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#Grand Rounds

Is Rifampin an Option for the Treatment of Intrahepatic Cholestasis in Pregnancy?

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BACKGROUND AND PURPOSE:

  • Intrahepatic cholestasis during pregnancy is an enigmatic disease that that is associated with significant adverse events, including preterm delivery, nonreassuring fetal status and stillbirth
  • Ursodiol therapy can be used to reduce pruritis and bile acid levels but is not curative and may not always lead to improvement
  • Rifampin
    • Antibiotic that inhibits RNA synthesis
    • Used to treat TB, Legionnaire’s disease and meningitis
    • Rifampin efficacious in treatment of pruritus and liver dysfunction associated with other chronic cholestatic liver diseases
    • FDA Category C due to rodent studies but no evidence of teratogenicity in pregnancy
      • CDC states “although the drugs used in the initial treatment regimen for TB cross the placenta, they do not appear to have harmful effects on the fetus”
    • Liu et al. (Obstetrics & Gynecology, 2018) provide a case study where rifampin was used to treat intrahepatjc cholestasis

METHODS:

  • The patient described in this report
    • 21 years of age, G3P011
    • Presented with severe intrahepatic cholestasis of pregnancy at 27w2d
    • Refractory to ursodiol
  • Patient started on 300mg rifampin po twice daily at 29w0d

RESULTS:

  • Pruritis improved within 2 days
  • 29w3d
    • BP elevated but returned to normal
    • Elevated AST and ALT improved but no improvement in elevated bile acid levels
  • 31w5d
    • Nonreassuring BPP leading to repeat cesarean section
      • Apgar: 6185 ; 1,540 g

CONCLUSION:

  • Rifampin administration to a woman with intrahepatic cholestasis lead to rapid improvement of symptoms but did not appear to improve pregnancy outcomes
  • Future studies are needed to understand the treatment potential of rifampin combined with ursodiol

Learn More – Primary Sources:

Adjuvant Use of Rifampin for Refractory Intrahepatic Cholestasis of Pregnancy

CDC: TB Treatment & Pregnancy

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Related ObG Topics:

Hidradenitis Suppurativa: Diagnosis and Management
Fatty Liver of Pregnancy: A True Obstetric Emergency
SMFM Releases Guidelines on Screening and Management of Hepatitis C in Pregnancy 

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