Grand Rounds

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

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

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

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

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

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