Intrahepatic Cholestasis of Pregnancy Warrants Aggressive Diagnosis and Treatment

Anonymous has left a new comment on your post "Intrahepatic Cholestasis of Pregnancy - A Bitch of an Itch...":

Dr. T,
This is Amanda I commented a while back and I am now 26 weeks into this pregnancy and I had my doctor do some blood work because my symptoms are back for the ICP (intrahepatic cholestasis of pregnancy). All I have heard so far is the liver enzymes and they were 317 and 325. My question is what is the earliest you have ever seen an ICP baby delivered. I am worried that they might have to take this baby really early. My doctor said the enzymes are higher right now then they were in my 36th week of my last pregnancy. I am not having to much itching yet. We are waiting to hear from the Bile Acids, but he went ahead and started me on Urso(deoxycholic) acid 250mg one tablet two to four times a day. Does that dosage sound correct, because he had no clue how to give it. In my last pregnancy the ICP was diagnosed so late in the pregnancy we decided the Urso wouldn't have time to start helping. Is there anything else I should do, like to help prevent a delivery before 36 weeks?

Amanda,
Your liver enzymes are already more than modestly elevated for ICP. Has your doctor ruled out other causes for this? At the least I would suggest a gallbladder ultrasound, screens for hepatitis B and C, a complete blood count, LDH, amylase, lipase, and serum bilirubin levels. Sometimes an autoimmune hepatitis can present this way as well. If the bile acids are elevated and no other source for hepatic cholestasis is found then this is very likely a genetic form of ICP. I would suggest starting with an Urso dose of 500 mg twice daily. That can be increased if your symptoms worsen. Here is a link that will provide you with some more information on ICP and other things you might try to improve the discomfort of the condition (http://www.americanpregnancy.org/pregnancycomplications/cholestasispregnancy.html). Controlling the bile acids may be your best bet at keeping the baby ‘happy’ (ie, minimizing the risks for unanticipated fetal death) and delaying delivery until 36 weeks. Best wishes and let us know how things turn out.
Dr T

Labels: intrahepatic cholestasis of pregnancy

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Combined First Trimester Screening for Aneuploidy Should be Just That - COMBINED

GB has left a new comment on your post "Fetal Nasal Bone Assessment in First Trimester Scr...":

Hi Doctor T,

I had my NT scan at 12 w 4 days and following results.I am of Indian origin..

Age : 31
CRL 57.3 MM
NT 2.0 MM
FHR 152 bpm
Nasal Bone : Absent/Hypoplastic
Everything else including tricuspid valve flow was okay
Background Risk for Downs 1:750
Adjusted Risk:1:135

I subsequently had blood serum test which resulted ok as per labs
Free Beta HCG 1.617 MoM
PAPP A 2165
RE-ADJUSTED RISK based on blood1:956 now.
My OBs says that isolated NB is not a strong marker in South Asians and says that’s currently I should wait for Triple test and Genetic sonogram at 18 weeks.

Please go through my case and let me know what you think as I am worried and losing sleep.

To GB:
In my opinion you should have NEVER been given an adjusted risk based on the ultrasound findings alone. The power of the first trimester screening is in the COMBINED risk assessment that includes the serum markers. Breaking down the individual test results and giving separate adjusted risks based on those individual parameters is contrary to the spirit of the screening and the science behind the screening and results in exactly the situation you are in now. I must say that I agree with your physician – with a “readjusted risk” (the ONLY result you should have been given) of 1 in 956, my ONLY recommendation would be to simply have an MSAFP (not the entire serum screen) at 16 weeks and a good ‘genetic sonogram at 18-20 weeks. If that is reassuring, your risk is reduced by AT LEAST another 50%, placing you in the range of 1 in 2000 or less. That is better than a 15 year old based on age alone! Best wishes!
Dr T

Labels: aneuploidy screening in first trimester

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Goodbye Blogger

Dear Readers,

We were just informed today that "Blogger" will soon be unable to support the capabilities required to continue the current format for "Fruit of the Womb" and the other HealthLine Experts. But, we have also been reassured that access to past posts should still be available once the transition to a new format has taken place. I am praying that is so!

We have also been told that the "Comments" sections under the posts will be disabled as of TOMORROW (April 15)! I am not entirely sure what this means for all of you in the queue for responses to your questions, but I fear they will be lost and I am not sure if the new format will provide the same interactive activities that I have tried to maintain since the inception of this blog - perhaps they will be better. But, in truth I have focused most of my efforts on this site over the past year responding to individual readers and that has become a part of my daily routine. As many of you know, we had to work around the quirks of Blogger and that meant at times it took an effort to communicate with each other, but we managed to do that remarkably well over time anyway.

In all honesty, this is a sad day for me, mainly because of the age old fear of the unknown. I do not know if "Fruit of the Womb" will be actually carried into the new format or if this is the last post I will have under that title. I was told that we would be involved in the new format but the level and the specifics of that involvement are yet to be determined.

If this is my last day as author of "Fruit of the Womb" then I want to tell you how much I have enjoyed the years we have spent together. We did much more with this blog than was ever anticipated. Indeed, it is probably unique among such sites on the internet. We have developed a worldwide following, I have found many new friends, and we have helped each other through good times and bad. I look at this as one of the most rewarding endeavors of my entire life, grateful for the trust you put in me and also for the gratitude you have shown for my efforts. I do not think this is "Goodbye", but if it is, then I want to thank all of you from the bottom of my heart for your loyalty, your trust, and your great respect for what we have tried to accomplish here!
Kindest regards,
Dr T

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Anti-M Isoimmunization

• Mon Mar 29, 02:24:00 PM 2010, Anonymous said…
Hello, I just found out that I tested positive for the antibody screen. I have a B positive blood type and do not understand the risks with my baby or how it affects or how it occurs. I am 5 months pregnant and am very worried. I have 2 children and never had this problem before. I've read that "anti-M are of apparent natural occurrence and not clinically significant", but then I read only 22% of a random population will be negative for the M antigen. How is that natural?

To anonymous Mar 29: Anti-M antibodies are generally "naturally occurring" which means that you develop them as the result of exposure to M-antigens found in the environment - usually expressed on bacteria or viruses. This is the same way we develop antibodies to the major blood group antigens A and B which are also considered to be “natural antigens.”

In most cases the only type of antibodies that individuals develop to these types of antigens are of the IgM subclass. IgM antibodies are very large and cannot cross the placenta and cause any problems for the baby. Occasionally (as can also occur with the A and B major blood group antigens), an individual will develop IgG antibodies to the M-antigen. IgG antibodies CAN cross the placenta and, indeed, are actively concentrated on the fetal side. Usually, these IgG antibodies are antibodies to a wide variety of things that are “foreign” to our bodies that we have been exposed to during our lifetimes and they provide protection for the baby against common environmental pathogens (e.g., viruses and bacteria) for the first 4-6 months of the baby's life following birth.

However, if you have IgG anti-M antibodies and the baby happens to have M antigens on its red blood cells, the antibodies can attach to the red blood cells and mediate their destruction by the baby's own immune system, ultimately resulting in fetal anemia and, in the worst case scenario, fetal hydrops and even death (as can occur with "Rh-disease"). This is uncommon with anti-M antibodies, but has been described on numerous occasions in the published literature. As with "Rh-disease", the risk for fetal complications generally increases with the level of the IgG anti-M antibody titers you have.

The first steps for you are to find out if you have IgG antibodies and if your partner is M-antigen positive on his red blood cells. If he is not, then your babies cannot be affected. If he is, and you have IgG antibodies, then your antibody levels (titers) should be ascertained and followed serially during the pregnancy. Severe fetal anemia usually is a risk when high titer anti-M is present as IgG antibodies at 37ºC.

If the IgG anti-M titers are 32 or higher, then the baby should be monitored serially for evidence of significant fetal anemia (just like we do with Rh-isoimmunization) by performing peak systolic velocity (PSV) measurements on the baby's middle cerebral artery using Doppler Flow Velocimetry. If the baby does develop significant anemia, then it should be either transfused with M-negative blood or delivered, depending on the severity of the anemia and the gestational age at which the baby gets in trouble. It would be a good idea for you to discuss this with a specialist in Maternal-Fetal Medicine before you conceive again. Thank you for reading and for asking such a great question.
Dr T

Labels: isoimmunization, Rh-isoimmunization, Rh-negative blood type

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More Questions on Group B Streptococcus (GBS) Infections

Despite not having published any new material recently during my recovery and rehab following surgery, our readers have kept me VERY busy behind the scenes responding to their many queries – could be a full time job all by itself. My willingness to continue this aspect of my writing is most rewarding to me, and apparently much appreciated by our readers, and probably makes this blog relatively unique. The topics that continue to generate the most interest from past posts are: 1) Screening for chromosomal abnormalities, especially in first trimester; 2) Miscarriage and recurrent early pregnancy loss; 3) Ectopic pregnancy and use of methotrexate; 4) Group B β-hemolytic streptococcus (GBS) infection; 5) Blood types and isoimmunization (such as Rh-disease); 6) Cervical incompetence (insufficiency) and cerclage; and, 7) Cytomegalovirus (CMV) infections.

I have received numerous individual questions and case situations which might have broad interest to our readers and would lend themselves well to new posts. Although I have shied away from public responses to these as a general approach to this blog, in view of my desire to be as ‘interactive’ as this site will allow, I have decided to make it more of the routine as I also explore new topics and updates for fresh discussion. Today I will respond to a couple queries related to GBS infection…

At Wed Feb 17, 06:03:00 PM 2010, Anonymous said…
Hi I'm 37 weeks pregnant and I was tested for GBS last week and at my doctor's visit today they said I tested positive. So I was informed as to how I'll be receiving antibiotics for the GBS, but my concern is even though it will help reduce my baby’s chances of getting it, will I be completely free of it after giving birth? Also, if I'm still being sexually active with my boyfriend (father of my child), have I passed it on to him? I was told it was not sexually transmitted, but I've heard you can get it from touching and we kiss and touch all the time. So I just want to know if I've given it to him and if he needs to be tested for it and if I'll be completely treated from it after giving birth.

To Anonymous Feb 17: It is VERY hard to completely "cure" you of GBS. It is carried in the gastrointestinal tract and more than 20% of all individuals are chronic carriers. Some people keep GBS in better check than others and some can be exposed regularly and never become carriers. So, even if you are “treated” in labor, do not expect to be completely free of the bacterium. Intimate contact is probably not as important to passing GBS to other individuals as much as is their susceptibility to it. The latter is probably determined by the individual’s immune response and some folks are immunologically hyporesponsive to certain strains of GBS. With regard to transmission to others, there are many documented examples of women who were heavily colonized with GBS who did not pass the bacterium on to their partners. So there is no reason for having your partner tested at this time. I would keep up the kissing and touching and not worry about who may or may not be passing it to whom! Best wishes for the rest of the pregnancy.
Dr T

At Wed Feb 24, 10:39:00 AM 2010, Anonymous said…
I sure am hoping that my question gets answered. I am only 10 1/2 weeks pregnant and I am SO confused! I just got a phone call from the doctor’s office telling me I tested positive for GBS and it is so weird I just got off of ampicillin about a week ago for a urinary tract infection. But the internet makes this sound as though ‘once I am a carrier then I am always a carrier’ and the doctor’s office made it sound like I just need to take penicillin and then I don't have to worry about anything. I am really confused...which one is it? Does it go away after medication or not? Also, is it really safe to take THIS much antibiotic so early in the pregnancy? First ampicillin and now this? If antibiotics take the good bacteria as well, then how in the world can it be safe for me to take so much while still in the first trimester??? I feel bad questioning what my doctor tells me but this is my first pregnancy and I was told I would never conceive on my own... I am trying to do everything I can to just have a healthy baby... Please tell me you have some answers for me doctor?? Thank you.

To anonymous Feb 24: If you had/have a GBS urinary tract infection (UTI), that does need to be treated and can be cleared. GBS UTIs place the pregnancy at increased risks for complications including premature cervical change, preterm labor, premature rupture of membranes, early delivery and chorioamnionitis. If a GBS UTI recurs, you will need to be retreated and in some cases may need to be on 'antibiotic suppressive therapy' for the duration of the pregnancy. Penicillins are very safe to take, even in first trimester. Remember, GBS tends to be carried in the gastrointestinal tract and antibiotics usually do not successfully eradicate the bacterium from there. As you point out, broad spectrum antibiotics can harm the "good bacteria" in your vagina and allow overgrowth of the unfavorable bacteria or, more commonly, yeast. So if you develop a malodorous or itchy discharge, you need to discuss that with your doctor as well. Best wishes for the rest of the pregnancy and please let us know how things turn out.
Dr T

Labels: GBS and pregnancy, Group B Strep

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