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17.4.2 INTRHEPATIC CHOLESTASIS OF PREGNANCY Intrahepatic cholestasis of pregnancy accounts for 20-25% of cases of jaundice during pregnancy. The etiology is unknown. There is a clear genetic predisposition, likely autosomal dominant, plump asian with an increased frequency in women of Scandinavian or Chilean descent. The cholestasis plump asian (failure of bile formation) represents an exaggerated response of the liver to the normal increase in endogenous estrogens during pregnancy. Presentation typically is in the third trimester with the insidious onset of pruritus. In half of these patients, jaundice follows. Other cholestatic features include dark urine and, occasionally, pale stool. Otherwise women generally plump asian feel well, without nausea, vomiting or abdominal pain. Serum alkaline phosphatase and cholesterol rise, but aminotransferases are only modestly elevated. Ultrasound and cholangiography are normal. The evaluation of the pregnant woman with cholestasis involves excluding other causes of jaundice and pruritus including viral hepatitis, primary biliary cirrhosis and biliary tract disease by the appropriate laboratory and ultrasound investigations.
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