Extreme Intrahepatic Cholestasis of Pregnancy With Fetal Ascites and Neonatal Meconium Peritonitis

Intrahepatic cholestasis of pregnancy (ICP) is a rare but potentially severe condition with significant maternal and fetal risks. A 28-year-old gravida 2 para 1 woman presented at 21 weeks’ gestation with pruritus and jaundice and was diagnosed with severe ICP (bile acids 297 μmol/L). Despite ursodeoxycholic acid (UDCA) treatment, escalation with rifampicin and antihistamines was required. At 23 weeks, fetal ultrasound revealed massive ascites and features suggestive of meconium peritonitis (MP). Intensive maternal-fetal monitoring allowed pregnancy prolongation to 36 weeks, when cesarean delivery was performed. The neonate, initially stable, developed bowel obstruction on day 7 and underwent surgical resection with ileostomy, followed by gradual recovery. This case illustrates the potential for rare but severe fetal and neonatal complications in the setting of extreme ICP. Early recognition, multidisciplinary management, and individualized delivery planning are crucial for optimizing maternal and neonatal outcomes.