Cholestasis of pregnancy
This condition occurs in about 1:1000 pregnancies in the United States. Although it may occur in any trimester, patients will usually present in the third trimester with complaints of new-onset itching throughout their body but notably on their hands (palms) and feet (soles). Usually there will be no rash / visible findings at time of examination. Symptoms are often worse at night and can vary in severity from mild to severe. Patients may also complain of right upper quadrant pain, fatigue, a change in the color of their bowel movements, or jaundice.
Bile acids cross the placenta and can build up in the fetus. Risks to the fetus include fetal demise in utero (FDIU), meconium-stained amniotic fluid, preterm delivery, and respiratory distress.
O26.619 – Liver and biliary tract disorders in pregnancy, unspecified trimester
235888006 – Cholestasis of pregnancy
Differential Diagnosis & Pitfalls
- Polymorphic eruption of pregnancy (PEP) / pruritic urticarial papules and plaques of pregnancy (PUPPP) – usually has itching as a focal factor, but mainly in areas of stretchmarks and with a periumbilical-sparing rash.
- Acute fatty liver of pregnancy – elevated liver function tests (LFTs), abdominal pain, nausea, and central nervous system abnormalities. Emergency condition that requires immediate action.
- Gallstones – liver test abnormalities, suggestive imaging, elevated WBC count.
- Biliary disease (eg, cholecystitis, cholangitis)
- Liver abscess (eg, amebic, pyogenic)
- Hepatitis B or hepatitis C
- Atopic dermatitis
- Preeclampsia – usually not associated with itching, will have proteinuria and elevated blood pressures.