Intrahepatic cholestasis in pregnancy: Increased surveillance and the role of bile acids in a patient with history of fetal demise

Abstract

Intrahepatic cholestasis of pregnancy (ICP) is a known risk for fetal demise and premature delivery and presents in up to one-third of all pregnancies. Cases traditionally present with pruritus, elevated bile acids, and/or elevated liver enzymes. We describe the case of a third-trimester patient with history of fetal demise and ICP that would have gone unnoticed based on laboratory reporting and symptomatic delay. The patient's symptoms presented weeks after bile acid findings and when tested again were sub-diagnostic. The patient declined pharmacological intervention and opted to induce labor during her 37th week where she delivered a healthy term child. The diagnosis was further complicated when the types and thresholds for bile acids varied between facilities. Our case highlights the importance timely assessment of itching in pregnant patients and the need to assess lab values objectively in the context of clinical features.