even vigilant fetal surveillance has not prevented, in certain cases, fetal death. Other researchers have demonstrated that the increased risk of respiratory  distress syndrome (RDS) in the newborn may be attributed to the ICP itself rather than labor induction at late preterm.

Case: Patients presenting with ICP have intolerable itching; they also face a decision-making process, with their providers, whether to undergo labor induction. The diagnosis of ICP, made through both the evidence of maternal pruritis and abnormal lab values, then poses  the question of how much fetal surveillance is truly enough, how to treat the pruritis, when and if amniocentesis for lung maturity is warranted, and when and if labor should be induced. A case study will be highlighted of a patient with ICP . She had pruritis and abonormal bile acid levels.  During  fetal surveillance,a  biophysical profile, a score of 6/10 was given for no breathing and non-reactive tracing. She and her physicians decided to induce labor that day, at 37 weeks. Her baby was admitted to NICU, diagnosed with pulmonary hypertension and RDS, and was discharged to home after 14 days in NICU.

Conclusion: Research findings  support both  early delivery of patients with ICP and support expectant management to term. Nursing interventions include relief of maternal pruritis, fetal surveillance, and monitoring lab changes. Nurses also work closely with patients and families to support their decision making process about early delivery. Nurses are vital to teaching patients about fetal activity changes and other signs and symptoms pertaining to fetal and maternal well-being.

Keywords: Cholestasis; bile flow and obstruction; pruritis