A case report of intrahepatic cholestasis of pregnancy with acute pancreatitis


  • Preeti Frank Lewis Department of Obstetrics and Gynecology, JJH, Mumbai, Maharashtra, India
  • Pratima Vinkare Department of Obstetrics and Gynecology, JJH, Mumbai, Maharashtra, India




Cholestasis, AFLP, Fetal distress


Cholestasis is a condition that impairs the release of a digestive fluid called bile from liver cells. As a result, bile builds up in the in the liver, impairing liver function. The problems with bile release occur within the liver (intrahepatic), the condition is described as intrahepatic cholestasis. Intrahepatic cholestatsis of pregnancy usually becomes apparent in the third trimester of pregnancy. Bile flow returns to normal after delivery of the baby, and the signs and symptoms of the condition disappear. However, they can return during later pregnancies. Intrahepatic cholestasis of pregnancy can cause problems for the unborn baby. The condition is associated with an increased risk of premature delivery and stillbirth. Additionally, some infants born to mothers with intrahepatic cholestasis of pregnancy have a slow heart rate and a lack of oxygen during delivery (fetal distress). Acute pancreatitis is defined as the sudden inflammation of pancreas manifested clinically by abdominal pain, nausea of dehydration that is usually self-limiting but occasionally can progress to severe disease and even death. Most cases of acute pancreatitis in pregnancy are caused by gallstone disease. It is thought with the weight and hormonal changes induced by pregnancy, gallstones are more likely to form and thus travel down the common bile duct to obstruct the pancreatic duct outflow. Another proposed mechanism for acute pancreatitis in pregnancy is high fat levels in the blood called triglycerides. Again, the hormonal changes of pregnancy can predispose certain women to developing this condition. When the triglycerides levels become too high, oxygen cannot adequately travel to the pancreas via bloodstream, and pancreatitis can ensue. Acute fatty liver of pregnancy (AFLP) is a rare but life-threatening complication that typically occurs in the third trimester of pregnancy. Extant studies show the low incidence of AFLP ranging from 1/7000 to 1/20000. Maternal mortality is 10% to 15%, and fetal mortality is up to 20% . The severity of this disease underscores the need for early diagnosis and management. The clinical diagnosis of AFLP is challenging, and the differential diagnoses includes other peripartum conditions such as severe viral hepatitis, pre-eclampsia, hemolysis, elevated liver enzymes, and a low platelet count (HELLP) syndrome or thrombotic microangiopathies. The primary treatment for AFLP includes rapid pregnancy termination and symptomatic therapy. Liver transplantation has been considered a last resort. We reported the case of 20-year-old primigravida at 36 weeks of gestation who developed IHCP mimicking Acute fatty liver of pregnancy with Acute Pancreatitis, however with multidisciplinary team approach she had a good feto-maternal outcome.


Lammert F, Marschall HU, Glantz A, Matern S. Intrahepatic cholestasis of pregnancy: molecular pathogenesis, diagnosis and management. J Hepatol. 2000;33:1012-21.

McKay AJ, O'Neill J, Imrie CW. Pancreatitis, pregnancy and gallstones. Br J Obstet Gynaecol. 1980;87(1):47-50.

Papafragkakis H, Singhal S, Anand S. Acute fatty liver of pregnancy. South Med J. 2013;106:588-93.

Fesenmeier MF, Coppage KH, Lambers DS. Acute fatty liver of pregnancy in 3 tertiary care centers. Am J Obstet Gynecol. 2005;192:1416-9.

Ko H, Yoshida EM. Acute fatty liver of pregnancy. Can J Gastroenterol. 2006;20:25-30.

Julie S, Moldenhauer MD, John M. Acute fatty liver of pregnancy associated with pancreatitis: A life-threatening complication. Am J Obstet Gynecol. 2004;190:502-5.

Naoum EE, Leffert LR, Chitilian HV. Acute fatty liver of pregnancy: pathophysiology, anesthetic implications, and obstetrical management. Anesthesiology. 2019;130:446-61.

Mikolasevic I, Filipec-Kanizaj T, Jakopcic I. Liver disease during pregnancy: a challenging clinical issue. Med Sci Monit. 2018;24:4080-90.

Vigil-de Gracia P, Montufar-Rueda C. Acute fatty liver of pregnancy: diagnosis, treatment, and outcome based on 35 consecutive cases. J Matern Fetal Neonatal Med. 2011;24:1143-6.

Zhong Y, Zhu F, Ding Y. Early diagnostic test for acute fatty liver of pregnancy: a retrospective case control study. BMC Pregn Childbirth. 2020;20:162.

Fields K, Barkin J. Pancreatic disease. In: Gleicher N, eds. Principles and practice of medical therapy in pregnancy. Stamford (CT): Appleton and Lange; 1998: 1142-7.

Ramin KD, Ramin SM, Richey SD, Cunningham FG. Acute pancreatitis in pregnancy. Am J Obstet Gynecol. 1995;173:187-91.

Legro RS, Laifer SA. First trimester pancreatitis: Maternal and neonatal outcome. J Reprod Med. 1995;40:689-95.






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