妊娠期肝内胆汁淤积症(intrahepatic cholestasisof pregnancy，ICP)是一种在妊娠期出现瘙痒及黄疸为特点的重要的妊娠期并发症，现在在中国内已普遍引起重视。ICP的早产率及围生儿死亡率高，其发病原因虽未完全阐明，但已知与雌激素有密切关系。

妊娠期肝内胆汁淤积症 - 概述

胆汁淤积症

ICP是一个谜一般的疾病对ICP的认识和命名经历一个较长的历程：早在1883年Ahlfeld首次报道一种在妊娠晚期出现并在以後妊娠中有复发倾向黄疸的妊娠并发症，直至1954年Svanborg及1955年Thorling对该病从组织病理学、症状学作了研究，并有比较详细的阐述後，不少学者又对ICP的流行病学及诊断学作了深入的探讨认识到本病是以肝内胆汁淤积为特点的疾病，1976年Reid明确提出ICP虽对母体无严重危害，但对围生儿却有发生宫内窘迫使围生儿死亡的不良影响，对ICP的研究开拓了一个新领域。由此，根据各个阶段对它的认识，曾经有过不同的命名：开始时由于同一患者每次妊娠晚期发生黄疸而发现本病故称之为妊娠期复发性黄疸(recurrentjaundiceofpregnancy)，後来又因其发生于妊娠期，表现为良性过程，故称之为特发性妊娠期黄疸(idiopathicjaundiceofpregnancy)，20世纪60年代以後，根据ICP的病理特征而改称为产科胆汁淤积症(obstetriccholestasis)，1960年Hammerli首次用ICP的命名，70年代以後，绝大多数学者在文献中普遍采用ICP为病名以与其他胆汁淤积症相区别。

在中国，1964年胡宏远等首次报道1例妊娠期复发性黄疸。至1984年吴味辛对重庆地区及1986年戴钟英对

妊娠期肝内胆汁淤积症 - 流行病学

结构图

1.发病率ICP健康搜索在各个国家的发病率有很大差异，南美的玻利维亚是高发地区。其中以智利的发病率最高，妊娠瘙痒高达13.2％，妊娠合并胆汁淤积发生率为2.4%Reyes发现智利的Araucanian印第安混血种人的ICP发生率最高，妊娠瘙痒高达22.1%，妊娠合并胆汁淤积性黄疸高达5.5%，提示该病的发生与种族及遗传学有关。中国上海等地区的发生率亦高，是应该引起注意的。

2.家族性不少文献报道ICP有家族性发生的倾向。早在1965年Holzbach报告1一例典型的家族性ICP病例，患者第12、3次妊娠均有严重瘙痒，第4胎为ICP，产後恢复正常但在服用固醇类激素激惹试验和组织相容性试验，结果表明ICP的亲代遗传是按照孟德尔优势遗传的模式进行的。因此Holzbach认为本症确有遗传的特点，家族中的男性可以是携带者，其表型是被抑制的。

3.基因研究，对有遗传性倾向的疾病其分子水平的研究已经成为病因学的重点。Jansen等(2000)对进行性家族性肝内胆汁淤积症(progressivefamilialintrahepaticcholestasis，PFIC)的基因水平作了阐述。他们将之分为3型鶒，：PFICⅠ型及Ⅱ型是各为染色体18及染色体2中位点的突变。PFlCⅡ型及Ⅲ型引起肝胆系统分泌胆酸和磷脂的缺陷。良性复发性肝内胆汁淤积(benignrecurrentintrahepaticcholestasis，BRIC)是与同样的家族性肝内胆汁淤积染色体18的1位点的突变相联系。胆酸合成的缺陷可能难以与这些转运的缺陷区分，ICP是与这些胆汁缺陷有关。

妊娠期肝内胆汁淤积症 - 病因

ICP是一种表现比较特殊的疾病，近20年来很多学者致力于ICP的发病机制研究，其确切的发病原因尚未十分明确，但从大量的流行病学材料以及临床观察及实验室研究，可以认为本病的发病原因与雌激素升高、发生率的地区差异以及遗传因素有密切关系。现在，尚有学者提出ICP可能与抗心磷脂抗体亦有关系。

妊娠期肝内胆汁淤积症 - 发病机制

细胞图

1.雌激素与ICP的关系

(1)临床依据：在临床上有很多表现提示雌激素水平过高可能是诱发ICP的病因，现列举如下：①ICP多发生在妊娠晚期，正值雌激素分泌的高峰期；②ICP在双胎中发生率较单胎明显增高，肝窦间隙区钠、钾-三磷酸苷酶(Na -K -ATPase)活性下降使胆盐转运受到阻碍；③窦状隙区域细胞膜的流动性下降，使胆盐的通过发生障碍；④雌激素代谢产物：D环葡萄糖醛酸雌激素与胆酸的结构相似而成为胆酸载体的竞争性抑制物。妊娠期产生大量雌激素导致妊娠期某些妇女的胆汁淤积；⑤肝的雌激素受体以及蛋白合成：人们推测雌激素可以使有机阴离子及胆酸载体合成减少，还影响细胞内结合蛋白的有机阴离子的易位、分泌小泡至胆小管区域的运行等。

2.ICP与孕激素的关系

胎盘分泌的激素，尽管人类通常对孕激素有良好的耐受性，但是晚近鶒的临床的观察及实验发现孕激素与ICP的发病也存在关系。Bacq等(1998)研究13例 ICP病人，其中10例发展成ICP前曾接受过孕激素(0.2～1.0g/d)治疗鶒，停止用药後，部分患者又自然恢复正常。然而对血清的肝酶、胆汁酸及胆红素升高外，在电子显微镜下可见的超微结构中血小板使血小板黏附、聚集并释放血栓素A2(TXA2)。而绒毛血管病变和胎盘血管内广泛的血栓形成和梗死是ACA阳性患者妊娠结局不良的主要病理基础。ICP患者循环ACA水平显著升高，提示两者间可能存在着某种联系。从血液流变性减退脂质代谢异常和血清层黏蛋白增高(与基底膜损伤)方面观察，ICP与妊高征有某些相同变化，因此有些学者认为免疫功能异常和自身免疫失调可能也是两种疾病共同的与发病有关的病理生理变化之一而肝细胞可能也受到ACA攻击，以致肝血流迟缓、肝细胞功能障碍，发生肝内胆汁淤积。这些尚有待于进一步研究

4.硒与ICP的关系

硒(seleniumSe)是一种微量元素，妊娠时为满足孕妇体内需求，Se的摄入量增加，Se是谷胱甘肽过维生素E相关。从王竹晨等 (2000)亦研究ICP患者血中硒胎盘中硒的水平以及其与谷胱甘肽过氧化酶的关系。ICP患者无论血中的硒及胎盘中硒水平均较正常者低，而谷胱甘肽过氧化酶的活性亦下降呈一致性；正常妊娠时抗氧化作用能预防雌激素的氧化损伤，而ICP患者当谷胱甘肽过氧化酶降低时，细胞抗氧化防御能力下降而雌激素的负荷增加，导致自由基形成，影响了肝的胞膜，降低了排泄胆汁的能力。

妊娠期肝内胆汁淤积症 - 症状

妊娠期肝内胆汁淤积症

临床表现：

ICP是以妊娠中、晚期无皮肤损害的皮肤瘙痒为主要特点，少数在孕25周前发病。瘙痒常是最主要的主诉。通常瘙痒开始于手掌、脚掌及肢体远端，之後向近端扩展，严重病例可累及面部、颈部及耳，但一般极少引起黏膜表面的瘙痒。这种瘙痒一般用搔抓不能缓解，临床上处理较为困难，瘙痒可为持续性也可为间断性，可为全身性也可为局限性。程度可轻可重，轻者不影响日常工作中重度瘙痒可影响患者睡眠，多数病人瘙痒在夜间加重，部分病人因为严重瘙痒影响睡眠而表现为极度疲劳或出现易怒。ICP患者瘙痒原因不明，有人认为是由于患者血中某种致痒物质沉积于外周皮肤神经末梢处，对之产生刺激所引起。有人通过研究认为这种致痒物质就是胆酸，因为大剂量红斑。另外，在所有的ICP患者中有17%～75%的病人表现为轻度黄疸，有时黄疸也可能是唯一的主诉，但多数黄疸是出现在瘙痒之後的l～4周。ICP是妊娠期黄疸的第2大原因，仅次于肝炎。黄疸的同时常伴有尿色加深及高胆红素血症，还有少数病人可有厌食、恶心及呕吐，但体检时肝区一般无压痛、肝大小也在正常范围，无急性肝病的证据，80%的病人症状出现于30孕周之後，少数病人症状出现于25孕周之前，瘙痒多在产後数天消退，多数患者瘙痒症状在产後2天内即消失，而黄疸一般消失较慢，但也多在数天内消失，个别患者在分娩後1个月才消失，但实验室检查结果完全恢复正常需在产後4～6周。但也有报道ICP患者产後 2年症状仍不消失不过这种情况非常罕见。

并发症：

1.早产1966年Haemmerli报告18例ICP患者，共43次妊娠，23次以早产为终结，其中22次早产集中于8名患者1976年Reid 报告56例ICP活产50例中早产18例早产率36%，体重＜2500g者13例，围生儿死亡率11%。中国吴味辛报告134例中早产24例(18%)，围生儿死亡率6%1984年Laatikainen报告117例ICP平均孕期为35 5周，1987年戴钟英等报告250例ICP平均孕期为38.7周，早产34例(13.6%)，新生儿体重≤2500g21例(8.2%)；以上数字均说明ICP的早产发生率确有明显增高。

对发生早产的原因，Laatikainen认为ICP孕妇的胎儿无能力将胎盘大量生产的16α-羟基-去氢表雄酮(16α-hydroxylate-dehydroepiandrosterone，DHAS)转变成惰性较大的雌三醇因此大量的DHAS通过胎盘的其他途径转变成具有活性的雌二醇而导致早产近来动物实验表明胆酸能增加小鼠健康搜索的子宫肌收缩力，胆汁酸还可以促进前列腺素的释放，以致诱发子宫收缩，发生早产。

2.胎儿窘迫Reid(1976)报告的56例中，6例死胎，围生儿死亡率为11%，50例活产中5例因头盆不称做剖宫产，余45例中，羊水严重污染者12例(27%)，胎心率＜100次/分者8例，其中妊娠瘙痒合并黄疸者的死胎和胎儿窘迫发生率远较单纯瘙痒者为高。吴味辛报告134例ICP中围生儿死亡8例，其中死胎5例均突然发生在临产前。戴钟英(1986)报告1984年全年围生儿死亡32例，围生儿死亡率为15.6?#65292;而同年74例ICP中有5例围生儿死亡(67.6?，其中4例为死胎或死产，均在将临产或产程中死亡，根据以上资料可见ICP的胎儿窘迫发生率确较一般为高。

Laatikainen(1977)对86例ICP根据其血清胆酸水平的升高程度将其分为3组，发现胆酸水平愈高，胎儿窘迫发生率亦愈高(表2)

1984年Laatikainen又报告117例ICP再次证明血清胆酸水平愈高，胎儿窘迫率也愈高，因此，动态测定血清胆酸水平可作为观察ICP患者胎儿预後的一种方法。

发生胎儿窘迫原因至今仍未明确。Laatikainen(1977)研究ICP孕妇胎儿血清胆酸水平与胎儿窘迫关系，在41例(1例双胎)ICP中有胎儿窘迫表现者16例。ICP胎儿脐血CA水平为3.74μg/ml而正常对照组脐血CA水平仅为0.94μg/ml；ICP胎儿脐血CA水平高于 3.74μg/ml的22例中，有胎儿窘迫12例，低于3.74μg/ml的20例中仅4例有胎儿窘迫。动物实验亦证明若予以口服或静脉注射胆酸可导致肝细胞损伤；故Laatikaine认为母体发生ICP使胎儿体内CA升高，对胎儿有不良影响，胎儿固醇类物质代谢的改变亦可导致胎儿出现窘迫。1991年Sepulveda报告用不同浓度的CA对游离的绒毛静脉的作用发现两者间存在一定关系，即高浓度时血管收缩明显，因此重度ICP，高CA血症可使血管痉挛阻力增加血流量减少，氧交换能力下降而导致胎儿宫内窘迫所致。

近年来人们认为ICP患者的胎儿窘迫与绒毛间腔的变小有一定关系。1980年Costoya等通过光镜及电镜的观察发现ICP患者的胎盘中合体细胞增多，绒毛基质稀疏水肿，合体滋养层增厚，细胞滋养层细胞数明显增加。Costoya认为无论这些变化是原发或是继发的，因为这些病变的结果是绒毛间隙缩小，单位时间内绒毛间腔内的母体血流量减少从而导致胎儿缺氧1987年刘伯宁等对20例ICP胎盘做了组织计量以测定多项参数，并以20例正常同孕龄孕妇胎盘作对照，发现 ICP组的绒毛间腔较正常对照组明显缩小P＜0.001，而其余各项参数P值均＞0.1因此，可以认为绒毛间腔狭小也可能是导致ICP围生儿死亡率增高的重要原因。

3.产後出血Reid(1976)报告ICP阴道分娩的50例中，出血＞500ml者10例，其中＞2000ml者5例；而Frielaender亦有相同报告；1988年侯丽蓉等对158例ICP产 後出血进行观察，并以158例产科条件相同的正常产妇对照，两组产後24h平均出血量各为234ml及177.1ml，其差别有显著意义Reid认为ICP孕妇胆汁的胎盘分泌量不足，维生素K的吸收量减少，使肝脏合成凝血因子Ⅱ、Ⅶ、ⅨX量亦减少而导致产後出血。

4.产科并发症

(1)ICP合并妊娠期高血压疾病：1987年戴钟英在总结250例ICP时发现其中合并妊娠期高血压疾病者竟高达24%继而黄亚绢总结 1986～1994年10243次分娩中有ICP451例(4.4%)，妊娠期高血压疾病901例(8.8%)，ICP与妊娠期高血压疾病共存者79例 (0.77%)，在ICP组中妊娠期高血压疾病的发生率为17.52%，而妊娠期高血压疾病组中ICP的发生率为8.72%，与普通人群中ICP及妊娠期高血压疾病的发生率比较均有明显升高；ICP妊娠期高血压疾病及ICP合并妊娠期高血压疾病3组的围生儿死亡率各为18.81%、13.30%及 59.52%，後者明显高于前两者。因此对于ICP同时并发妊娠期高血压疾病者，应更积极地处理，包括加强对胎儿的监护，促胎肺成熟以及适时终止妊娠。

(2)ICP合并多胎妊娠：1987年戴钟英在总结250例ICP时，即已注意到其中有双胎5例1989年Gouzale报告62例双胎中合并ICP者高达20.9%，与单胎的ICP发生率4.7%比较，差别极为显著，在两组尿雌三醇(E3)定量测定中，双胎较单胎明显增高，虽然尚未达到有统计学差异程度但已可说明雌激素在ICP形成中的作用。1997年陶敏芳等报告在12886次分娩中，共有双胎90 例(7?，对资料完整的80例双胎的分析其中合并ICP者24例(30%)，与12796次单胎中合并ICP者540例(4.2%)从发生率比较两者有极为明显的差异，双胎中合并ICP与不合并ICP者，孕龄各为34 3周及36 1周，并发妊娠期高血压疾病者各为54.2%及33.9%，发生产後出血者各为37.5%及16.1%，其差别均有显著意义

诊断：

对ICP的诊断，具体可按以下标准：

1.在妊娠期出现以皮肤瘙痒为主的主要症状。

2.肝功能异常，主要是血清SGPT或SGOT的轻度升高，达60～100U，超过200U以上者较少。

3.可伴有轻度黄疸血清胆红素在18.81～85.50/μmol/L(1.1～5mg/dl)。

4.患者一般情况良好，无明显呕吐、食欲不振、虚弱及其他疾病症状。

5.一旦分娩，瘙痒迅速消退，肝功能亦迅速恢复正常，黄疸亦自行消退。

在以上症状及体征中，瘙痒是最重要的，可以表现轻微，故每次产前检查时均不可遗漏。

鉴别诊断：

主要是妊娠合并病毒性肝炎，本病常有消化系统症状，SGPT及胆红素升高明显，病程并不随妊娠终止而迅速好转或结束，故区别该两病并不困难。

妊娠期肝内胆汁淤积症 - 治疗/h2>

妊娠期肝内胆汁淤积症

治疗ICP的目鶒的是缓解因胆盐潴留于皮肤深层而刺激皮肤感觉神经末梢引起的全身瘙痒症状；恢复正常的肝功能；降低血中胆酸的浓度，从而降低因高胆酸血症所致的胎儿宫内窘迫及死胎发生率、改善产科的结局。故所选的药物应该对母、婴均无不良影响。

1.药物治疗本病目前尚无特殊的治疗方法。现临床上多以对症与保肝治疗为主。

(1)S-腺苷基L-蛋氨酸(S-Adenosyl-LMethionine，SAMe)：商品名腺苷合成并作为许多生物反应的底物遍布机体。所有组织之中，它作为甲基提供生理性巯基化合物前体参与体内重要的生化反应。它可通过甲基化对雌激素代谢物起灭活作用，并刺激细胞膜的磷脂合成，通过增加肝浆膜磷脂成分，防止雌激素引起的胆汁淤积，它可通过转巯基反应促使胆汁酸经硫酸化的途径转化，还可防止或减轻毒物和胆汁酸引起的氧自由基对肝细胞的损伤。其与熊去氧胆酸合用效果最佳，可减轻痉挛、降低胆汁酸、胎盘单位，胎儿硫酸脱氧表雄酮(简称DHEAS)http://www.huoguan.com，它是胎盘产生雌激素的前身物质。地塞米松能通过胎盘减少胎儿肾上腺DHEAS的分泌，降低了雌激素的产生从而减轻了胆汁淤积此外，它还可以解除小血管痉挛性收缩，降低周围血管阻力，加强心肌收缩力，改善母体循环及灌注的能力，并能促进胎肺成熟。Hirvioja等对10例孕28～37周的ICP患者用地塞米松每天12mg口服，连用7天，後3天逐渐减量而停药。结果所有患者瘙痒症状缓解明显减轻，血雌三醇(E3)、血雌二醇(E2)及总胆酸水平均明显下降。治疗期间未发现对母、婴有毒性反应。故认为地塞米松是治疗ICP的首选药物。

(3)诱导剂，可以促使肝细胞增加胆红素与葡萄糖醛酸结合的能力因而增加了肝脏除去胆红素的能力使血中胆红素下降，它还可以增加胆小管胆汁酸分泌速度，并通过改变胆固醇 -7α-水解酶的活性以影响胆汁酸的生成。但是有报道此药可以引起新生儿呼吸抑制的危险，故孕期不宜长期连续服用此药，用法：每天口服100mg。

(6)人血白蛋白或血浆：有利于游离的胆红素的结合，减少胆红素进入胎儿体内，亦提高绒毛腔隙的血流灌注量。

(7)中药治疗：中医理论认为ICP属湿热内蕴、营卫不和、气滞血行不畅，可以给予中药茵陈汤：柴胡10g，郁金10g，丹参15g，茵陈10g泽泻10g，当归10g；1次/d7～10天为1个疗程1996年哈宝书等报告应用中药结合方法治疗ICP63例，无围生儿死亡，瘙痒症明显好转，对照组 40例，围生儿死亡5例。

2.产科处理对ICP患者，应该列入高危妊娠的管理进行系统监护，加强产前宣教对中、重度患者应该提前入院，积极治疗直到分娩，并及时终止妊娠入院後可以给予以下治疗：

(1)氧气吸入2次/d，左侧卧位，每天按时计数胎动。每周测宫高，腹围，体重以检测胎儿在宫内生长发育情况。

(2)孕35周以後，每周进行胎盘功能测定如检测24h尿E3，血HCG，E3等了解胎盘功能；胎儿生物物理相评分；B型超声波监测胎儿双顶径及胎盘成熟情况，羊水情况；多普勒超声波检查胎儿血流动力学的改变可以用无负荷试验(NST)随时监测胎儿宫内状况临产後密切注意胎心率及羊水的变化。

(3)终止妊娠：对ICP孕妇适时终止妊娠是降低围生儿发病率的重要措施。

①终止妊娠的时机当孕周≥35周时估计胎儿体重≥2500g时，可以考虑终止妊娠如果有胎盘功能减退，或者胎动忽然减少，生物物理相评分减少NST为无反应型时，则需要及时终止妊娠。

②终止妊娠的方式：

A.病情轻胎盘功能良好，可以选择

妊娠期肝内胆汁淤积症 - 预後

妊娠期肝内胆汁淤积症妊娠期肝内胆汁淤积症

针对ICP对围生儿有前述不良影响目前基于改善ICP围生儿预後的产科处理方案也较多。20世纪70年代以前对ICP的认识不足ICP的处理只是一般的期待疗法等其自然分娩，其围生儿的死亡率达10.7%，之後随着对ICP的认识的增加在产前采取加强监护，胎儿一旦成熟即选择性终止妊娠，则ICP的围生儿的死亡率下降到3.5%。但尽管如此，对于ICP患者来说目前各种产前监护措施尚不能很好地预测ICP患者胎儿宫内死亡。有人报道在胎儿宫内死亡前数小时胎儿监护仍正常，NST在胎儿死亡前2天仍正常，另外，胎儿死亡前数小时母亲仍能感到正常的胎动。说明目前的一些产前胎儿宫内健康状况的评估方法的标准尚不适合ICP。

Rioseco等回顾性地评估了对ICP的不同处理方案与围生儿预後的关系。发现轻度ICP患者34孕周後常规每周行NST检查，在38孕周并肯定胎儿已成熟时予以引产。其围生儿预後与36孕周伴有黄疸的ICP患者予以引产之间也无明显差别。上述积极处理後ICP的围生儿预後与正常妊娠围生儿预後并无明显差别。其中早产的发生率及羊水胎粪污染的发生率也与正常妊娠之间无明显差别Alsulyman等研究ICP患者与有胎死宫内病史的正常妊娠在孕34 周时每周常规行NST检查及羊水量的评估，若无异常则不做任何干预，直至自然发动分娩或到孕42周时给予引产，发现ICP与正常妊娠之间围生儿预後无差别。ICP组有2例胎儿宫内死亡，围生儿死亡率为25?#12290;这2例死胎都是在NST检查正常後的5天之内死亡的。因而他也认为ICP的胎儿死亡，用传统的产前监护手段也是不可预测的。目前ICP 患者产科处理方案最好还是在确定胎儿在宫内已成熟即予以终止妊娠，这也是降低ICP胎儿死亡的较好方法。

妊娠期肝内胆汁淤积症 - 预防

由于ICP的主要後果是围生儿发病率和死亡率升高，因而，产科处理的目的应是使胎儿顺利足月分娩。若有胎儿窘迫且胎儿已成熟则应当机立断终止妊娠且以剖宫产为宜，因为经阴道分娩会增加胎儿缺氧程度。有报道ICP经积极主动的处理，可以明显降低围生儿死亡率。[1]

Gestational intrahepatic cholestasis (intrahepatic cholestasisof pregnancy, ICP) is an important pregnancy complications characterized by itching and jaundice during pregnancy, now in the domestic general attention. ICP rate of preterm birth and perinatal mortality and its causes are not yet fully elucidated, but known to be closely related to the estrogen.


Intrahepatic cholestasis of disease - Overview
Cholestasis
ICP is an enigmatic disease experienced a long history of ICP understanding and naming: Ahlfeld in 1883 first reported a in the third trimester of pregnancy and the tendency of recurrence of jaundice of pregnancy complications in subsequent pregnancies until 1954 Svanborg and 1955 Thorling disease learn from histopathology, biochemistry, and symptoms were studied, and a fairly detailed, many scholars learn epidemiology and diagnosis of ICP was discussed in understanding Although this disease is the disease of intrahepatic cholestasis characterized Reid clearly stated in the 1976 ICP maternal serious harm, but the perinatal Erque the adverse effects of fetal distress in the perinatal death, the ICP The study opens up a new field. As a result, according to various stages of awareness of it, have had different names: the beginning of each trimester of pregnancy due to the same patient jaundice and found that the death of the deceased is called gestational recurrent jaundice (recurrentjaundiceofpregnancy), and later because of the occurrence pregnancy, the performance of a benign process, it is called idiopathic pregnancy jaundice (idiopathicjaundiceofpregnancy) after the 1960s, according to the pathological features of the ICP instead called obstetric cholestasis (obstetriccholestasis), the the Hammerli first time in 1960 ICP named after the 1970s, the vast majority of scholars in the literature, commonly used for disease name to distinguish with other cholestasis.
In China, Hu Everest was first reported in 1964 one cases of pregnant women with recurrent jaundice. 1984 Wu Weixin made a more detailed report of the Chongqing area and in 1986, Dai Zhongying ICP Shanghai region, then the domestic reporting an increasing number.
Intrahepatic cholestasis of disease - epidemiological
Chart
The incidence of ICP health search in the incidence of various countries are very different, Sweden and Finland in Northern Europe, South America, Chile, Bolivia is prone areas. Which the highest incidence rate in Chile, up to 13.2% pregnancy itching, cholestasis of pregnancy with 2.4% incidence of Reyes, found that Chile Araucanian Indian mestizo people ICP incidence of pregnancy itching up to 22.1%, pregnancy with cholestatic jaundice up to 5.5% prompted the occurrence of the disease with race and genetics. Shanghai, China and other regions of incidence is also high, and should attract attention.
2 family, many literatures reported the familial tendency to occur in ICP. Holzbach report early in 1965 a typical example of familial ICP cases, patients 12,3 times of gestation had severe itching, 4 tires for the ICP, postpartum return to normal after taking birth control pills norethindrone and mestranol the jaundice reproduce withdrawal 20 days after the regression of pregnancy are itching of the patients mother, his sister pregnancy also have jaundice subsided after childbirth in 1976 the DePagter reported a family of four generations of the 133 members in the four cases occurred by ICP, nine cases during pregnancy itching or jaundice, there are two cases of itching after oral contraceptives. Holzbach again in 1983 on the one prone to the ICP-generation family of 50 people in three generations of men and women over the age of 18 made a detailed study on which clinical signs of objects (including men), oral steroid hormone stimulated provoke trial and histocompatibility testing, results showed that the ICP, parental inheritance is in accordance with the Mendelian mode of the advantages of genetic Therefore the Holzbach think this disease, genetic characteristics, family men can be carriers, their phenotype is suppressed.
(3) genetic research, have a hereditary tendency to the disease at the molecular level has become the focus of the etiology. Jansen (2000) elaborated on the level of progressive familial intrahepatic cholestasis (progressivefamilialintrahepaticcholestasis, PFIC) gene. They divided into three type Chi: PFIC type Ⅰ and type Ⅱ is the mutation of chromosome 18 and chromosome 2 locus. PFlC type Ⅱ and type Ⅲ caused by the defects of the hepatobiliary secretion of bile acids and phospholipids. Benign recurrent intrahepatic cholestasis (benignrecurrentintrahepaticcholestasis BRIC) is a mutation associated with a point in the same familial intrahepatic cholestasis of chromosome 18. Bile acid synthesis defects may be difficult to distinguish between defects in these transporters, the ICP is associated with these bile defects.
Intrahepatic cholestasis of disease - the cause of
ICP is a manifestation of a particular disease, the past 20 years, many scholars committed to the ICP in the pathogenesis of research, its exact etiology is not yet very clear, but a large number of epidemiological materials, as well as clinical observation and laboratory studies can be considered the etiology of this disease and estrogen increased the incidence of regional differences, as well as genetic factors are closely related. Now, there are scholars ICP may also relationship of anticardiolipin antibodies.
Gestational intrahepatic cholestasis - pathogenesis
Cells in Fig.
An estrogen and ICP
(1) the clinical basis: there are a lot of performance in clinical practice suggesting that high estrogen levels may be the cause of induced ICP, are listed as follows: ① The ICP occurred in the third trimester of pregnancy, the peak period of time when estrogen secretion; 2 ICP in twin incidence significantly higher than single births, Shanghai Sixth People's Hospital report ICP incidence of twins six times higher than singleton pregnancies, it may and twin placental volume was significantly greater than that of estrogen secreted by the single births than single births and more relevant ; ③ the occurrence of cholestasis in the performance of the applications of women in birth control pills containing estrogen and progestin and the ICP is very similar to the symptoms; ④ application of contraceptives women pregnancy occurred ICP, subsequent pregnancy, the recurrence rate than is generally high.
(2) laboratory studies: Many scholars have used animal studies estrogen on bile secretion. Estrogen lead to cholestasis may be through the following means: ① The bile of the permeability increased; the the ② sinusoidal gap area sodium, potassium - triphosphate glycosidase (Na-K-ATPase) activity of the bile salt transporter hindered; ③ The antral decreased membrane fluidity of the gap region, so that the bile salt that barriers; to ④ estrogen metabolites: D ring glucuronide estrogen and bile acid structure similar to a competitive inhibitor of the bile acid carrier. Produce large amounts of estrogen during pregnancy cause cholestasis of pregnancy some women; ⑤ liver estrogen receptor and protein synthesis: It is speculated that estrogen can reduce organic anion and bile acid carrier synthesis, but also affect the intracellular binding protein organic anion translocation, secretion of vesicles to the bile duct region running and so on.
2.ICP relationship with progesterone
Progesterone is a hormone secreted by the placenta, although human usually well tolerated progesterone, but the recent Chi clinical observation and experimental progestin and the incidence of ICP relationship. Bacq et al (1998) study of 13 cases of ICP patients, 10 cases developed into ICP before received progesterone (0.2 ~ 1.0g / d) treatment Chi, after stopping the treatment, some patients also naturally return to normal. However little is known about the mechanism of intrahepatic cholestasis caused by progesterone. Early studies suggest that the mechanism of cholestasis similar to estrogen and progesterone during pregnancy, Meug (1997) Simultaneous determination of bile acids and progesterone metabolites in ICP and blood and urine of normal pregnant women. The result is the ICP maternal serum 5β-pregnane-3α, 20α-pregnanediol-curing product increase, while the product of glucuronide conjugates of progesterone did not change or even reduce the metabolites of progesterone in the blood is excluded from the bile approximately 30% of progesterone sulfuric acid sulfuric acid combine with the coke, and may the Department by the organic anion carrier transporters, of progesterone coke sulfate increase in ICP in patients may reflect impaired biliary secretory function, the glucuronic acid does not change This shows that selective defects in patients with ICP biliary secretion of sulfated steroids. Dingxi to (2001) for animal experiments in pregnant mice, progesterone daily 150mg/kg dose in the first 13 days of pregnancy to 20 days of gestation intramuscularly, results of serum liver enzymes, bile acids and bilirubin l high, the ultrastructure visible in the electron microscope telangiectasia, its high electron density of the deposition, the results to the pregnant rats to estrogen blood biochemical manifestations of liver pathological changes similar from the electron microscope, the change more similar to human ICP. Therefore, progesterone may also be the reason of the ICP, but its real mechanism of action yet to do further research in molecular biology level.
3.ICP relationship with anticardiolipin antibody
Anticardiolipin antibodies (anticardiolipinantibody, ACA) is an autoimmune antibody, target antigen of autoimmune abnormalities important manifestation of ACA is located in the heart of the vascular endothelial cells and platelet membrane phospholipids ACA role in the target, vascular endothelial cells, prostaglandin I2 (PGI2) synthesis decreased; the same time to activate the platelet-platelet adhesion, aggregation and release of thromboxane A2 (TXA2). Extensive villous vascular lesions and placental vascular thrombosis and infarction is the major pathological basis of ACA positive patients with poor pregnancy outcome. ICP circulation of patients with ACA levels were significantly increased, suggesting a link between the two may exist. Decline from the hemorheology in increased lipid metabolism and serum laminin (observation and basement membrane damage), some of the same changes in ICP and pregnancy-induced hypertension, some scholars believe that the immune dysfunction and autoimmune disorders may also be two disease common incidence one of the pathophysiological changes and liver cells may also attack by ACA, resulting in hepatic blood flow is slow, the liver cell dysfunction, the occurrence of intrahepatic cholestasis. These are yet to be further studied
4 the relationship between selenium and ICP
The selenium (seleniumSe) is a trace element, the pregnancy to meet the needs of pregnant women, the increase in intake of Se in, Se, glutathione peroxidase, an active ingredient of its functions related to vitamin E From epidemiological observations, the incidence of ICP seems to seasonal changes. Reyes (2000) Determination of the concentration of selenium in the blood, compared with nine years ago, Se, increase in non-pregnant women, since (0.85 ?0.13) μmol / L increased to (1.43 ?0.34) μmol / L,. To (1.08 ?0.25) μmol / L, in the third trimester of pregnancy. To study the seasonal relationship Reyes trying to from SeZn, and Cu in blood levels in pregnant women in different seasons. The results of Se in blood levels as high as in summer (1.34 ? 0.19) μmol / L Zn and Cu decreased, Reyes, that in recent years, ICP, decrease the incidence may be associated with Se increased during the summer months when lower the incidence of related to the summer of selenium blood levels. Domestic Wangzhu Chen (2000) also studied the selenium levels in the blood of patients with ICP selenium placenta and its relationship with the glutathione peroxidase. Selenium levels in ICP patients regardless of the selenium in the blood and placenta compared with the normal low glutathione peroxidase activity decreased was consistent; normal pregnancy, the antioxidant effect of estrogen can prevent oxidative damage, while the ICP patients when reduced glutathione peroxidase, the cellular antioxidant defense decreased ability to increase estrogen load, resulting in the formation of free radicals, affecting the liver membrane and reduce the excretion of bile.
Intrahepatic cholestasis syndrome - symptoms
Gestational intrahepatic cholestasis
Clinical manifestations:
ICP is a pregnancy and late skin lesions of the skin itching for the main features of a small number of onset before 25 weeks of gestation. The itching is often the most important chief complaint. Usually itching began in the palms, soles and distal limbs, and then extended to the proximal, serious cases involving the face, neck and ears, but in general seldom causes the itching of mucosal surfaces. This itching is generally used to scratch can not alleviate the clinical management more difficult, for persistent itching can also be an intermittent nature, can also be systemic limitations. The degree of light weight, light does not affect the daily work of moderate to severe itching that can affect patients with sleep, the majority of patients itching aggravated at night, and some patients because of severe itching of sleep manifested as extreme fatigue or display anger. ICP in patients with pruritus of unknown cause, some people believe it is caused due to some patients with blood caused itching material deposition in peripheral skin nerve endings irritation. Through research that this caused the itch material is acid, because large doses of acid-induced human itching, but has not yet found the itching of the skin receptors at the presence of bile acid composition. Surgical removal of itching of the skin organization also found that bile acids exist, and thus that this itching is not caused by bile acids in peripheral sensory nerve endings in the skin caused by certain stimuli. Some people think that this is due to patients with ICP in vivo accumulation of endogenous opioid substances. In summary so far with ICP itching reason is not clear. ICP patients generally do not have a rash, but can scratch and scratch. It should be noted that normal pregnancy, liver disease, about 60 percent of pregnant women, there may be erythema telangiectasia and the palm of your hand. In addition, all patients with ICP, 17% to 75% of patients present with mild jaundice, and sometimes jaundice also may be the only chief complaint, but the majority of jaundice and itching after l ~ 4 weeks. ICP is the major reason of the jaundice during pregnancy, second only to hepatitis. While jaundice is often accompanied by dark urine and hyperbilirubinemia, there are a few patients may have anorexia, nausea and vomiting, but the physical examination the liver area are generally no tenderness, liver size is also the normal range, no evidence of acute liver disease 80% of patients with symptoms after 30 weeks of gestation, a small number of patients the onset of symptoms before 25 weeks of gestation, itching, mostly subsided in a few days postpartum, the majority of patients pruritus disappeared in 2 days postpartum, and jaundice generally disappear slower, but also disappear in a few days more than individual patients disappear after giving birth a month before, but the laboratory test results are completely back to normal needs in the post-natal 4 to 6 weeks. But there are also reports of ICP patients after 2 years of symptoms does not disappear, but such cases are very rare.
Complications:
Of prematurity in 1966 Haemmerli report 18 cases of patients with ICP, a total of 43 pregnancies, 23 as an end to premature birth, in which 22 preterm concentrated in eight patients the Reid report 56 cases of ICP live births in 1976 18 cases of 50 cases of premature delivery rates of preterm birth 36%, weight <2500g, 13 cases of perinatal mortality of 11%. Wu Weixin report 134 cases of premature birth in 24 patients (18%), perinatal mortality rate of 6% in 1984 Laatikainen report of 117 cases of ICP average pregnancy is 355 weeks, the average gestation of 38.7 weeks in 1987, Dai Zhongying reports 250 cases of ICP , premature birth, 34 cases (13.6%), birth weight to ≤ 2500g21 cases (8.2%); The above figures are of ICP incidence of preterm significantly higher.
On the causes of preterm birth, Laatikainen ICP pregnant women fetal placental mass production of 16α-hydroxy - dehydroepiandrosterone DHEA (16α-hydroxylate-dehydroepiandrosterone, DHAS) into inert larger estriol is a lot of DHAS other ways through the placenta into the active estradiol lead to preterm recent animal studies indicate that bile acids can increase the health search in mice uterine muscle contractility, bile acids can also promote the release of prostaglandins, resulting in induced uterine contractions occurred premature birth.
2 fetal distress, Reid (1976) report of 56 cases, 6 cases of stillbirth, perinatal mortality was 11%, 50 cases of live births, five cases of cephalopelvic disproportion called a cesarean section, more than 45 cases, amniotic fluid serious polluters of 12 cases (27%), eight cases of fetal heart rate <100 beats / min by pregnancy itching Jaundice stillbirth and fetal distress rate than simply itching. Wu Weixin reported 134 cases of ICP perinatal child death in eight cases, five cases in which stillbirth are suddenly occurred prior to delivery. Daizhong Ying (1986) reported 1984 full-year Wai born child deaths in 32 cases, the perinatal mortality rate was 15.6 per thousand, the same year 74 cases of ICP, five cases of perinatal child death (67.6 ?, of which four cases of stillbirth or death production, death will give birth or the birth process, the incidence of fetal distress according to the above information is visible to the ICP is indeed higher than usual.
Laatikainen (1977) 86 cases of ICP according to the serum bile acid level increased divided into three groups and found that bile acid level of the higher fetal distress rate is also higher (Table 2)
Laatikainen 1984 reported 117 cases of ICP proved once again that the higher the serum bile acid levels, the higher the rate of fetal distress, therefore, the dynamic determination of serum bile acid levels can be used as a way to observe the fetal prognosis of patients with ICP.
Fetal distress reasons has not yet been clear. Laatikainen (1977) study the ICP pregnant women, fetal serum bile acid levels and fetal distress, fetal distress in the performance of 16 cases in 41 cases (cases of twins) ICP. ICP fetal cord blood CA level for 3.74μg/ml normal control group cord blood CA levels only 0.94μg/ml; ICP fetal cord blood CA levels above 3.74μg/ml 22 cases, 12 cases of fetal distress, low 3.74μg/ml of 20 cases, only four cases of fetal distress. Animal experiments also proved to be oral or intravenous cholic acid can lead to liver cell damage; the Laatikaine mother occurred ICP fetus CA increased adverse effects on the fetus, fetal metabolism of steroid substances change may also cause the fetus to appear distress. 1991 Sepulveda report on the role of free fluff veins with different concentrations of CA there is a certain relationship between high concentrations of vasoconstriction, severe by ICP, high CA hyperlipidemia blood vessels spasm resistance to increase blood flow to reduce The oxygen exchange capacity decreased and lead to fetal distress caused.
In recent years, people think that ICP in patients with fetal distress and fluff cavity smaller. The 1980 Costoya syncytial increased ICP in patients with placenta, villus matrix sparse edema, thickening of the syncytiotrophoblast, cytotrophoblast cells were significantly increased by light microscopy and electron microscopy observations. Costoya whether these changes are primary or secondary, as a result of these lesions is fluff gap shrink, fluff between the cavity per unit time mother reduced blood flow leading to fetal hypoxia in 1987 Liu Boning, etc. on 20 cases of ICP placenta measurement of the organization to determine the number of parameters, controls, and 20 cases of normal gestational age placental cavity between the villi of the ICP group compared with normal control group was significantly reduced (P <0.001), while the rest of the parameters of P values> 0.1 Therefore, it can be considered a small cavity between the villi may also lead to an important cause of increased ICP perinatal child mortality.
3, 50 cases of postpartum hemorrhage Reid (1976) report ICP vaginal delivery, bleeding> 500ml in 10 cases, of which> 2000ml those five cases; Frielaender also the same report; 1988, Houli Rong et al observed 158 cases of ICP postpartum hemorrhage and 158 cases of obstetric conditions are the same normal maternal control, two sets of post-natal 24h mean blood loss was 234ml and 177.1ml each, the difference was significant Reid ICP pregnant women, placental secretion of bile, the absorption of vitamin K reduced liver synthesis of coagulation factors II, VII, Ⅸ X-amount of reduction in lead to postpartum hemorrhage.
(4) obstetric complications
(1) by ICP with hypertensive disorders in pregnancy: 1987 Dai Zhongying summary of 250 cases of ICP, which merged with hypertensive disorders in pregnancy as high as 24% and then yellow Asian silk summary 1986 to 1994 of 10243 births ICP451 cases (4.4% ), hypertensive disorders in pregnancy, 901 cases (8.8%), ICP and hypertensive disorders in pregnancy coexistence in 79 cases (0.77%) in the ICP group, the incidence of hypertensive disorders in pregnancy rate was 17.52%, while pregnancy blood pressure disease group ICP was 8.72%, with the general population in the ICP and the incidence of hypertensive disorders in pregnancy were significantly increased; the ICP hypertensive disorders in pregnancy and the ICP merger hypertensive disorders in pregnancy perinatal infant mortality of 18.81%, 13.30% and 59.52%, which was significantly higher than the first two. Therefore, for ICP at the same time concurrent hypertensive disorders in pregnancy, should be more active treatment, including on the guardianship of the fetus, the fetal lungs mature and timely termination of pregnancy.
ICP combined with multiple pregnancy (2): 1987 Dai Zhongying summary of 250 cases of ICP, already noted that up to 20.9% of twin five cases in 1989 Gouzale report 62 cases of twin merger ICP, ICP occurred with a single fetus. rate of 4.7% difference is extremely significant, the quantitative determination of the two groups of urine estriol (E3), the twins than single births was significantly higher, although not yet reached the degree of statistical difference, but may indicate the formation of the estrogen in the ICP. role. 1997, Tao Minfang reports in 12,886 births, a total of twins, 90 cases (7 ?, which merged with ICP by analysis of the data of 80 cases of twins, 24 cases (30%) and 12 796 singleton pregnancies in the merger ICP 540 cases (4.2%) from the incidence of very significant differences between the two twins combined ICP and the merger ICP gestational age 343 weeks and 361 weeks, complicated by hypertensive disorders in pregnancy by incidence of postpartum hemorrhage was 54.2% and 33.9%, 37.5% and 16.1% of the difference were significant
Diagnosis:
ICP diagnosis, according to the following criteria:
The main symptoms of itchy skin mainly during pregnancy.
2 abnormal liver function, mildly elevated serum SGPT or SGOT, up to 60 100U were less more than more than 200U.
(3) may be associated with mild jaundice, serum bilirubin the 18.81 the ~ 85.50/μmol/L (1.1 ~ 5mg/dl).
The general condition of patients, no significant vomiting, loss of appetite, weakness and other symptoms of the disease.
Once childbirth, itching faded rapidly, liver function rapidly returned to normal, jaundice subside on their own.
In the above symptoms and signs, itching is the most important, can be expressed in a minor, so each prenatal care can not be omitted.
Differential diagnosis:
Mainly pregnant women with viral hepatitis, the disease often have digestive symptoms, SGPT in and bilirubin increased significantly, the course is not with the termination of pregnancy and rapid improvement in the end, it is the difference between the two diseases is not difficult.
Intrahepatic cholestasis of pregnancy disorder - treatment / h2>
Gestational intrahepatic cholestasis
Head Chi's treatment of ICP is to alleviate the systemic itching caused by skin sensory nerve endings and stimulate bile salt retention in the skin deep; restore normal liver function; reduce the concentration of bile acids in the blood, thereby reducing due to high bile acid acidosis caused by fetal distress and stillbirth incidence, improve obstetric outcome. The selected drug should be on the mother, the infant had no adverse effects.
(1) drug treatment of this disease there is no special treatment. Is clinically more symptomatic with liver treatment-based.
(1) S-adenosyl-based L-methionine (S-Adenosyl-LMethionine, SAMe): trade name thought the United States and Thailand, foreign research in recent years more, the effect of new anti-drug cholestasis. Physiological molecular structure of both the efficacy of its active ingredient S-adenosyl-L-methionine of acute and chronic liver disease in pregnancy and drug-induced intrahepatic cholestasis is a common in all organisms in the human substrate the body adenosylmethionine from methionine and adenosine synthesis, and as many biological reactions throughout the body. Among all organizations, physiological thiol compounds as methyl precursors involved in important biochemical reactions of the body. It can from the inactivation by methylation of the estrogen metabolites, and to stimulate the cell membrane phospholipid synthesis, by increasing the phospholipid composition of the liver serosa to prevent estrogen-induced cholestasis, which can be transferred thiol reaction prompted the bile acid by sulfuric acid way of transformation, but also to prevent or mitigate the poison and bile acids caused by oxygen free radicals on liver cell damage. The combined effect of ursodeoxycholic acid, reduce spasm, reducing bile acid, conjugated bilirubin transaminase abnormal biochemical indicators. General 800mg daily, intravenous, 14 to 20 days for a course. Most patients with symptoms and liver function were significantly improved the drug on the maternal and fetal side effects have not been reported.
(2) dexamethasone: estrogen during pregnancy cycle mainly from the fetal - placental unit, fetal adrenal sulfuric acid deoxy table androsterone (referred to as DHEAS are) http://www.huoguan.com, it is the placenta to produce estrogen the predecessor of the material. Dexamethasone through the placenta to reduce fetal adrenal DHEAS secretion, reducing the production of estrogen and thus alleviate cholestasis addition, it can lift the spasmodic contraction of the small blood vessels, reducing peripheral vascular resistance and enhance myocardial contractility, improve maternal circulation and perfusion capacity, and to promote fetal lung maturity. The Hirvioja such as patients with ICP space of 10 cases from 28 to 37 weeks of gestation dexamethasone 12mg daily oral, once every seven days, three days after tapering and discontinuation. Results All patients itching symptoms significantly reduced blood estriol (E3), serum estradiol (E2) and total bile acids were significantly decreased. During treatment was not found on the mother, infant and toxic reaction. It is felt that dexamethasone is the drug of choice for the treatment of ICP.
(3) of ursodeoxycholic acid (referred to as UDCA): a natural water-soluble bile acid, and its mechanism is not clear may be related to the following factors: oral can change the composition of the bile acid pool to replace the toxic on the liver cell membrane endogenous bile acids, inhibition of intestinal reabsorption of hydrophobic bile acids improve liver function to reduce the bile acid level, to improve the metabolic environment of the fetal placental unit, thus extending the gestational age; its choleretic effect, to prevent cholestasis reduce serum bilirubin. Ursodeoxycholic acid (UDCA) every 1g orally 3 times, once every 20 days, the results reduce the itching, blood, bile acids and ALT decreased, but can recur after discontinuation
(4) test to the enamine (cholestyramine): a strong basic ion exchange resin is absorbed after oral administration combined with bile acids, the formation of a complex absorption from the feces excretion, thus blocking the bile acid enterohepatic circulation to reduce the concentration of serum bile acids, have a certain effect on the elimination itch, but can not improve the blood biochemical indices and fetal prognosis. To test the enamine (cholestyramine) of fat, vitamin K and other fat-soluble vitamin absorption, increase the incidence of steatorrhea reducing leaving prothrombin time and prothrombin extend. Available test to the enamine (cholestyramine) 4g 2 ~ 3 times / d. Vitamin K and other fat-soluble vitamins
There are two kinds are experimenting with drugs: ① The epomeidolhttp :/ / www.huoguan.com: a terpene compounds can restore liver plasma membrane fluidity, reversed estrogen-induced cholestasis can be significantly improved itching and found no clear toxic side effects of biochemical indicators significantly improved; ② guar gum: the formation of a gel fiber, can promote intestinal excretion, relieve itching symptoms prevent elevated levels of bile acids, but can not improve cholestasis.
(5) phenobarbital: an enzyme inducer, can promote liver cells to increase the ability to bind bilirubin with glucuronic acid thus increasing the liver removed the ability of bilirubin in the blood bilirubin level, it can also increase the bile canalicular bile acid secretion rate, and by changing the cholesterol-7α-hydrolase activity in order to influence the generation of bile acids. But reported that this drug can cause the risk of neonatal respiratory depression, so the pregnancy should not be long-term use of this drug usage: daily oral administration of 100mg.
(6) human serum albumin or plasma: the combination of of free bilirubin to reduce the bilirubin to enter the fetus, but also improve the perfusion of the villi lacunar.
(7) traditional Chinese medicine: Chinese medicine theory that ICP is a damp, business health, qi stagnation and poor blood, can be given herbal capillaris soup: in bupleurum 10g, turmeric 10g, Salvia 15g capillaris 10g Alisma 10g , angelica 10g; 1 / d7 10 days of combination treatment of ICP63 case report application of Chinese medicine as a treatment in 1996 Habbo books, perinatal death, pruritus significantly improved the control group 40 cases, perinatal death five cases.
Obstetric management of ICP patients should be included in high-risk pregnancy management system guardianship, strengthening prenatal missionary severe patients should be admitted to hospital ahead, aggressive treatment until delivery, and timely termination of pregnancy after admission can give the following treatment:
(1) oxygen inhalation 2 times / d, the left lateral position, and time every day to count fetal movement. Weekly measuring fundal height, abdominal circumference, body weight to detect fetal growth and development in the uterus.
(2) after 35 weeks of pregnancy, the weekly Determination of placental function, the understanding of placental function, such as detection of 24h urine the E3, the blood of HCG, E3, etc.; fetal biophysical score; the B-type ultrasound monitoring of fetal biparietal diameter and placental maturity, amniotic fluid pay close attention to changes in fetal heart rate and amniotic fluid; Doppler ultrasound fetal hemodynamic changes can be at any time with no-load test (NST) the monitoring of intrauterine status of labor.
(3) termination of pregnancy: pregnant women, the ICP timely termination of pregnancy is an important measure to reduce perinatal morbidity.
① timing of termination of pregnancy when the gestational age ≥ 35 weeks, estimated fetal weight ≥ 2500g, you can consider termination of pregnancy if there is placental dysfunction, or fetal movement suddenly decreased, biophysical score to reduce the NST is reactive, the need for timely termination pregnancy.
② termination of pregnancy:
A. condition light placental function, you can choose induction of labor.
B. The following conditions should cesarean section: a history of premature birth, stillbirth and recurrent ICP; (b), longer duration, bile acids and bilirubin, or pregnancy induced hypertension and obstetric complications; c. oligohydramnios persons.
(4) the prevention of postpartum hemorrhage: vitamin K, postpartum strengthen uterine contraction to reduce postpartum hemorrhage.
Intrahepatic cholestasis of pregnancy disorders - prognosis
Gestational intrahepatic cholestasis
ICP perinatal aforementioned adverse effects of obstetric management program based on improving the ICP perinatal child prognosis more. The 1970s, the previous lack of knowledge of ICP ICP processing is just the general expectations of therapy and other natural childbirth, perinatal child mortality rate of 10.7%, With the increase of the ICP to take prenatal intensive care Once the mature fetus, ie, selective termination of pregnancy, the the ICP perinatal child mortality rate dropped to 3.5 percent. Nevertheless, for patients with ICP of a variety of prenatal care measures is not yet a good predictor of patients with ICP intrauterine death. Was reported before intrauterine death a few hours of fetal monitoring is still normal, NST is normally two days before fetal death, in addition, fetal death a few hours before the mother can still feel normal fetal movement. The standards of the description of some of the current prenatal intrauterine health status assessment method is not suitable for ICP.
Rioseco such as the retrospective assessment of the relationship between the different treatment programs for ICP and perinatal prognosis. Found mild ICP patients after 34 weeks of gestation regular weekly line NST check to be sure the fetus has matured in the 38 weeks of gestation and induction of labor. Perinatal child prognosis of 36 weeks' gestation with jaundice patients with ICP to be no significant difference between the induction of labor. Actively seized of the ICP after perinatal prognosis and normal pregnancy perinatal child outcomes there is no significant difference. Which the incidence of preterm birth and the incidence of meconium stained amniotic fluid and also with no significant difference between normal pregnancy Alsulyman such as research of ICP patients with a history of fetal death in normal pregnancy at 34 weeks pregnant a week routine NST examination and amniotic fluid the amount of assessment, without exception without any intervention, until the launch of natural childbirth or to give induction of labor at 42 weeks of gestation, found that the Perinatal children between ICP and normal pregnancy prognosis undifferentiated. ICP group 2 cases of intrauterine fetal death, perinatal mortality rate was 25 per thousand. Two cases of stillbirth in death within five days of the examination was normal after NST. Thus, he also believes that the fetal death in ICP, the traditional means of prenatal care is unpredictable. Obstetric management of patients with ICP is best to determine the fetus in utero has matured to be termination of pregnancy, and this is a good method to reduce the ICP fetal death.
Intrahepatic cholestasis syndrome - Prevention
The main consequence of the ICP is elevated perinatal morbidity and mortality, and thus, the purpose of the obstetric management should be to the fetus successful term delivery. If fetal distress and the fetus has matured should act decisively to the appropriate termination of pregnancy, cesarean section, vaginal delivery will increase the degree of fetal hypoxia. Reported ICP proactive treatment can significantly reduce perinatal mortality. [1]