Intrahepatic Cholestasis of Pregnancy - A Bitch of an Itch

Wednesday, January 10, 2007

Kenneth F. Trofatter, Jr., MD, PhD

Recently, we had a woman diagnosed late in pregnancy with intrahepatic cholestasis of pregnancy, or obstetric cholestasis (OC). Despite reassuring fetal heart rate testing, the baby died in utero awaiting induction of labor that had been scheduled within 48 hours of diagnosis. As is usually the case in OC, no specific fetal or placental abnormalities were noted at the delivery. The baby had no evidence of growth restriction or infection, but had passed meconium (had a bowel movement) prior to delivery and was found to have aspirated that material into its lungs.

OC is an enigmatic, relatively common, and potentially serious complication of pregnancy, as the aforementioned case illustrates. Most women with this condition present in third trimester with intense itching (pruritus) without a rash. Generally, the itching is localized to the abdomen, legs, palms, and soles, but can be generalized. The itching can be so intense that these women develop excoriations, secondary infections, and even scarring as a result of their scratching.

Although specific criteria for the diagnosis are not agreed upon, the condition is characterized by some degree of hepatic dysfunction, as manifested by elevated levels of serum bile acids and, often, modest elevations of serum transaminases (ALT and AST). Generally, these abnormalities are not more than two- to three-fold normal levels, but more than 90%, if not all, patients with OC will have both bile acid and transaminase abnormalities. Itching is not uncommon in ‘normal’ pregnancy with complaints of the same occurring in about 50% of all gestations (particularly in first trimester and localized to the abdomen), but this is not accompanied by hepatic involvement to the extent that laboratory abnormalities are found early and only about 3% of these women will go on to develop true OC. Cases of OC have been described wherein the laboratory abnormalities did not develop until 15 weeks or more after the “itching” began.

There appears to be a genetic predisposition to the condition. About 0.5-1.0% of Caucasians develop OC, but these figures are doubled in women from Southeast Asia, and certain ethnic subgroups can have even much higher rates. For example, Reyes and colleagues (Ann Intern Med 1978;88:487-93) showed OC affects 5.5% of pregnancies in Chilean Araucanians. Others have also shown that sisters have a 17% coincidence of OC (Eloranta ML, et al., Clin Genet 2001;60:42-5). Recent studies have shown mutations in specific genes, MDR3 (ABCB4) and BSEP (ABCB11), that affect hepatic phospholipid and bile acid transport, respectively, and the presence of these mutations have been correlated with cases of poor fetal outcomes (Schneider G, et al., Hepatology 2007;45:150-8). As a consequence, women with OC seem to have an increased sensitivity to the cholestatic effects of pregnancy hormones, especially estrogens, but how this translates to fetal complications remains unknown. Women with true OC may have a history of “itching” while taking estrogen-containing oral contraceptives.

In the next post, we will go on to discuss maternal and fetal risks of OC, as well as management options…

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163 Comments:

At Sun Apr 15, 08:51:00 AM 2007, Anonymous said…

My daughter recently gave birth. She was induced at 38 weeks as she had OC. The baby after had been observed not to have grown in the later stages too. At birth the baby (a boy who always had a very strong heart beat) had the cord wrapped around his body and neck, causing in the end an emergency delivery.
I know little is known about this condition, we are white English, and had not known of this in our family.
The one thing that did strike me was that this condition developed late in the pregnancy, when my daughter was receiving a great deal of stress and anxiety from her place of work. Could there be a link? As a there is a known saying in the past of someone 'having their bile-up' when very stressed.
Also since the birth, 10 weeks ago, blood tests show normal, but she has a persistent itcy red rash on her face.
At Thu Apr 26, 06:36:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

I think it is unlikely that her stress contributed significantly to her OC, but I wouldn't completely rule out the possibility. I am a little more worried about the rash. A facial rash in a young woman after pregnancy may be the result of an autimmune condition such as systemic lupus erythematosus (which can also affect the liver and perhaps set her up for the OC). I would suggest you take her to a dermatologist to evaluate the rash if it persists and certainly if she develops any other symptoms. Thanks for writing!
At Fri Jul 13, 10:45:00 AM 2007, Anonymous said…

I am realizing that this is what I had in both my pregnancies with my son & daughter. Neither time was the condition diagnosed. Both times, my doctor/midwife wanted to just treat the symptoms with Benadryl, which I refused to take. I would itch so bad that I scratched until I bled. I itched all day, including in my sleep. It started with my hands & feet & then progessed to my legs...pretty much everywhere except my face. There was no rash. I just recently found out that I am pregnant again! I am 7 weeks along & want to make sure that I will find a good OB/Gyn or midwife who is knowledgeable about this condition. I had both of my children vaginally. My daughter was full-term. My son came 3 weeks early on his own (no induction). Although I would like another natural birth, I am not opposed to caesarean if that is what is required for a healthy baby. I was wondering if can tell me if there have been any studies on this condition. Since this happened with both my son & my daughter, I am wondering if this will most likely occur in this pregnancy as well. I am of English decent and am not aware of anyone else in my family that this occurred with. I am also wondering if there are any preventative measures (diet,herbal) that I can do? Thank you.
At Wed Jul 18, 06:27:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous July 13: Hi there and thanks for reading. Yes, there is a VERY high risk of recurrence (as high as 90%) and of serious complications for the baby. I am glad things have turned out well with your previous pregnancies. Some of your questions may be answered in my follow-up post on this subject January 13, 2007. Hope things turn out well, but be careful!
At Mon Jul 30, 06:52:00 PM 2007, Anonymous said…

Is there a definitive blood test that will confirm ICP? I am 33 weeks and have some itching, how would a physician tease out if the itching is ICP or just dry skin....I itch more at night maybe because I am less busy and the itching is on my bi/tricep and front of calves...but can be on my scalp and back, anywhere....thanks Stacy
At Thu Aug 02, 08:46:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Stacy: I wish there was a definitive blood test (because then we would know who to worry about and who to not), but there is not. If your serum bile acids are significantly elevated, that's a strong hint that you have cholestasis, but the diagnosis is more one of the entire clinical picture as detailed in my post. Itching during pregnancy is not at all unusual, but that associated with cholestasis is usually unbearable! Hope you don't have it! Thanks for reading.
At Mon Aug 20, 05:22:00 PM 2007, Rani B said…

I am interested in knowing what I can do to prevent or at least delay the onset of cholestatis of pregnancy.

I had cholestasis of pregnancy in 2004 when I was pregnant with my son. I was diagnosed at 35-1/2 weeks and induced for delivery at 37 weeks (because tests showed my bile acids were significantly elevated). Thankfully, my beautiful baby boy was born healthy (though a bit jaundiced).

I am now pregnancy (at 19 weeks) with my second child (another boy). So far, so good, but I am watchful for symptoms due to the high rate of recurrence of this condition.

I would like to take any steps that I can in terms of diet, exercise, homeopathic treatments, etc. to aid my son's healthy arrival into this world. Do you have any suggestions? For example, should I take water-soluble prenatal vitamins? (and if so, can you recommend one)?

Thanks in advance for any guidance you can provide.
At Fri Aug 24, 06:12:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Rani B Aug 20: You are correct. There is a very high rate of recurrenec if you truly had cholestasis because of the genetic predisposition to this condition. There is no way to absolutely prevent its recurrence either. I think you have the right ideas though. I would minimize the fat content of your diet (at least during pregnancy), consider the use of a water-soluble PRENATAL vitamin (there are many on the market such as Vegan Prenatal), and try to get some light exercise every day - I suggest walking, swimming, treadmill, stepper or elliptical trainer, or stationary bike. Drink lots of water in your diet and stay away from too much free sugar as well. Although ursodeoxycholate appears to be of benefit in treating this condition, as far as I know, no one has ever done a study to seee if it helps to prevent the RECURRENCE of cholestasis on a prophylactic basis. Thanks for reading and for a VERY good question. Dr T
At Tue Sep 11, 05:25:00 AM 2007, Anonymous said…

I have 3 sons all of which i was induced at 37 weeks due to cholestasis. During all 3 pregnancies I also had gallstones, after my third baby i had my gallbladder removed. I am now 28 wks pregnant with a girl and have no gallbladder, am I likely to get cholestasis in this pregnancy the same as the others? or should I be ok as i have no gallbladder/stones this time?
At Wed Sep 12, 05:05:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Sept 11: True cholestasis of pregnancy is linked to genetic polymorphisms involved in bile acid metabolism in the LIVER, not the gall bladder. Think of the gallbladder as simply a storage sac for certain digestive enzymes produced in the liver and released when fatty foods are present in the digestive tract. So, true pregnancy cholestasis will probably NOT be improved by removal of the gallbladder. However, if you had cholestasis related to obstruction of the bile duct by gallstones, not by an enzymatic defect in the liver, then you might just do better this pregnancy. But, having your gallbladder removed is a heckuva way to confirm the diagnosis of true pregnancy cholestasis! Hope you don't itch this pregnancy. Thanks for reading and for a great question! Dr T
At Mon Sep 17, 03:18:00 AM 2007, Anonymous said…

thanks you for answering my question (12th Sept, 3 sons already) are you saying that you can get cholestasis due to having gallstones, and not necessarily when you are pregnant? does this mean that because I had OC during each pregnancy that it is more likely to have been down to the pregnancy and not gallstones? thank you
At Tue Sep 18, 11:16:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To anaonymous Sept 17: You can get cholestasis with gallstones if they obstruct the bile duct and the bile backs up into the liver. However, your problems during pregnancy were probably NOT casued by your gallstones. True cholestasis of pregnancy is caused by a genetic defect in one or more of the enzymes that help us to metabolize and transport bile in the liver. That's why it recurs at such a high frequency. It is a liver problem and not a gallbladder problem! Hope that answers your questions. Thanks again for reading and good luck with this pregnancy. Dr T
At Sun Sep 23, 10:32:00 PM 2007, Valerie said…

Hi, Dr. I am currently at 28 weeks gestation with my second pregnancy, both of which I experienced cholestasis. This pregnancy, it is much worse. I have not been diagnosed by my OBGYN, and I have gotten the brush off from the local Labor & Delivery departments. Would you recommned I go to a high risk OB? I don't know where to turn for help. I know this runs in the family, and I am concerned for baby and her health. I have every symptom in the book, as far as the severe itching all over my body. So much so that it is interfering with my daily life and my sleep at night. I find myself groaning, in fact. Family and friends have identified a change in my behavior as soon as this started, just as they did in my first pregnancy.
This runs in my family, I just found out.
Thank you for your time.
Valerie
At Mon Sep 24, 07:04:00 PM 2007, Anonymous said…

hi
i've never been pregnant, but lately in the past 3 days or so my breast have been itching like crazy, and i don't really know what it is, and as i searched it online i say ur article.
can you please tell me what to do ?
At Thu Sep 27, 06:55:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Valerie Sept 23: It sounds like you have the real deal - pregnancy cholestasis - and that is something that should be taken very seriously. It is a 'genetic problem' and that's why it runs in families. As described in my post, it also places your baby at risk. By all means, if your doctors won't take you seriously, ask for a referral to a specialist in Maternal-Fetal Medicine. Current recommendations are to follow you and the baby very closely and deliver no later than 37-38 weeks. Best wishes to you and I pray that things turn out okay. Thanks for reading! Dr T
At Thu Sep 27, 06:57:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Sept 24: Breast itching alone during pregnancy is very common. and does not necessarily mean you have intrahepatic cholestasis. It is usually related to stretching of the skin as your breasts enlarge during pregnancy. Is this your first baby? How far along are you now? Dr T
At Mon Oct 08, 03:31:00 AM 2007, Anonymous said…

Hi, I am 32 weeks into my 4th pregnancy, I had cholestasis with the previous 3 and induced at 37 weeks. If cholestasis does not show up this time, I am still very worried about going past 37 weeks. Could it still be dangerous for me to go that far especially if cholestasis showed up after 37 weeks? Coul I still be induced at 37 weeks this time for peace of mind? thank you
At Thu Oct 11, 05:11:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Oct 8: If you had cholestasis with your last 3 pregnancies there is more than a 90% chance you will get it again. If you do not get it again, you probably do not need to be delivered early, unless there is another fetal or maternal indication for delivery. It is the elevated bile acids accompanying cholestasis that not only make you itch, but also put the baby at risk, although we do not understand completely why. If you do feel like you just have to be delivered at 37 weeks for "peace of mind," I would strongly suggest you have an amniocentesis done first to document fetal lung maturity. Late preterm births can be associated with significant short- and long-term morbidity and mortality and these now constitute 75% of all preterm deliveries. There is nothing sadder than seeing a 7lb baby laying in the NICU on a ventilator because they were delivered a little too early for no real good clinical indication. This happens much more frequently than patients and providers realize! Thanks for writing and I hope you don't get cholestasis again and everything turns out well! Dr T
At Mon Oct 22, 02:03:00 AM 2007, Anonymous said…

when does cholestasis show up? i am 34 and have had it before but it started at 30 weeks. would i have developed it by now or could it still show up right up until the end of pregnancy?
At Mon Oct 22, 08:01:00 AM 2007, Anonymous said…

Hi MD,

I am 16 weeks pregnant. I have had 3 early miscarriages at 5 1/2 weeks, 4 1/2 weeks, and 8 weeks, so I am thrilled to make it this far.

I am a thin woman who atypically had my gallbladder removed in 2001 due to Chronic Cholecystitis due to abnormal twisting of the gallbladder duct that caused problems.

The last two days I have had itchy palms and I am nervous about possible O.C. since I am so "high risk" for miscarriage already. Should I call my MD? I don't have very good insurance right now and I know I'll have to pay out of pocket for any testing. Thanks!
At Mon Oct 22, 04:05:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Oct 22 0203 AM: In different people, it tends to recur around the same time in each pregnancy, but could be anytime up until you deliver. Then again, perhaps you did not have the hereditary form of cholestasis the last time and if you are REALLY lucky, it won't recur at all! I hope not for your sake. Just out of curiousity, is there anything different about this pregnancy than the last. Different vitamins, a new father of the baby, different medications, different gender of the baby, etc..??? Good luck and thanks for reading! Dr T
At Mon Oct 22, 04:13:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Oct 22 0801 AM: There is certainly the possibility that your gallbladder condition was related to problems that might also increase your risk for cholestasis, although this is still a little early. Other conditions associated with this incude hepatitis virus infections and occasionally other viral infections such as cytomegalovirus that might otherwise be asymptomatic. Also, certain medications and prenatal vitamins can sometimes cause these symptoms, as can certain autoimmune conditions. Contact your doctor if the itching becomes intolerable, or if you develop any other symptoms, and he/she can send off a screen for bile acids in your blood. If you really have pregnancy cholestasis, I am afraid you are going to have a long pregnancy ahead of you! Hope it's not so and best of luck to you. Please let me know what they find out! Dr T
At Tue Oct 23, 10:07:00 AM 2007, Anonymous said…

i am the lady who is 34 weeks pregnant with 3 boys already and cholestasis with each of them. it hasnt showed up yet and this baby is a girl. my bilirubin is high but bile salts are ok, however i am still itching on arms and legs. i am a bit confused!!!
At Fri Oct 26, 03:41:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Oct 23: Did you have ANY other laboratory abnormalities (e.g., liver function tests). Is there any evidence of a chronic liver problem such as viral (or other)hepatitis (which frequently accompanies cholestasis), hemochromatosis, or an autoimmune condition? Do you use much tylenol or any other medications that are metabolized by the liver? What is your hemoglobin and hematocrit? Regardless, please let me know how things turn out. Itching is NOT at all unusual during pregnancy for reasons we are often not smart enough to figure out. By the way, congratulations on the girl! Does that mean it's time to quit! Dr T
At Sat Oct 27, 04:16:00 AM 2007, Anonymous said…

i am the lady with 3 boys, lft's all ok, bile acids 4.2, bilirubin 96. am 35 wks pregnant now so i guess things will be ok with this pregnancy apart from baby is breech at the moment! no cholestasis so far though. previous bile acids last month were 3.6 so going up very slowly but not enough to worry about. thank you for your comments!!
At Sat Nov 03, 05:12:00 AM 2007, Anonymous said…

hello, i am now 36 wks (mum of 3 boys all had cholestasis in pregnancy) had gallbladder removed now expecting a girl. Am now itching uncontrolably on hands and feets with extremely dark urine, am 99% convinced it's cholestasis again, having bloods done in 2 days time on monday.
At Tue Nov 06, 11:59:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Mum of 3 boys: Yep, it sounds like you have the REAL disease. Like I said before, having your gallbladder removed does not remove the cause of pregnancy cholestasis. It sounds like things are coming on very quickly now, so I hope your doctors keep a real close eye on that beautiful daughter of yours. Let me know how she does...Dr T
At Wed Nov 07, 04:37:00 AM 2007, Anonymous said…

hi, mum of 3 boys here again! have had cholestasis confirmed, alt 102, alp 213, being induced next week at 37 weeks! gallbladder removal and babies sex has had made no change to the cholestasis!!
thank you for your concern!!!
At Tue Nov 13, 05:25:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Mum of 3 boys: You are most welcome. Tell us about your delivery! Dr T
At Thu Nov 15, 01:39:00 PM 2007, Anonymous said…

Hi Dr. Trofatter I am 39 weeks pregnant and I have OC. Itching started around week 29. My itching was terrible and my doctors didn't believe that I had OC for about 6 weeks because my LFTs and Bile acids did not raise. Even after I brought in research, they still thought it was "normal" pregnancy itchBut they did rise finally and after much begging on my part they prescribed me Ursodiol, bi-weekly non-stress tests, and weekly blood tests. Luckily, since going on Urso, my itching has stopped and my bile acid levels have gone down to 9. My question is, would it be wise to still induce labor? My cervix is favorable (1 cent, 80% effaced as of 4 days ago). My doctors never seemed to think I needed to induce labor, even after I brought them research explaining the risks to the baby after 37 weeks. Since my levels have gone down, I haven't pushed the issue, but someone recently informed me that there could still be a risk to my baby girl. I'm not confident in my doctors' knowledge about OC. There are 9 doctors in my practice, and each one has given my husband and I different facts about the condition, and sometimes the info they have told us completely contradicts what we have researched online through medical documents. I've been searching for someone who is knowledgeable on this subject, so any help you could give would be great. Thank you very much.
-Carrie
At Fri Nov 16, 09:01:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Carrie Nov 15: Presuming you really do have pregnancy cholestasis (there are other things that can lead to your symptoms and laboratory abnormalities), if you are a well-documented 39 weeks, I would suggest you consider induction. OC is notorious for being associated unanticipated bad outcomes, despite fetal monitoring. You are probab;y at lower risk if your bile acids have normalized, but I don't know if I would take a lot of chances at this point either! Good luck and let us know how things turn out! Dr T
At Mon Nov 19, 06:08:00 AM 2007, Anonymous said…

mum of 3 boys and now a dughter here! cholestasis all 4 pregnancies. Labour last week was an hour and a half long, perfect delivery, no stitches, baby girl no problems at all. Sleeps 6-8 hours at night and never crys, perfect baby and delivery so far!!! 8lb 12oz at 37 weeks, not bad weight!! Itching completely gone too.
At Tue Nov 20, 07:35:00 AM 2007, meg said…

My baby died on Oct 20th. I was 37 weeks and my dr kept putting me off. i begged tem to take my baby because of the complications that could happend and they did. Now i am the one with not baby and all the pain. How do i find out if it is gentic or not. I want to make sure i find adr for next time that knows about ICP and will induce me if it happens again. Please let me know what i can do for next time
At Tue Nov 20, 05:06:00 PM 2007, Anonymous said…

Hi just wanted to send a quick update. This is Carrie who just posted a few days ago. I had my baby on 11/18 (water broke naturally). She's beautiful and perfect and is happy and healthy. I lost a bit of blood when I hemmoraged after the birth but other than that I'm doing fine and recovering. The itching has disappeared (knock-on-wood) thankfully. We have so much to be thankful for this Thanksgiving! Thanks again for all your help!
-Carrie
At Mon Nov 26, 06:37:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Meg Nov 20: Oh, Meg, I am so sorry. You cannot know how many times I have heard this same story. It sounds like you most likely did have pregnancy cholestasis and in MOST cases it is genetic and has a recurrence rate as high as 90%. Since you lost your baby, you are at even higher risk. There is no sense treating you until you get pregnant and devlop symptoms again. Then, placing you on ursodeoxycholic acid will, hopefully, reduce the bile acids in your blood that contribute to both your itching and the baby's risk. Your baby will still have to be followed very carefully, and even if things are going well, I would suggest testing for the baby's lung maturity at 36 weeks and getting you delivered then rather than taking any chances of waiting longer. Again, I am so sorry. If you get pregnant again, write back and I may have some other suggestions for you. Dr T
At Mon Nov 26, 06:59:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Carrie Nov 20: Congratulations Carrie!!!!! Whew, bet you're glad that's over! Dr T
At Mon Nov 26, 08:55:00 PM 2007, Anonymous said…

Hi, I'm a mother of two children. I had a tubal ligation over 5 years ago and I was told I couldn't have any more children. I just logged in and read about the "Inrahpatic Cholestasis of Pregnancy- A Bitch of an itch". My breast have been itching severly for about 2 wks now. I didn't think anything of it until now. Should I be seeing a Dr. about it?
At Thu Nov 29, 11:41:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Nov 26: You should see a doctor, but if you are not pregnant, it is NOT pregnancy cholestasis. Dr T
At Thu Dec 13, 10:45:00 PM 2007, Anonymous said…

I am a mother of one and 31 weeks pregnant with my second. I had cholestasis with my first and was induced at 39 weeks as I had problems being taken seriously and finding someone who would do the research nescessary. My son was very jaundice as was I. I now have the same symptoms of itchy hands and feet, dark urine etc.... thankfully this time my Dr. is more aware and has put me on Urso, but I'm just wondering if my tests show that my bile acids are relativly low, due to the treatment with Urso, what is the latest I should go in my pregnancy, and what kind of test do you need to do to know the baby's lungs are mature?
At Fri Dec 14, 06:41:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Dec 13: It sounds like you have TRUE pregnancy cholestasis. I would recommend an amniocentesis to assess fetal lung maturity at 36-37 weeks; if there is any suspicion of a problem at that point, I would recommend delivery, regardless of fetal lung maturity. I have even thought about offereing all women with cholestasis as seever as yours corticosteroids to help accelerate fetal lung maturity at about 34 weeks. Read the comment from Meg (Nov 20) above. This can be a very dangerous condition and babies are sometimes lost even with very careful monitoring. Best of luck to you. Please let us know how things turn out. Dr T
At Sat Dec 15, 09:51:00 AM 2007, meg said…

This is meg again--- Just wanted you to know I went in for my 6 week checkup and I am still furious. They said they didnot induce me because my blood pressure was not high, so they played the odds that nothing would happen to my baby because of the ICP even though I begged them to take her. It ws a military hospital. I have been having really bad pains. They have done a million tests. They thought it was my gallbaldder, they can't find my gallbaldder- they even had the surgery team waiting . Can this be possible. i want to get pregnant so bad but I want to make sure I am ok first as to not hurt my baby.
At Mon Dec 17, 11:58:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Meg Dec 15: You have had a time of it girl! With ICP, you do not have to become hypertensive to have a baby get in trouble as you found out. You could also still have either a gallbladder, liver, or pancreatic problem that is contributing to your pain at this point. Are they considering looking inside your abdomen with a laparoscope and then removing your gall bladder (or what's left of it) that way? I would certainly recommend waiting to get pregnant again until all this is sorted out. Does the military have any way you can get a 'second opinion' with an outside provider or an expert in the military? Again, best of luck to you and let me know what happens. Dr T
At Wed Jan 02, 03:02:00 PM 2008, Anonymous said…

I was diagnosed with ICP in early November 2002. I was 22 and pregnant with my son and in my mid 2nd trimester. I delivered him on December 18th 2000 at 37 weeks. I am of Swedish decent. I support this article and find it to be very true. I can not take birth control. I had severe gallstones and had my Gallbladder removed in April of 2002. All of my research indicates that the possibilities of ICP returning even with out a gallbladder is up tp 90%. I have been told by one mother that she felt it was worse. This illness was just a nightmare. The itching, the sleeplessness. I could not walk barefoot on the carpet, I could not where a bra. I would wake up and felt as if somebody had dumped acid all over my body. I often spent nights in tears wrapped in a cold sheet with my feet in cold water.

But I would go thru all that again for my son. He is now 7 and was worth every second of that agony.
At Sat Jan 05, 01:57:00 AM 2008, Rachie said…

HI Dr.
I am having my 6th baby. With my last pg I had severe itching. I immediately changed my diet to almost no fat and the itching resolved over a week. I was also having very low fluid that went up as the itching resolved.

I had my gallbladder removed after my first pg. With my first pg, and was having severe gall bladder attacks, and ended up having an emergency csection due to all my fluid being gone.

Anyhow it seems I only get this problem when pg. with girls. My last was a girl and the problems started at 32wks.
Anyhow I am trying to prevent a reoccurance. I am 20wks and have been eating low fat. My dr. really doesn't know alot about OC. Should I ask for a referral? I live near the Mayo clinic. I am positive I had OC, as the itching was my hands and feet and it kept me up all night. It also felt like my organs itched. I also sometimes get that internal itching feeling throughout my menstrual cycle.

Any suggestions would be great!

Rachel
At Sun Jan 06, 04:45:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Jan 2. Thanks for reading and for your testimonial. You accurately describe, much better than I, what women with real ICP have to contend with in pregnancy. It can be a miserable experience and many women do forego another pregnancy once they have suffered with the condition once. Best wishes. Dr T
At Thu Jan 10, 10:33:00 AM 2008, Anonymous said…

I had OC with my second child. I "slept" with ice packs on my hands and feet until I was diagnosed and medicated. Since then, I can no longer take birth control pills because they bring on the same itching. I can also tell when I'm ovulating, because my feet and hands start itching. I gave birth 5 years ago, yet still have some effects of OC. Is there a higher risk for future liver problems for women who've had OC?
At Fri Jan 11, 11:19:00 PM 2008, rachie said…

Any suggestions...I posted about a week ago. Does it sound like OC?
Rachel
At Sun Jan 13, 10:31:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Jan 10: You know, that is a GREAT question and I honestly do not know the answer. I will try to look into it. My common sense tells me there ARE gretaer risk for complications, particularly if ypu continue to have problems unrelated to pregnancy. The risk probably depends on the underlying genetic defetc you carry. But, you seem unusually sensitive to 'estrogens' and may not entirely get relief until menopause. Have you seen a gastroenterologist about this? You could have some underlying liver probleme, such as hemochromatosis, that is contributing to the inability of your liver to metabolize certain things even when it is not stressed by the hormonal overload of pregnancy. Thanks for reading and if I find out anything else, I will post back here. And, by the same token, if you find out anything else, please let me know! Dr T
At Wed Jan 16, 08:45:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Rachel Jan 5/11: Sorry, but I missed your message before. You had many of the symptoms of OC, but I have to wonder if your gall bladder problems caused your problems the last time around and not the pregnancy per se. If you didn't have OC with any of your other pregnancies, it is unlikely the last time ws the result of any of the genetic causes of the condition. You just might not have been clearing bile acids well because of your gall bladder and corrected the problem for both you and your baby by increasing fluids and decreasing fats. Most folks with the most severe forms of OC don't improve with that alone. Then again, you might just have a mild genetic predisposition to the problem. Let's see what happens this pregnancy now that your gall bladder is gone! Hope you don't get it again! Dr T
At Sun Jan 20, 03:57:00 AM 2008, rachie said…

Hi Dr. T,
Thank you for the reply. I actually had my gallbladder removed with my first pregnancy. With my last (5th) pregnancy it had been over ten years since the gallbladder had been removed.

When I thought back to my other pregnancy's I do remember having an internal itching feeling, like I wanted to reach inside and scratch my organs. It was pretty annoying, but it wasn't the classic hands and feet itching that occurred with my last(5th) pregnancy.

I am glad you think it may not be Cholestasis. I guess I am just worried that cholestasis was the cause of gallstones with my first baby.

I hope I do just have a very mild case that can be altered by diet. I have been sticking to my low fat foods, which can be a real challenge when your craving a GREAT big cheesburger. However I feel it is important.

I will be meeting with a Fetal Medicine dr. on Wed. Thank you for your thoughts!
Rachel
At Fri Jan 25, 08:12:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

Hi Rachie: Thanks for getting back to us. I bet you'll do just fine. Let us know how things turn out! Dr T
At Fri Feb 08, 11:28:00 AM 2008, rachie said…

Hi Dr.T. I went and saw a Fetal Medicine specialist at Mayo. He thought I definantly has OC during my last pg. We checked Bile Acids, and Liver Function and both were normal. As of right now I have very mild itchig occasionally. My low fat diet seems to be helping. Should I still consider early delivery, or if symptoms are under control is the baby usually not at risk. Also is the fact that I have OC related to having VERY jaundice babies?
At Wed Feb 13, 09:38:00 AM 2008, Anonymous said…

i'm 31 wks and just went to the doc about itching palms, feet, etc after doing dome research online. Doc says yes is oc, just did some testing, not back yet. i guess i have to have testing every two weeks. Doc told me to take Zyrtec & or Benadryl for itching. I asked about inducing labor before 38 wks. & she told me probably not as long as labs come back ok through rest of pregnancy. Doc also seemed to not be too worried b/c i 'm not jaundiced yet. should i question this or see where things go w/ labs? Thanks so much-Racheal
At Fri Feb 15, 09:55:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Rachie: I would agree. If the bile acids and the liver function tests are normal, you are probably at low risk for fetal complications. If they really think this is OC, however, I would suggest an amniocentesis to assess fetal lung maturity at 37-38 weeks and delivery if there is reasonable assurance the baby's lungs are ready to work. Good luck and please keep us informed regarding your progress! Dr T
At Sat Feb 23, 05:55:00 PM 2008, Anonymous said…

hi Dr. Thi is meg again . I am the one he lost my baby in oct. I don't know if you remembe. Well they made me remove my gallbladder becaused of many stones and hey said it was non functioniong and since they knew I want to get pegnant again hey said I had to get it removed. Its been two weeks now I have been keeping a low fat diet and now Iam really ready to start rying to have a baby now Any help you can give me Is there anythin I cn do to try and help not get i again. i will ry anythin I want a baby so bad TGhey are trying to say maybe since I ahd my gallbaldder out I wont have problems this time------That is how ou know they really dontunderstand cholastasis
At Mon Feb 25, 04:09:00 PM 2008, angie said…

Hi,
I am 37.2 weeks pregnant with my third child(boy), my first pregnancy was fine , no complications no itching, with my second pregnancy I noticed a severe itch around 39 1/2 weeks and was diagnosed with cholestasis and induced the next day. In the last couple of days I've noticed little itches here and there mainly at night. I'm wondering if the itching usually starts off mildly and then gets worse??? How likely is it to return this pregnancy and should I get tested now or wait and see if the itching becomes stronger?
At Wed Feb 27, 05:42:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Meg Feb 23: No other advice other than the low fat diet to start off with! Guess you will have to take your chances! If problems develop again, your doctors can try ursodeoxycholic acid. Let us know what happens, Meg! Dr T
At Wed Feb 27, 05:55:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Angie Feb 25: Your obstertical history is a little unusual for OC. True 'Obstetric Cholestasis' often begins much earlier in pregnancy and there is a very high rate (about 90%) of recurrence with subsequent pregnancies because of the genetic basis for the condition. If you are developing itching, you can ask your doctors to check your bile acids and liver function tests. If these are normal, there is a good chance this isn't the 'bad disease' and your baby should be at low risk! Anyway, best of luck and let us know how things turn out. Dr T
At Sat Mar 01, 09:53:00 AM 2008, Anonymous said…

My daughter had a baby 13 months ago and had oc. Baby born 37 weeks Mother and Baby very yellow at birth. Everything turned out well in the end.5 days later she had a gallbladder attack hospital told her she had an infection in her uteris gave her meds. Had another attack one week later went different hosp and told it was gallbladder not infection. Her liver emmzine were high this whole time. planned to remove gallbladder she got pregnant again lost the baby at 3 months. Almost didn't have her gallbladder removed because liver emmzines took so long to go back to normal. over 7 months. After gallbladder was removed liver is working normal So i have 2 questions. Could the gallbladder and liver problems caused her to lose her baby. In the 3 months she had 6 attacks that sent her to the hospital and alot more at home that she could deal with. And will oc happen in her next pregnancy now that her liver is back to normal
At Sun Mar 02, 10:19:00 PM 2008, Anonymous said…

Hi Dr. T.
Rachie here! My first bile acid result was 8.9 at 22wks, and we tested again a month later at 26wks and it was 5.6, so...my low fat diet is working well. I will get checked again in 2 wks. Do these numbers sound really good? However in the last 2 days, I have had loose stool and it looks very green like bile. Should I be concerned, or is that a good sign that it is flowing? Any thoughts?
Also can morning sickness be connected to the liver? I have had terrible sickness this time. It still lingers at 28wks.
Thanks...Rachel
At Wed Mar 05, 10:38:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Mar 1: I doubt the abnormal liver function tests contributed to the pregnancy loss, but whatever really caused the abnormal liver funcion tests could have. Your daughter's clinical course is not typical for obstertic cholestasis and could have been related to the gallstones or infection/inflmmation of the gallbladder; viral hepatitis; autoimmune hepatitis, or a number of other causes. She may be one of those individuals who is low risk for recurrence of her "OC" because she has had her gallbladder removed and has recovered from her liver disease (presumably). True OC WILL usually return with a subsequent pregnancy, if she has the underlying genetic basis of the disease, even if she has had her gallbladder removed. Let us know what happens to her in the future. Thanks for reading! Dr T
At Wed Mar 05, 10:43:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Rachie Mar 2: I am NOT going to argue with success. It sounds like you are doing well at this point. Some women have morning sickness throughout their pregnancies. It is related to the "pregnancy hormones" and you liver is involved with metabolizing those. Perhaps if your liver is not working quite as well as it should be, you are not getting rid of those excess hormones that can cause the morning sickness. I don't know for sure, it's just a thought. Good luck, Girl, and let me know how things turn out. Dr T
At Tue Mar 25, 03:36:00 PM 2008, Anonymous said…

Dr Trofatter,
I'm 32 weeks along in my 3rd pregnancy, 2nd with cholestasis. Last pregnancy, my symptoms began around week 35 with severe rashless itching. Bile salts were 75 when first tested, 2 days later, it was 175. My results did not come back until I was 36.4 weeks, and they induced right at 37. All turned out well, thankfully. However, when they broke my water, they commented on how much meconium she passed, and said she'd done it "a while ago." We caught the cholestasis earlier this time (and have only a 2 day turnaround for results). My bile acids were 33 and they immediately put me on Urso 2x a day. My itching has subsided after a week, though I notice it starts up again as my morning dose "wares off". Here's my question: Since it occurred earlier this time, I presume it has more time to affect my baby, and possibly encourage meconium passage earlier. They are inducing me at 37 weeks, but I'm still nervous since last time I only had it a few weeks, and she passed so much. Now that it occurred earlier, I'm concerned this baby will pass earlier and complicate her health. Any thoughts?
At Wed Mar 26, 09:50:00 AM 2008, Kelley said…

Dr Trofatter,
I'm 32 weeks along in my 3rd pregnancy, 2nd with cholestasis. Last pregnancy, my symptoms began around week 35 with severe rashless itching. Bile salts were 75 when first tested, 2 days later, it was 175. My results did not come back until I was 36.4 weeks, and they induced right at 37. All turned out well, thankfully. However, when they broke my water, they commented on how much meconium she passed, and said she'd done it "a while ago." We caught the cholestasis earlier this time (and have only a 2 day turnaround for results). My bile acids were 33 and they immediately put me on Urso 2x a day. My itching has subsided after a week, though I notice it starts up again as my morning dose "wares off". Here's my question: Since it occurred earlier this time, I presume it has more time to affect my baby, and possibly encourage meconium passage earlier. They are inducing me at 37 weeks, but I'm still nervous since last time I only had it a few weeks, and she passed so much. Now that it occurred earlier, I'm concerned this baby will pass earlier and complicate her health. Any thoughts?
At Wed Mar 26, 03:01:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Kelley: My thoughts are that this condition scares the pants off of me because it is SO unpredictable. Even with fetal monitoring, one cannot be assured of a good outcome. There is no "right answer", but I would make the following suggestions: 1) limit the fats in your diet; 2) stop taking your prenatal vitamins because they have fat-soluble vitamins A,D, and E (you can substitute other supplements that do not have these); 3) Begin AT LEAST twice, if not three times per week antepartum testing (NSTs); 4) keep taking the URSO; 5) consider an amniocentesis at 36 weeks to assess fetal lung maturity and if mature, or if there is meconium already in the fluid, then deliver. Best of luck and let us know how things turn out! Dr T
At Sun Mar 30, 07:07:00 AM 2008, Anonymous said…

Dr. Trofatter,
I am currently only 14.5 weeks pregnant (with my third child - currently I have 2 healthy boys and have never had anything like this before) and about 10 weeks I began itching mostly on my stomach and sides. Then at 13 weeks I began itching all over and I could not sleep. I called my dr. he said to take zyrtec at bedtime. That seemed to take the edge off for a week or so but now the ALL-OVER itching is back and the zyrtec is not helping. I do not have a rash or any other symptoms. I am nervous it may be ICP, but this early??? And I'm afraid when I see my dr and ask him he will think I'm crazy. - Jay
At Mon Mar 31, 02:59:00 PM 2008, Kelley said…

Dr. T-

Thank you so much for your time and suggestions. Right now we are scheduled for delivery in 4 weeks, but will certainly discuss the amnio with the perinatologist on Tues and NSTs more often. Bile acids have gone down with the URSO. Will definitely keep you posted on the outcome. Thank you again - and thank you for posting this article. So many people are unaware. Blessings.
At Tue Apr 01, 06:26:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Kelley: You are most welcome and thank you for sharing your story! Best of luck! Dr T
At Thu Apr 03, 11:16:00 AM 2008, Anonymous said…

Dr. T-
I really appreciate the way you're taking OC seriously and trying to inform pregnant women with this condition. Fetal death/stillbirth should not be an option!

My question is, should I be tested for OC prior to having symptoms (itching, dark urine) if I had OC in my last pregnancy? I am 31 weeks now, and so far I'm symptom free. The severe itching on palms & soles plus dark urine presented at 36 weeks last time. Two consecutive blood tests showed elevated liver levels (sorry, I don't remember the #'s or exact terminology). I went into spontaneous labor at 38 weeks - with meconium and a scary episode during labor in which baby's heartrate plummeted for what seemed like an eternity. She recovered somehow, and was born healthy & normal. I've read on some of your earlier posts that some women had the itching without elevated lab #'s, so I'm not sure any test would give me any kind of "heads-up" or confirmation of a recurrence.
All I know is, I want to be ready to "jump," at the earliest moment, if I present with this condition again. I guess I'm afraid that I might have it before symptoms start presenting themselves, and I'm so afraid of losing a perfectly healthy, beautiful baby girl when there's something I can do about it.
Can you please advise? Thank you!
At Thu Apr 03, 01:27:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Apr 3: Different folks have different approaches. If you had the 'real deal' with regard to OC the last time, there is such a high risk of recurrence, that I would lean toward screening you even before symptoms (bile acids and liver function tests) for two reasons: 1) If they are starting to get abnormal, then you could begin treatment now with ursodeoxycholic acid and possibly prevent the symptoms and decrease the risk to your baby) and 2) If they are all normal, then at least you could put your mind at ease for the time being and your doctors would have a 'baseline' to compare them to later on if you develop symptoms. I wish you luck with the rest of the pregnancy and hope you don't develop OC again! Please let us know how things turn out. Dr T
At Fri Apr 04, 07:44:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Jay Mar 30: It would be unusual to develop OC this early in pregnancy, and it would be even more unusual in someone who did not have that problem with any other pregnancies. This could simply be 'stretching' of the skin, an allergic reaction or sensitivity to something in the environment (detergent, fabric sotener, animal, etc.), or even another cause of elevated bile acids (hepatitis, gallstones, etc.) Regardless, I doubt this is really OC and, even if you are miserable right now, be grateful that it isn't! Best of luck and let us know what you find out.
Dr T
At Sun Apr 06, 03:36:00 PM 2008, Anonymous said…

i had this with my last pregnancy but its been nearly three years and im still itching they also told me at my last dr vist that i have high cholesterol i am 26 120lb and 5feet 3 inchs i exercise on a regular bases it dose not make sence can this condition be messing my liver up? confused
At Tue Apr 08, 04:30:00 PM 2008, Anonymous said…

My daughter in law had OC with her third child. She heard a rumor that if she got pregnant again the baby could be born with brain damage. Is this true?
At Tue Apr 08, 04:36:00 PM 2008, Anonymous said…

Can this cause brain damage in the newborn baby?
At Tue Apr 08, 04:50:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Apr 6: if you are "still itching" then this is not 'obstetric cholestasis'. You may have another liver problem or it may not be related to your liver at all. I suggest that you see an internist or a specialist in gastroenterology to sort out what is going on BEFORE you get pregnant again! Thanks for reading. Dr T
At Wed Apr 09, 10:03:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Apr 8: OC by itself is NOT a common cause of brain damage. There are lots of other more common causes. It is, however, a condition that may cause, relatively, sudden fetal deaths and it is difficult to monitor which patients are at risk for thes and which are not. This has led most of us to offer delivery to women with OC between 36-37 weeks to help prevent those late pregnancy losses. Thanks for reading. Dr T
At Wed May 07, 01:02:00 PM 2008, Kelley said…

Dr. T-

I wanted to follow up my Mar 26 comment. I delivered a beautiful, healthy baby girl last Weds @ 37 weeks. The delivery went fine with no meconium staining. My bile acids only reached a high of 38 (vs 175 last go round - yikes!) and after 4 weeks on URSO, low-fat diet (mostly) and vegan prenatals, they went down to 13 before they settled at 20 prior to delivery. I was amazed, and so thankful, it got so low. Thank you for all your advice on the subject and time you spend informing pregnant women of this condition. Bless you.
At Fri May 09, 07:47:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Kelley: Congratulations and thanks for your kind comments. Glad everything turned out so well. Have fun with the baby! Dr T
At Sat May 24, 01:48:00 AM 2008, Rahha said…

Dr. T,
I am a patient here in Greenville, and I go to Piedmont OB. I had ICP with my son 2 yrs ago. It was horrible and I was not diagnosed until 36 weeks. Well I am now 32 weeks and you can probably tell it is 4:45am and I am awake itching. But.. my labs keep coming back normal. Can I come for a consult I have seen one of your partners when I first was pregnant.
Thanks
At Mon May 26, 08:21:00 AM 2008, Anonymous said…

Dr. T. - I have found this blog to be extremely helpful. My story is a little interesting. At 14 weeks gestation, I came down with a nasty head cold and took 650mg of Tylenol 3 times over the course of 2 days (I usually never take Tylenol but did so this time because of my pregnancy). Later in the week, I had noticed that my urine was darker than normal (like a darker beer). A week after taking the Tylenol, I went to the ER with excruciating upper right quadrant pain and suspected a gall bladder attack. US revealed several gallstones but no duct blockage. Everything else appeared WNL. LFT revealed moderately elevated AST and ALT. Subsequent tests performed 2 days later noted enzymes were falling back to normal. Blood tests revealed no viral or autoimmune cause for the liver enzyme elevation. My doc speculated that it could have been due to the Tylenol. My urine remained dark until a few days after these tests. At 16 1/2 weeks (about a week after the ER visit, tests, etc.), I started to itch and occasionally I still have a little "stitch" of pain, urine looks fine now. The itch began on my scalp and seems to "jump around" in my legs, my back, my arms, my chest. Interestingly, my palms and soles to not itch at all. The itch is relatively mild at this point. My question is, should I be concerned that this is early onset ICP or something else related to the gallstones/liver problem I had a couple of weeks ago? This is my first pregnancy, and liver and gall bladder problems are common in my mother's side of the family. But, as far as I know, no one in my family has ever had ICP. Any information you could provide would be much appreciated.
At Mon May 26, 09:47:00 AM 2008, Anonymous said…

Dr T. - This blog site has been extremely informative, thus far. Thank you for taking the time to answer people's questions. My story is a little bit complex. I am currently 17 weeks pregnant with my first baby. I have a family history on my mother's side of gall bladder and liver problems. No ICP that I am aware of, though. When I was 14 weeks pregnant, I came down with a nasty head cold and took 650 mg of Tylenol 3x over the course of 2 days. Prior to becoming pregnant, I never took Tylenol. My cold cleared up after about 6 days. On day 6 of my cold, I noticed that my urine was darker that normal (like a heavy beer, but not like dark tea), but I felt fine. About 4 days later (15 weeks), I went to the ER with excruciating upper right quadrant abdominal pain. It felt like I was having a gall bladder attack. An US revealed that I had several gall stones, none of which appeared to be blocking any ducts. Blood tests were normal except AST and ALT were moderately elevated (in the 200s). Over the next few days, I still had darker urine, but no other symptoms other than lessening pain. F/U tests 2 days later revealed that my AST and ALT levels were falling toward normal (AST almost normal, ALT down by a factor of 2). Further tests for a cause indicated no viral (hep a, b, c, d, e, CMV, parvo, toxoplasmosis, herpes) or autoimmune (ANA) causes for the elevated liver enzymes. My urine went back to a normal color after a couple more days and I felt fine. I occasionally got a little "stitch" of pain in the same area after I'd eat, but nothing else. Within a week (16 weeks gestation), though, I started to itch! It started on my scalp and spread to my arms and legs, back, chest. No itching on my palms or soles. It seems to jump around and be almost non-existant at times to quite noticeable. it feels almost tingly at times. I f/u with my GP later this week to check my liver enzymes again. I am wondering how one should approach my issues given my myriad of symptoms over the last few weeks. Could they be an early indicator of ICP or something related to my gall bladder/gall stones? Could the itching be due to something entirely different? Any information you could pass along would be much appreciated. Thank you - ED
At Tue May 27, 06:05:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To ED: It sounds like your pain was probably secondary to passage of one of the gallstones into your bile duct. If that was accompanied by temporary obstruction and inflammation, that could have easily caused not only the pain but the transient abnormalities of your liver function tests. You did not take much tylenol, ut if there was some obstruction, that might have contributed as well since tylenol is metabolized by the liver.

As for the itching, it could have also been the result of transient accumulation of bile acids with deposition in the skin and subsequent reaction to this. I would be hard-pressed to call this ICP at this point, but when you have your LFTs rechecked, if you are still hving the itching, ask your doctor to send off a test for bile acids as well and perhaps a lipid profile. Itching is a very common complaint during pregnancy and there are so many causes that it would be hard to discuss that here. You might consider starting a low-fat diet, increasing your fluid intake and seeing if those things help. Some women are also very sensitive to their prenatal vitamins, so you might consider stopping these for awhile or changing brands to see if that helps as well. Anyway, good luck to you and sorry I couldn't be more help! Let us know how things turn out! Dr T
At Thu May 29, 04:24:00 PM 2008, Anonymous said…

Dr T - ED here (original post May 26, 2008), and I wanted to let you know that my LFT came back normal (bile acid test is still out). Consultation with a liver specialist indicated that AST and ALT elevations can be associated with the passing of a gall stone. So, at this time, this is what my doc is hypothesizing. So your hunch was correct! The itching has subsided, and I only occasionally experience it mildly. It is likely that I will have to go on the med used to treat ICP anyway given that it helps to normalize the bile and dissolve the stones. I will likely need my gall bladder out (assuming no other attacks occur between now and the end of my pregnancy) after the baby is born. Thanks, again, for your valuable input!
At Thu May 29, 05:52:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

Hi ED: Thanks for letting me know. Hope everything turns out just fine! Best wishes again!
Dr T
At Fri May 30, 03:26:00 AM 2008, Rahha said…

Dr. T,
I had a consult in your office yesterday with one of your partners I am grateful for your wealth of information. I can tell your partners are up to date as well. I will be delivering in 3 weeks.

Thanks again for all your knowledge on the subject.
At Fri May 30, 06:01:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Rahha: I am sorry I could not see you. Thank you for the kind comments. Best wishes for the next few weeks! Dr T
At Fri Jun 13, 10:18:00 PM 2008, Jessica said…

Hello there. I am 34, currently pregnant with my first baby. At around 28 weeks, I found myself with this famous unbearable itch that everyone has been talking about on here, related to OC. Definitely enough, it wasn't until I went on my 2nd walk-in visit to my OB, when she decided to order some lab results, and there it was. It was soon discovered that I have the condition. I have been on URSO, but it so far, it hasn't really done anything. I have been prescribed Zyrtec, Benadryl, and Atarax (not all at once), but it seems like none of those work for the itching either. I am concerned with those medications passing on to the baby, and also, that my condition is uncontrollable, thus, very risky for my baby. I have even tried Milk Thistle supplements (a natural supplement known for improving the liver function). I am now 31 weeks. My OB/GY is suggesting an Amnio at 36 wks, and deliver at 37, however I am concerned that this is too far away. Is it less risky if I deliver any earlier? Thanks for all the good information offered here!
At Mon Jun 16, 05:42:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To jessica: You might also try a VERY low fat diet and eliminating your prenatal vittamins. Sometimes that can help a little. In true OC, we would recommend aggressive fetal monitoring (2- times per week), perhaps offering corticosteroids to accelerate fetal lung maturity, and then the amnio and delivery at 36-37 weeks. The risk of an unexpected fetal demise may be lower at this point in the pregnancy, but that has to be ballanced against the complications of prematurity. Good luck and let us know how things turn out! Dr T
At Mon Jun 23, 09:24:00 AM 2008, Anonymous said…

hi,
i've been diagmosed with ICP. I had had 2 tests that shows bile swalt levels at 13.4 which I'm told by my doctor there is nothing to worry about. He is a high rish specilaist OB and his feedback was that ICP is "overrated". I have severe itching all over including hands and feet and am very worried about this condition. I am just starting my 36th week and I have had the itchiness for 2 weeks now.

He has suggested a non stress test for the baby and additional ultrasound. Do yuo have any advice? Are there any additional tests that I should be requesting of my doctor? Iwas told they do not take any action unless bile salt levels are above 40.
thank you
Karen
At Sun Jun 29, 02:46:00 PM 2008, Anonymous said…

Hi Dr.,

I am 32 weeks pregnant today and for the past 2 weeks have been having pretty severe itching on my feet, legs and arms. I was diagnosed with Hepatitis C when I was 15 (though I did not fit into any of the risk categories) so I have been seeing a high risk ob for this pregnancy. Because OC is more prevelant in Hep C patients, my doctor assumed that I had this and put me on Urso while the blood tests were being processed. We got the blood tests back and everything fell into the normal range, with the bile acid test being 15 (though I don't have the labs range for this). After reading a bit on the disease, it seems that you can still have OC and have normal bile acid levels. In my case, what would you recommend? Repeating blood tests in a week or two? Inducing early regardless given my higher risk?

I am a little concerned that my wonderful doctor is perhaps a bit too laid back with this and I want to make sure that I am extremely proactive. Any advice would be helpful.
At Wed Jul 02, 05:49:00 PM 2008, Jessica said…

For anonymous, JUN 29 .. I believe that by you being a Hep C patient already would probably give you a higher probability of developing OC (or ICP). Especially if you are just now noticing the effects around your 30th week! I have switched to 3 different OB providers just because 2 of them believed I really didn't have anything other than PUPPS (another pregnancy related itching disorder, for the simple fact that OC / ICP isn't really common. But after noticing this itch at around 28 weeks, and the itching just got worse as time went by, I knew it had to be something else. I at first was taking simple Benadryl , but really didn't see much improvement. My itching started at first only at the palm of my hands, and feet, but gradually started to spread towards my ankles, arms, and eventually on my entire body's 'trunk'.

It wasn't until visitng a 3rd OB Nurse, when she decided that the possibility of OC/ICP still existed, and she decided to test my Bile Acids, as well as test my blood enzyme levels .. and bingo .. there it was. I was finally diagnosed with OC at 31 wks. I've been on URSODOIL, 3 x day, and been getting Non-Stress tests performed on my baby 2 times /week. I have also been scheduled to have an Amniocentisis to evaluate my baby's lung maturity at 36 wks, and to induce labor shortly after, at 37 wks, depending on the results of the Amnio. I have already discussed this with several OB Docs and they all suggest the same. I think you should try to get a 2nd OB opinion, maybe a 3rd. I can almost bet that your itching IS in fact this condition.

Good luck!
At Thu Jul 03, 04:40:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Karen: True ICP is NOT overrated - it may be over-diagnosed, but in women with the real thing, the loss of a baby can occur unexpectedly and even with antepartum fetal monitoring with NSTs. So, if your doctor really believes you have ICP, then he/she should not take that lightly and an amniocentesis and/or delivery is frequently recommended at 36-37 weeks. Good luck and let us nnow how things turn out. Dr T
At Thu Jul 03, 05:17:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous June 29: There is no 'right way' to handle you at this point. If the Urso has helped, you might just continue that. You also might want to decrease the fat in your diet. Repeating the bile acids and liver function tests in 2 weeks would certainly be reasonable as well. I don't think I would recommend delivering you early based on what you have told me unless fetal lung maturity is first documented by amniocentesis or you clearly have stronger evidence of ICP or fetal compromise. Although antepartum fetal testing doesn't necessarily prevent unexpected fetal losses with ICP, I still think it is worth doing on the chance of picking up another complication that would suggest delivering he baby is warranted. good luck and let us know how things turn out.
At Tue Jul 08, 08:21:00 PM 2008, Anonymous said…

dear doc.. i have am waiting on results of icp tests i took yesterday. im only 22 wks along and i started itching a few weeks ago and since the severity has increased markedly. at first i thought i may have had athlete's foot but soon realized that that wasn't it. i awake in the night to itch my hands and feet vigorously with a brush for 2 to 3 or more hours. i take cold showers and wrap my feet and hands with wet towels and ice packs (before i even researched icp) because it was the only way i could think of to help me temporarily. the itching continues all over my body throughout the day. its absolutely excruciating. i have actually made myself bleed several times. i can barely sleep longer than an hour or two at a time at night and maybe three or four hours during the day. it's hard to function- i can't work, and even regular cooking and cleaning is hard to keep up with. i have been extremely fatigued have a not-so-good appetite. i didn't gain any weight in the last month. my urine is dark usually only in the morning, as i drink a lot of fluids all day. i was born with hep c. i already see a high risk ob because of the hepatitis, stg 2 hypertension (controlled with beta blocker and hctz before pregnancy and taken off meds secondary to drop in bp during pregnancy; normal at this time just being monitored), and a previous early miscarriage. i am 27y/o, 5'4, 125 lbs prior to being pregnant and 138lbs now. my ob immediately suspected icp and ordered tests despite how early i am (before i even had the chance to suggest it), and i am so grateful after reading about others' stories here. i was wondering are the risks to my baby greater because i am experiencing this problem so early? how great are the risks? what are the odds of me having a viable baby? all in all, how worried should i be? am i experiencing this so early because of my hcv infection? my viral load is greater than one million, is that significant? i've once been treated with interferon/ribo combo unsuccessfully (remission follwed by relapse) a few years ago as well. of course i will ask my ob, but i don't go back for two weeks and i am having trouble finding statistics and i am SO worried. it would also be nice to have a second informed opinion. she said the results would take a week to come back and to call to find them out so she can start me on the meds before my next appt. one more thing.. do all pts with icp need to be seen twice a week? is that something i should expect? i know- kind of a lot of questions but it's so scary to think my baby might not make it. thank you so much for helping people, you're like, an awesome person. michele
At Wed Jul 09, 02:06:00 PM 2008, Robyn said…

I am 40 weeks, 2 days pregnant and started itching less than a week ago. It started on my stomach and has since moved to my arms, legs, wrists, ankles and back. The itching seems to create a rash, not the other way around. Is it possible for OC to occur so late? Also, my palms and soles of my feet are not itchy at all. My doctor isn't concerned (we may be inducing in a few days anyway because I'm overdue, except my cervix isn't dilated at all). I just want to know if I should press the issue. What would be the best course of action this late?
At Sat Jul 12, 04:04:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Michele: You poor thing. I know how miserable you must be. Whether you have a genetic cause for ICP or you are having problems related to liver damage from your chronic hepatitis C (this is actually more likely), you are in for a difficult pregnancy. Under the circumstances, I would probbaly try treateing you with ursodeoxycholic acid, and antihistamine and perhaps even corticosteroids (although that may increase the activity of the hepatitis C). You might try a very low fat diet and avoid high doses of fat soluble vitamins. I don't know if twice weekly office visits will help at this point, but the growth and well-being of the baby should be carefully monitored from this point forward. Your doctors can explain how that is done. Wish I had a time machine to add about 10 weeks to your pregnancy at this point! Best of luck and hang in there. Dr T
At Sat Jul 12, 04:06:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Robyn: This is probably not true ICP, so other than routine monitoring, you probably do not need to push the issue. Delivery will probably cure your problem! Good luck. Dr T
At Sun Jul 20, 03:26:00 PM 2008, Anonymous said…

I am 30 weeks pregnant with my second child. During my first pregnancy 4 years ago, I developed a severe itching of my palms and soles around 22 weeks. At 28 weeks, it was determined I had a severe case of Cholestasis of Pregnancy. To avoid risk, my son was delivered via c-section at 36 weeks and was perfectly healthy. This pregnancy I was fully expecting the disorder to return, but so far I have been itch free. However, I am experiencing severe abdominal pain with deep green colored diarrhea. Could this be caused by the ICP?
At Tue Jul 22, 06:56:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous: There is a possibility you have gall bladder problems that contributed to your previous obstetric cholestasis and your current problems, or some other gastrointestinal disorder. I would suggest that you ask for a referral to a gastroenterologist. Please let us know what you find out! Dr T
At Thu Jul 24, 10:50:00 AM 2008, Melissa said…

to michele (from July 8)-your story is like mine with my first pregnancy EXACTLY!! I would keep a fork next to my bed and a bowl of ice to dip my hands in for when I woke up in the middle of the night with the horrible itching of my hands and feet. Isn't it funny how the cold temporarily helps!I, too, was diagnosed at a young age with chronic Hepatitis C. I had a c-section at 36 weeks and my son was perfect and healthy. I am now 31 weeks pregnant with my second child and the ICP has (miraculously) not returned!! So hang in there, it will disappear literally minutes after delivery!! Also, my viral load is very high, and it has not gotten any higher as a result of the ICP.
At Fri Jul 25, 07:07:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Melissa: Thanks for sharing your story. Regards, Dr T
At Tue Jul 29, 06:11:00 PM 2008, Anonymous said…

I am 16 weeks and 2 days pregnant with my 3rd pregnancy (1st ended in miscarriage, 2nd was fine). I started itching all over 8 days ago. I have no rash but am bleeding and have welts from scratching. My OB says that it can't be obstetric cholestasis because it is too early. He recommended Benadryl-didn't help. He hasn't come up with any other possibility-should I get a second opinion? I am afraid that if I wait too long I will develop complications. Please help!!
At Tue Jul 29, 10:36:00 PM 2008, savita said…

Hi, I am 34 weeks along and my blood tests for bile acids are normal. But I am still itching in the palms and soles, especially at night. is cholestasis ruled out? or am i still at risk?
At Wed Jul 30, 05:34:00 AM 2008, Kate said…

Hi Dr, I am most interested in any possible link between fat and cholestasis. I have no history of OC in my family. However, I was itching from 28 weeks (thought it was a reaction to other persons blood product - anti d shot...). Finally had it looked into at 34 weeks when it became unbearable. I knew what it was before seeing the doc and he knew immediately what it was without prompt. Lucky me by the sound of it.

What I would like to know if there is a link between cholestasis and cholesterol. Two other friends I made and myself all had cholestasis as well as diabetes requiring insulin.

Are all these problems because we are overweight with higher than normal fat content in our bodies??????

One friend had to be induced even earlier than expected due to pre-eclampsia at the last minute. Then there was me, who had major high BP after pregnancy. Still have it now! My BP before pregnancy was always normal...

Thanks for your help, I really appreciate that someone knows something about this unknown condition... it's somewhat comforting, even after the event.
At Mon Aug 04, 01:37:00 PM 2008, Julie said…

Hi, I am 38 weeks tomorrow and also have an OB visit scheduled where they are going to test for this for me. I just started itching pretty much last night and it hasn't let up. It's all over. I did noticed some itchyness on my ankles last week, but I thought it was from walking in our tall summer grass. Maybe it was the start of something to do with OC? My appointment is not until 4pm tomorrow...is there anything I should do in the meantime other than pay attention to my baby's movements? Should I try to go in earlier tomorrow? My first boy passed meconium in utero and had to be in NICU for 9 days. I was hoping for something a bit easier this time around. Also, I'm scheduled for a repeat c-section next week, do you think there is a chance they might do that early...does the blood test come back pretty fast? Thanks.
At Thu Aug 07, 11:43:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous July 29: Many different things can cause itching in pregnancy. Your doctor is correct, this early it is unlikley to be true obsteric cholestasis. You should still probably be screened for serum bile acids and any abnormalities in liver function tests. If you have recently changed bath soaps, skin creams, detergents or fabric softeners, you might want to discontinue these and/or return to your old products. My recommendation if the itching persists is that you ask your doctor for a referral to a Dermatologist before you begin too many different medications that might interfere witth establishing a diagnosis. Good luck! Please let us know what you find out.
Dr T
At Thu Aug 07, 11:54:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Savita: No, obstetric cholestasis cannot be entirely ruled out at this time, however, with low bile acid levels, the baby is at very low risk for complications. Itching can precede the onset of rise in bile acids by several weeks, but you are getting far enough along in the pregnancy that the diagnosis of ICP is less likely. Have you been tested for any evidence of liver function test abnormalities? Best of luck and please let us know how things turn out. Dr T
At Thu Aug 07, 11:59:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Kate: As far as I know, there is no direct link between obstetric cholestasis and hypercholesterolemia - ICP really is the result of a genetic defect. However, people with hypercholesterolemia, obesity, and/or insulin resistance are at gretaer risk for other problems that can cause cholestasis, particularly, extrahepatic cholestasis associated with inflammation of the bile ducts and gallstones. These same individuals are also at increased risk for diabetes in pregnancy and preeclampsia. Thanks for the question and for reading! Dr T
At Thu Aug 07, 12:03:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Julie Aug 4: This is unlikely to be true obsteric cholestasis. However, FYI, a recent paper by Yoong and colleagues (Acta Obstet Gynecol Scand 2008;87:419-22) did correlate itching late in pregnancy with passage of meconium by the baby and some other pregnancy complications. So, I don't know whether this is grass allergy (likely if it started on your ankles) or history repeating itself in your case with regard to meconium (or both). Let us know how things turn out! Dr T
At Fri Aug 08, 10:43:00 PM 2008, MafaldaMay, Qc, Canada said…

Hello,

I am 34.5-week pregnant. I'm 26 years old and this his is my first pregancy. Three nights ago, I started suffering a generalized itch that completely prevented me from falling asleep. The itching moves from place to place, like my veins were injected with some kind of acid and it moves around with blood circulation. Although it is much worse at night (my third sleepness night tonight), it doesn't completely go away during the day either.

I went to the perinatal clinic today to get tested and, according to the doctor, my blood tests were normal. NST was also showing a very active and responsive baby. However, they want me back for another NST and blood tests next Tuesday, just to make sure.

I have four questions:

1) With ICP, is it possible that the itching start before the liver enzymes go out of the normal range?

2) You mentioned on a few occasions that there are other causes for itching during pregnancy. Considering there is no rash involved in my case (it's not PUPP and not restless leg syndrome), what are the other possible causes?

3) There is no family history of ICP in my family on my mother's side. I'm not very familiar with my father's family, but I know his mother died of liver cancer, and so did one of his brother. I myself suffered an auto-immune hepatitis simultaneously with EBV in 2006 and now have ME/CFS. I don't know about ICP on his side of the family. When you say ICP can be genetic, is it only passed on from the mother or can it also come from the father?

4) If you were me, what would you do if results came back normal again on Tuesday, but the itch remained?

Thanks a lot for your help!
At Tue Aug 12, 07:01:00 PM 2008, fisherblog said…

I have been reading these entries in amazement that mothers have gone through the same thing I experienced with OC and my OBGYN. I had OC and was not taken seriously. I diagnosed myself (through sleepless itchy nights) and then I was told to stay off the internet and to take a benedryl. I finally researched the tests and made my doctor give me the bile tests. I was diagnosed and induced (3 days later with no urgency on her part) at 36.5 weeks. My son was jaundice along with myself and we both had hemmoraging after the birth. (He had an issue with his circumcision). No one told me this was a possiblity. The doctors and nurses at the hospital seemed to brush off this disease, and most hadn't even heard of it. One nurse told me I should of tried changing my soaps to see if I was just allergic. I wanted to show her my scars from the extreme itching and tell her I hadn't slept in two months and cried everyday. The last thing I needed was medical staff acting like it was all in my head again. Fortunately, I have a beautiful 10 month old who is thriving and healthy. We are contemplating getting pregnant again, but I am scared of going through this all again.

It is wonderful that you are taking the time to answer these mothers questions. This is a disease overlooked and frustrating for anyone who has experienced it first hand. My questions to you at this point, are what can we do to help awareness of OC and educate the doctors who are not treating this disease with respect?

When will this condition get the attention it deserves?

How do we (patients who know they have a 90% chance of it reacurring) find a doctor that has experience with this disease?
At Wed Aug 13, 03:37:00 PM 2008, Anonymous said…

31yrs old 34weeks preg,second pregnancy,Same symptoms of itching in first pregnancy. The difference being I had high Blood pressure starting in about the sixth month of my first pregnancy that escalated from there on. I was on close watch for preclampsia and had tons of blood work and protein analysis done without ever actually getting preclampsia. I had itching starting at 30+ weeks that was progressively worse until delivery. I was induced a couple days before due date due to my BP being so high. I don't believe they ever tested me for Cholestasis however. They said the itching was just my sensitivity to the build up of hormones and no treatments ever helped with the itching. My son was born very healthy. But when I was induced I was on my third day with no sleep, not a wink. With weeks of very poor sleep leading up to that due to the itching. I was hallucinating from combo of meds and sleep dep by the night after delivery because I didn't sleep the night I was induced or the next night when I finally gave birth at around 11pm. So 5 days without any sleep and very little sleep before that.
This pregnancy I have had itching since week 20 or so but it was mild more annoying and usually just when I would get overheated, being a summer pregnancy I found this to be normal to most pregnant women. Around 30 weeks it started getting worse by week 32 I was getting worried of a repeat of last pregnancy because it was getting severe, at this time I was blood tested for cholestasis, coming back clear. MY BP has been perfect this pregnancy but the itching is now so bad I can barely function. I have tried creams, benedryl, steroid pack,tagamet,phenegrin all prescribed by the doctor none have helped. The only help comes from the slightly sleepy feeling you get from the meds taking off the edge so I don't completely go off the deep end.

The itching is most severe on the trunk but all over my body, worse at night but Its to the point of also being terrible all day making it hard to function, interact with anyone or think of anything but the relentless itching not to mention hardly being able to sleep.

Also like Mafaldamay says in her post there is no rash unless I itch my stomach or breast then it will appear clearing up if I don't itch it. I try not to actually scratch because it really only makes it worse.

After reading death to the baby can be associated with it I am very worried. I also don't know if I can handle this itching anymore. I am getting very irritable and tired.

My question echo's Mafaldamay Aug 08 post

If I am testing clear for not having Cholestasis but having the very severe itching is it still possible I have it and its just not showing up?
Should I push for induction?
At Thu Aug 14, 03:48:00 PM 2008, Anonymous said…

HI DR. TROFATTER I WROTE YOU LASTNIGHT. I AM SO SORRY FOR SUCH A LONG POST. I WOULD LIKE TO SHORTEN EVERYTHING UP. I AM 31.5 WEEKS PREGNANT WITH FATERNAL BOYS.
I WAS WAKING UP AT NIGHT WITH SEVER ITCHING LIKE NOTHING ELSE I HAVE EVER FELT BEFORE. I AS USING A FORK TO SCRATCH MY FEET AND HANDS. IT WAS ONLY MY HANDS AND FEET THAT ITCHED. I HAVE NO PROBLEMS HEALTH WISE. MY LABS ARE GREAT AND I HAD DOC CHECK FOR HEP C AND MY BP IS GREAT.
I HAVE HORRIBLE ITCHING AT NIGHT AND I CANNOT SLEEP. I AM GOING CRAZY MENTALLY WITH NO SLEEP. MY DOC DID AN ULTRASOUND AND THE TECH SAW ALOT OF SLUDGE BACK UP AND MY DOCTOR CHECKED MY BILE LEVELS AND STUFF AND WAS SURE I HAD ICP. WE WOUILDN'T KNOW FOR A WEEK AND SO SHE HAD ME START URSODIOL 300 MG 3 TIMES DAILY. SHE PRESCRIBED ME HYDROXYZINE 25mg TO TAKE 2 TABLETS UP TO 4 TIMES A DAY TO HELP SLEEP. AND WHEN THE RESULTS CAME BACK THAT MY LEVELS WHERE FINE AT 9 I THEN QUITE TAKEN THE MEDS. I THEN STARTED TO ITCH AGIAN A FEW DAYS AFTER COMING OFF. BUT A WEEK AFTER STARTING THE MEDS I HAD MY BILE LEVELS CHECKED AGAIN AND THEY WHERE LOWER ONLY 5. BUT NOW THE ITCHING IS FULL BLOWN AT NIGHT ONLY. I WAS TAKING THE HYDROXYZINE BUT THE NEXT DAY MY BRAIN DIDN'T WORK AT ALL I WAS BETTER LOSING THE SLEEP AND FEELING TIRED THEN ALL HUNG OVER. WHEN I TAKE THE URSO I GET REALLY BAD HEART BURN AND ON THE BOTTLE IT SAYS DO NOT TAKE ANTACIDS CONTAINING ALUMINUM WITHIN 1 HOUR BEFORE OR TWO HOURS AFTER TAKING THIS MEDICINE. I WENT TO THE DOCTORS TODAY AND HAD MY LEVELS CHECKED SO NOW I HAVE TO WAIT. MY DOC SUGGESTED ME TO START THE URSO AGAIN AND I WANTED TO MAKE SURE I HAD A PLAN FOR THE HEARTBURN AND I CALLED MY PHARMICIST AND HE TOLD ME THAT I NEED TO WAIT TO TAKE ANY ANTACID. I HAVEN'T TAKEN ANY URSO OR ANYTHING YET. I AM SCARED THAT I WILL ITCH TONIGHT AND I ALSO AM AFRAID OF THE URSO BECAUSE OF THE HEARTBURN I GET FORM IT.
I WENT TO THE DOCTOR TODAY AND I LOST 2 LBS SINCE MONDAY AND I AM
HAVING A HARD TIME GAINING WEIGHT WITH THIS PREGNANCY, MY URINE IS SO DARK, AND I ITCH . IN A WAY I AM HOPING I HAVE ICP SO I CAN UNDERSTAND WHAT IS GOING ON WITH ME. I AM SO FUSTRATED. I HAVE TWO LITTLE GIRLS AND I NEVER HAD THIS PROBLEM WHEN I WAS PREGANT WITH THEM.
I REALLY WANTED THIS PREGNANCY BUT I FEEL AS THOUGH I AM GETTING DEPRESSED FROM NO SLEEP. I CANNOT BE THE MOTHER OR WIFE THAT I WANT TO BE. I FEEL AS THOUGH I WON'T BEABLE TO HANDLE THE TWINS WHEN THEY ARIVE.
IS IT POSSIBLE FOR ME TO HAVE ICP WHEN ALL THE LABS COME BACK FINE?
WHEN MY FEET AND HANDS ITCH MY BREAST LEAK AT THE SAME TIME. I ALSO GREW SKIN TAGS IN THE GROIN AREA AND HAD TO HAVE THEM REMOVED ON MONDAY BECAUSE THEY WHERE RUBBING ON MY PANTIES AND GOT GOOD SIZED. I MEASURE 45 WEEKS PREGANT I CONTRACT ALL THE TIME. I HAD A fFB TEST TODAY AND IT CAME BACK NEGATIVE MY CERVIX HASN'T CHANGED SINCE 29 WEEKS AND IS ONLY 1CM DIALATED AND LONG. MY DOCTOR IS NEW SO SHE DOESN'T SAY MUCH BUT I LIKE HER ALOT. I FEEL LIKE IF I ? HER TO MUCH SHE WILL GET ANNOYED. I AM THE ONE WHO BROUGHT UP ICP AND I ALWAYS ? HER ON HER NEXT ACTION, SHE GIVES ME HECK FOR KNOW TOO MUCH OR BEING AN ACTIVE PARTICIPANT IN MY HEALTH CARE. I REALLY WANT TO CRY WHEN I SEE HER BECAUSE I DON'T WANT TO BE PREGNANT ANYMORE BUT I KNOW THEY ARE NOT READY TO COME YET. BUT I NEVER THOUGHT THAT I WOULD BE HERE. I DON'T COMPLAINE EVER. FOR BEING PREGNANT WITH TWINS I DON'T MIND A SORE BACK AND ALL THE PEEING AND THE SKIN TAGS. I NEVER HAD TAGS WITH MY OTHER PREGANCIES. I JUST CANNOT BELEIVE THE ITCH. NOT REALLY WANTING TO EAT MUCH AND THE DARK URINE IS WHAT WORRIES ME.
I HOPE YOU CAN SHINE SOME LIGHT ON THIS FOR ME. SORRY TO SEND ANOTHER LONG POST.
JESSICA
At Sat Aug 16, 04:39:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To MafaldaMay: 1) The itching can come before any abnormalities of your serum bile acids or liver function tests; 2) There are too many other causes to list, but they include other liver abnormalities or liver infections (hepatitis, EBV, CMV), allergic reactions to things you have not been allergic to before or from new exposures (e.g., detergents, soaps, fabric softeners, body lotions, medications, vitamins, foods, etc), an autoimmune skin condition, and even as a consequence of the baby having had a bowel movement (meconium) in the womb; 3) It could be that this is the result of your previous problems with autoimmune hepatitis?!? 'Genetic' meaans you could inherit the abnormal genes that caise ICP from either or bot parents; 4) If the itching continues, your doctors could try an antihistamine, steroids, or an empiric course of ursodeoxycholic acid. And, I would recommend continuing the frequent fetal monitoring! Good luck and let us know how things turn out...I know you are miserable! Dr T
At Sat Aug 16, 04:43:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To fisherblog: Thanks for sharing your story. I would hope, now that you have been through this, your current doctor (and staff) will have learned from your experience. You probably are at high risk for recurrence, so all you can do is watch your diet, drink plaenty of fluids, get some exercise, and start treatment with ursodeoxycholic acid at the first hint of the condition! Thanks for writing. Dr T
At Sat Aug 16, 04:50:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 13: Has your doctor tried simply starting ursodeoxycholic acid to see if that helps. I am assuming by your stating that your tests are normal that the bile acids were not elevated and liver function tests are normal? Have you had any blood lipid studies done? I would push for fetal monitoring, but would only induce you early when fetal lung maturity was documented first. Sorry for your misery...unfortunately it will probably return with another pregnancy. Let us know what happens. Dr T
At Sat Aug 16, 04:56:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Jessica: You poor thing. Nothing is more frustrating for doctors and patients than to have a condition that does not respond to therapy and knowing it will probably all get better within a short time following delivery. If teh URSO was working, you might consider restarting that. I would recommend eating a diet high in protein and complex carohydrates and VERY low in fats and simple sugars. The twins should be monitored very carefully through all this. There is a greater fetal complication rate whever a mother has persistent itching, even if we are not smalrt enough to figure out why. Other than that, I wish I had a time machine to make the next few weeks go by more quickly. Best wishes! Dr T
At Mon Aug 18, 02:54:00 PM 2008, Anonymous said…

I previously posted, Aug. 2, about not having any symptoms. Well last night I started itching all over. I am 38 weeks 2 days now. I was itching a lot this morning but it has stopped as of now. I have my regular appointment tomorrow. I plan on having blood work done but was wondering if I should wait until we get the results or schedule induction. I am worried because I am already into my 38th week and I know with Cholestasis you don't want to wait. I had it with my last pregnancy but not with my first, that I know of. Thank you for any help you can provide.
At Fri Aug 22, 02:58:00 AM 2008, Anonymous said…

Hi all, i havent been on for a while as been in and out of hospital for monitering every 2 days, i need some advice, im 37 weeks on sunday had MAJOR itching of hands and feet mainly at nite, now on my back and belly and legs, infact everywhere. Hospital took liver func tests that were ok, im waiting on my bile acid tests which take a week, but imagine if my lfts were normal then these will be? I feel like crap ecuse my language got flu symptoms, major headache and feel sick as a dog, generally unwell. I had a big scare when i went for monitering yesterday as soon as they put me on the moniter babys heart was 210 and didnt come below 200 for around 25 mins. Doc came straight away and made me drink loads of water, although i told her i had been drinking plenty. I was kept in 6 hours until it returned to normal 150 base rate. And then they were happy, im not ive been petrified, i cant sleep for itching and blocked head, worried sick about my baby moving, and fed up. My ob said hes booked in my c sec for 39 weeks and wont do it before if my bile acids come back normal as theyre is no need to. I feel myself strongly that 38 week delivery would be fine, ive had steriod jabs for babys lungs, and had severe post natal depression with last baby, and as im so upset worn down and stressed i can feel it heading that way with this baby, which i really dont want. Oh and forgot to mention ive got low platelets of 100, not sure what thats linked to but would very much appreciate anyones views pls, thanks
At Fri Aug 22, 06:01:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 18: If the blood work suggests cholestasis, then induction would be appropriate. If they do not, you could have an amnio done to assess fetal lung maturity and check for meconium or wait another week for an induction. If the itching becomes persistent, the baby should be carefully monitored because itching alone this late in pregnancy (even without true ICP) is associated with a higher risk for poor fetal outcome. Good luck and let us know how things turn out. Dr T
At Tue Aug 26, 06:45:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 22: You worry me. Have you asked your doctors why they thought the baby's heart rate was 200+ for 25 minutes and your platelets are so low? Wish I could help but I am not there and do not have a crystal ball. Don't miss ANY of your fetal monitoring visits! Let us know how things turn out and good luck. Dr T
At Sat Sep 13, 05:24:00 PM 2008, Anonymous said…

dear doctor, first of all, thank you so much for such dedication!!! I have a question. I had my son about 3 years ago. Now I am pregnant with number 2. About one week ago I started to experience itching during the night of my feet and hand. If I put cream, it seems to solve the problem a little bit, and I have hardly any itching during the day. Also, I have dark urine which seems to go away if I drink water. Also, I have loss of appetite and insomania for the past several day which I also attribute to anxiety and itching. Should I ask my doctor to test me for OC, and how likely that it is considering that itching and dark urine are not consistent. I am 33 weeks and 2 days now. THANKS.
PS I also had some episodes of upper abdominal pain that I attribute to heart burn
PSS We live in Alaska and the air is very dry here so I just pray that the itching and dark urine is attributed to that!
Again thanks for your support so much.
At Sat Sep 13, 10:17:00 PM 2008, Anonymous said…

Dear Dr. T.-I'm 43 yo; 34 wks preg with my 3rd child. My last pregnancy was 13 years ago. This pregnancy is with a different father. I started itching on the soles of my feet 3 nights ago. The itching has moved up my body and I now itch all over...it's worse at night. I saw the NP yesterday and she was resistant to doing any tests because I didn't have ICP with my first 2 pregnancies. I insisted, and after she discussed my case with the MD, liver function tests and SBA were ordered. A non-stress test was done in the office yesterday also. Only 1 deceleration was noted during a contraction. I had 5 contractions during the 30 minute test. Also, I've been on bed rest for 11 weeks for preterm labor. Could I have ICP with this pregnancy as I'm now older and there's a different father? If the tests come back normal, should I request further screenings? Thank you!
At Tue Sep 16, 04:08:00 PM 2008, Ramblin' Red said…

Dr. Trofatter,

I am 8 weeks pregnant and thought that the itching on my palms was just a quirk of pregnancy - albeit a painfully irritating one - I've been losing sleep over the itching on my feet and hands.

Yesterday at my first OB appt I mentioned the itch (I thought perhaps it was related to my having had urticaria pigmentosa as a child and maybe pregnancy relapsed it?) and my doc grew very concerned. She told me about ICP, did a bile salts test, and now I am just dying to know if my bile salts test will turn out ok.

This is my 3rd pregnancy and the first time this has occurred for me.

I have also noticed darker urine/lighter stools (though not gray like the medical sites I've read indicate) but had chalked it up to my prenatals.

How likely is it that I could have OC/ICP this early?

And if I do have it this early, how much will my baby have been/be affected?
At Wed Sep 17, 08:12:00 AM 2008, Leslie said…

I just wanted to say how nice it was to find this blog, and know Im not alone!

I had my first baby at 39 weeks diagnosed with ICP (they thought it was fine to just watch her closely despite the research I showed them) I was on the urso, and fetal monitoring.

Right now I am 35 weeks pregnant with my second and once again the severe itching struck at 32 (literally overnight). My last bile acids were up to 31 and hopefully this week they will have come down.

This time I have a dr who wants to do the amnio at 36 and deliver if lung maturity is present (Im having a c-sec). I am so thankfull, that this has become more common knowledgeable.

Can I ask you how great are the risks prior to 36 weeks? (I do not want to deliver any earlier than that) I just still have such uneasiness this time, about his safety. Is 900mg of Urso a day sufficient as a safety percaution for him, I had so much more with my daughter?

Thank you so much for all your wisdom and help to people. Its hard to get straight answers about choleostasis.
At Tue Sep 23, 05:27:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 13: Yes, you should be tested for serum bile acids, liver function tests, and bilirubin. The itching and the dark urine could indicate obstetric cholestasis, but with the upper abdominal pain, it may also be a gall bladder problem that is causing retention of bile acids. An ultrasound of the gall bladder and the common duct should be able to tell you if there are gallstines and possible obstruction. Good luck and please let us know what you find out!
Dr T
At Tue Sep 23, 05:32:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 13: Paternity does not affect your risk for OC. And, it is reassuring that you did not have it with your other pregnancies. However, we are learning that "itching" in the latter stages of pregnancy may be a risk factor for fetal complications unrelated to OC! Sometimes babies will have a bowel movement inside because they have been stressed and that meconium, as it breaks down and gets into your blood stream, can be associated with itching as well. It may also be associated with an increased risk for preeclampsia. In your case, because you have had complications with preterm labor, this is certainly a possibility. I would suggest having the blood work done and for reassurance, continuing the fetal monitoring. Best wishes and please let us know how things turn out. Dr T
At Tue Sep 23, 05:38:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Ramblin' Red: Fortunately, it is unlikely that this is OC this early in the pregnancy. You might have a gall bladder problem, so I would recommend a gall bladder ultrasound in addition to the blood tests. The best thing have going for you from the OC perspective is that you did not have it with your other pregnancies, so I really would be looking for another problem. You might consider trying a different prenatal vitamin. Also do not rule out the possibility that this is a return of your childhood urticaria! Best wishes and let me know what you find out. Dr T
At Tue Sep 23, 05:42:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Leslie Sept 17: The URSO dose is fine. Some experts are recommnding delivery at 36 weeks in true OC even without an amnio for lung maturity. I haven't gotten that brave yet unless there is already some indication of fetal comprommise, especially if you are planning an elective c/section. The risks are relatively low before 36 weeks if you have been taking the URSO regularly and the baby is looking good. Best wishes for your delivery and let us know how things turn out. I appreciate the kind words as well. Dr T
At Mon Sep 29, 01:32:00 PM 2008, Anonymous said…

I'm 34 weeks along with my 2nd child and for the past 3 days my soles of my feet have been itching like crazy off and on. It will even wake me up at night and i cant seem to scratch hard enough to make it stop. I called my midwife today and they have me scheduled for lab work tomorrow morning. I also have noticed my urine is getting darker and has a funny smell, but it doesn't hurt to pee. With my first pregnancy i had Gallbladder pains and ended up have to get it removed after my son was born. Should i be concerned with having OC? I have noticed that after i had my son almost 3 years ago that my palms will itch really bad off and on, but this is the first time my soles of my feet have itched like crazy.
At Tue Sep 30, 06:13:00 PM 2008, Anonymous said…

Dear Doc and everyone. This site is great! I am 33 y/o and was diagnosed w/ OC at 33 weeks with my first pregnancy 2 yrs ago after about 4 weeks of horrible itching. It was like no one believed me and though I was crazy pregnant lady!! Went into labor at 34 and was delivered by C-sec. 3 days later do to breach presentation only 2 days after starting cholestramine (which I now read is not preferred treatment). I had been given steroids when I first went into labor and my little guy was born 4 lbs. 10 oz (stayed in NICU 8 days and he is amazing:) I am now 6 weeks with preg. # 2 and already dreading it. Am going to high-risk OB early on to get help but am already "jumping" at every little itch. My regular OB is pretty clueless about this illness. I just hope I am doing the right thing trying for another one and hope that with earlier intervention the end of my pregnancy won't be so awful. Thanks everybody.
At Tue Sep 30, 06:55:00 PM 2008, Anonymous said…

Hi,

I have a 2 year old daughter and 4 month old son. Both pregnancies I was diagnosed with ICP. With the first pregnancy I only took Benadryl, but the second pregnancy my obgyn prescribed Urso. With both, I was delivered via c-section at 37 weeks. Both of my kids are fine, although my daughter was jaundiced and was very large (I had preeclampsia with her too). My question is....my husband and I would like to have a third child...but I am scared to go through all that again. The itching, the worry, possible preeclampsia....ugghhh, it's so overwhelming! Add to that I had horrific nausea and had to go on meds for that, and I failed the diabetes tests and had to go back for those awful three hour tests (though no diagnosis of diabetes). I aslo had to stay on my ssri during the pregnancies due to severe antepartum depression, and I still had postpartum depression issues that led to med changes after each pregnancy. BUT...we still want a third. If I have had two ICP pregnancies that turned out fine, do I stand a chance of having another good outcome with a third ICP pregnancy (there's always such a worry over the stillborn issue)? We are definitely having a third...but sometimes I want to adopt. But then I look at the cost of adoption and figure I'd be better off braving the pregnancy waters again.
Alysha
At Wed Oct 01, 03:53:00 PM 2008, Tara said…

I have had 2 children, I did not have OC with the 1st but did with the 2nd and went through the amnnio and fetal heart monitoring from 33 weeks on. My 2nd was born very healthy at 37 weeks. I am thinking about having a third and no one seems to be willing to say if that is a good or bad idea. I would really like to have one more but I don't want to take the chance if a medical professional says no. My biggest question is am I less likely for reoccurance since I only had it in one pregnancy. Any advice would be greatly appreciated.
Thanks,
Tara
At Sun Oct 05, 05:47:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 29: OC usually resolves following pregnancy, but there are other reasons for cholestasis that might lead to itching as well - like your gall bladder problems. There are also many other reasons for itching in pregnancy that have nothing to do with cholestasis! Let me know what the test results show and then I will tell you what I think. Best wishes! Dr T
At Tue Oct 07, 06:12:00 PM 2008, Meghan said…

Hi DR.
I am currently 36 weeks and 4 days. My nurse just called and said my test results came back and that I have Cholestasis. At 35 weeks they noticed my baby's abdomen was measuring small so they said it was "IUGR A symmetrical" and that they would do stress test twice a week and monitor him but they would not be able to get a accurate reading in two weeks so they decided to wait till i was 38 weeks to decide to induce if he had not changed or gotten any bigger by then. Does IUGR and Cholestasis go together? I dont go to the doctor for 3 more days and I was wondering will they induce my labor at 37 weeks because of this condition? I noticed on here that most women with cholestasis get induced at 37 weeks. Also what risk do these things have on the health of me and my baby boy? Thank you so much for your help and sorry for all the questions I am just concerned.
At Tue Oct 07, 08:09:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 30: Thanks for sharing your story. Sounds like you had the real deal which, unfortunately, puts you at high risk for recurrence with the current pregnancy. Try redcuing the fats in your diet, staying well hydrated, and starting ursodeoxycholic acid with the onset of your symptoms. Best wishes and thanks for reading!
Dr T
At Tue Oct 07, 08:12:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To alysha Sept 30: If you had ICP twice, there IS a very good chance you will have it again! Treatment with the URSO will hopefully minimize your risks for the baby, but unfortunately, you will be on the edge of your seat until the baby is in your arms. Thanks for sharing your story and best of luck to you. Let us know what happens when you get pregnant again! Dr T
At Tue Oct 07, 08:16:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Tara: Was there anything different about the second pregnancy? Boy vs girl; different father of the babies; had the second baby had a bowel movement (meconium); did you have gestational diabetes, hypertension, or any other medical problems with the second pregnancy. ICP often is present in all pregnancies, but there are other reasons people develop itching and I am wondering if that might be your case. Regardless, if the itching returened with another pregnancy, I would suggest starting the ursodeoxycholic acid at the onset of symptoms. Best of luck and thank you for writing. Dr T
At Fri Oct 10, 10:47:00 PM 2008, Simone said…

I am 33 years old. I have 3 children and have experienced Cholestasis with all three pregnancies. I was 27 when I had my first child and had extreme symptoms of being itchy to the point of my skin bleeding from scratching. My second and third pregnancies showed (with bile acid test being performed) that I had cholestasis although thankfully, my symtoms were not as severe as with my first pregnancy.

After my second child, I also developed gallstones and then had to have my gallbladder removed.

With my thrid pregnancy, I developed High Blood Prssure which unfortunately did not go back to normal after the birth of my third child which means I'm now on permanent medication.

All babies were induced at 38 weeks and delivered without complication and are healthy which is great.

I do wonder if there is a link with the three (Cholestasis, Gallstones and High Blood Pressure)??

My mother also had gallstones and her gallbladder removed and also has high blood pressure. I guess genetics plays a big part.

I must admit, I did think I was too young to have high blood pressure, when diagnosed at age 29. I'm also a slim build so not generally thought to be in the 'high risk' category of developing high blood pressure.

Simone Husband
simonehusband@yahoo.com.au
At Wed Oct 22, 07:11:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To meghan: I am sorry but I just received your question in my mailbox, so I am sure you have delivered already! To answer one question though, IUGR does not typically accompany obstetric cholestasis. If you get this response, please let us know how things turned out! Dr T
At Sat Oct 25, 09:56:00 AM 2008, mds said…

I am 32 weeks pregnant with my second child - my itching began just before my third trimester. With my first child I experienced all the signs of ICP- unbelievably intense itching on the palms, feet, arms and legs. My liver function test showed elevated ALT, AST, and Alkaline Phospatase, but we did no more testing and my healthy baby boy was born at 40 weeks on his own, naturally. This time around, I'm more miserable simply because it started earlier. I don't sleep and I'm desperate for help. I'm currently awaiting results from a Bile Acid test, but I've been told that no matter the results there won't be any change in my obstetric care. My question is, what are other possibilities if this isn't ICP? I have no rash and it only develops during the end of my pregnancy. Living day-to-day is miserable, but above all I'm concerned about my baby.
At Tue Oct 28, 07:16:00 PM 2008, Leah said…

Wow... I'm so glad I found this article. I have just been diagnosed with ICP. I also have chronic Hep C, but still believe the ICP is the issue. I have PCOS so when I was 16 I was prescribed oral contraceptives and within a day or two of starting them I started itching. Over the next few years I was told to continue trying different kinds of birth control to make sure it wasn't the brand. I always itched with the combination pills, though never had a reaction to the mini-pill, which is progestin only. So it makes sense. I had undiagnosed ICP with my first pregnancy and was lucky that an ER doc decided to try prednisone for the control of my symptoms. It helped, though it never took the itch away completely. I was happy to just get some sleep at night. I was diagnosed with SLE earlier this year and chalked up the itching OR sensitivity to estrogen to that. I had developed the ICP around the 13th-14th week of pregnancy lst time around, though when I had my bile acids tested they were never elevated. I'm guessing it was just too early. I am currently at week 24 in my second pregnancy and developed the horrible itch about 2 1/2 weeks ago. I worked with my rheumatologist thinking it was the SLE, and she was stumped and turned me over to my OB. He sent out some labs for bile acids and LO and BEHOLD I have ICP. I don't know how many times I told my previous doctors that I thought it was that. I even had one OB tell me that she thought it was all in my head. Needless to say I changed OB's shortly after. I just started the Actigall and am hoping it does the job. I would love to get a good night's sleep without having to pull my foot up so that I can reach the spaces in between my toes to scratch with no mercy. My poor hands and wrists are just shredded. OUCH! Anyway, I do actually have a question. I was considering asking my OB to start me on prednisone a few weeks before week 37 and bringing up induction. Do you think that would be necessary considering my son came spontaneously at 36 weeks after PROM (premature rupture of the membranes)? I am wondering if a previously preterm birth can determine whether or not a subsequent birth will also be preterm? My son was born healthy at 7 lbs 2 oz, breathing normally and slightly jaundiced. I am thinking the 20 weeks of prednisone developed his lungs, not to mention the fact that I also developed gestational diabetes and was on insulin.
At Tue Dec 09, 04:29:00 PM 2008, Anonymous said…

I posted on September 13. Thank you so much for your reply. Here is my story. I went into labor shortly after I posted, on September 18. I delivered at 34 weeks a healthy baby girl. She is there lying next to me as I type this:)
I went into hospital because of severe abdominal pain and vomiting. I was diagnosed with gallstones which led to pancrities. I had a few milder episodes of these attacks throughout my pregnancy (even prior to itching). After my massive attack I went into labor within 24 hours. I had my gallbladder removed since (6 weeks post delivery), and have no problem so far. But I read an article today that ICP can lead to higher rates of other liver malfunctioning. Now I am freaking out that I might have something (or will have) :( Just wanted to see what is your intake on this? My first pregnancy was ICP free, and then I developed it during second pregnancy. Am I even at higher risk for developing these other things like cirrhosis?
what about baby? does icp had an effect on your baby in terms of development /health???
Also, how likely you think that this ICP was the case related to gallstones (when I was in the hospital my liver enzymes levels tripled within 24 hours. Note all the tests went back to normal right after delivery)? How likely will I develop it if I decide to have a third baby since I did not have it with baby number one? Why do you think some women do not develop it during first pregnancy and then develop it during second?

thanks for support...
At Tue Dec 09, 06:19:00 PM 2008, Anonymous said…

Hi, I am now 36 week and 1 day pregnant with my first baby. I suffered from PUPPP which is another kind of pregnancy rach/itchiness problem between 26 and 32 weeks. Then, I had been fine enjoying the pregnancy without itchness for about 4 weeks, and then last week, itchness came back. This time, the symtom is quite different from last time with PUPPP. Last time, raches were all over and the rashes started on the tummy. But, this time, my fingers and toes started to itch, then moved to legs and arms, and occasionally chest and tummy. A few bugbite like bumps develop as I itch severely. Otherwise, there would not be apparent rash, but the skin is itchy like crazy. I saw my OB/GYN today and I had to convince her to consider giving me a blood test for OC, and she finally gave in. But, the blood work she ordered was for "free fatty acid" and "CMP" (or something similar to this since I can't exactly remember this abbreviation). I was just wondering if these are the right tests for OC. Also, I was wondering if it is common that OC develops 35 or 36 weeks of pregnancy. I'd thank your response, Dr. T. - Liz
At Mon Dec 22, 03:10:00 PM 2008, Anonymous said…

I have had two miscarrages since may 2008. My husband and i are wanting a baby more then anything in the world. Both of them were mother nature no birthdefects. We found out last wednesday that i was pregnant yet again and had an hcg level of 800 (lmp being 11/17). The doctor is sending me for another blood test this week to see if my levels have gone up like they should be in the past four days. What are the chances that i would have another misscarafe and is it posible for me to have a normal pregnacy this time?
At Wed Dec 24, 08:26:00 PM 2008, Dorothy said…

Hello Dr. Trofatter,
I have an appointment on the 5th for antenatal testing related to slightly elevated HGF, and an appt with a midwife on the 6th, and I'm hoping to address this with them; however, for sanity's sake I'm trying to figure out how concerned I should be about OC as a diagnosis. I am 30 and 1/2 weeks and for the past week or so, I have had severe evening itching of my ankles and the fatty portion of the bottom of my foot (the internal "pad" of the arch; not exactly the sole of the foot), with itching also accompanied by small rash on my upper and lower legs and arms, and also in areas where I previously had extremely mild eczema (my inner elbows, for example). This itching is quite severe at night, and is only quieted with oatmeal baths. I have not experienced loss of sleep with the itch, although I do occasionally wake up with scratches from where I have itched. In addition to this (and why I feel concerned that it might be OC) itching, I've recently developed soreness (it's not overt pain, per se) in my right upper quadrant, right below my right breast. It is tender to the touch, but has only actually "hurt" once or twice, which I assumed was just the baby kicking me (smile). A few questions that I have: 1) Are there cases of OC without intense palm and foot sole itching? 2) Should I be tested earlier than my next Dr.'s visit? (I'd prefer not to spend the holidays in the ER, but I don't want to harm my baby in any way!) 3) Has OC been shown to be related to high HGF in any studies (I'm a (PhD) scientist, so any references would be appreciated)? Finally, does my situation sound like it could be OC?

Thank you in advance for your time and attention to this matter.
At Mon Jan 05, 01:58:00 AM 2009, Renee said…

Hello Doctor

In 1999 I was diagnosed with OC at 32 weeks gestation. There was nothing I could do for the itching. I was in hell. The doctors were very aggressive in fetal monitoring. I had steroids and amnio done weekly until his lungs matured. I delivered at 37.5 weeks. He was blue at birth, and had significant developmental delays. About 10 months after his birth I had been rushed to the hospital for liver failure due to gallstone blockage.
skip forward ten years to my current situation- I have edema that is has lasted continuously for several months. right flank pain, and lymph node hardening and swelling. I went to the hospital a few months ago and was dx'd with cat scratch fever. The swelling and adema did not go down with anti-biotics. My throat was extremely swollen and forced me to go to the hospital again thinking I had strep. negative. nevative mono as well. I had a cat scan and discovered my liver is enlarged and has cysts. I was told I needed follow up as systemic lymph node swelling was present and a biopsy should be considered.
My grandmother died of liver cancer before I was born. Is there a link? what is the precentage of women who have developed oc and were later diagnosed with liver cancer?
At Mon Jan 19, 12:04:00 AM 2009, Kate said…

Hi Dr, I have left a post before (thanks for responding) re possible link btw fat store and OC.

Anyway, it seems that I test positive to having had EBV recently (as in I have only just recovered - shown by my lft's only just going back to normal).

Dr, if EBV caused my cholestasis, will I get OC again next time? I have yet to discuss this with my OB (in Aust, on medicare, it's a bit more difficult to pin him down after the event). Is there any chance that I won't get this again next time if it was a temporary ailment?

They did so many tests on me in hospital, I just can't believe that they would miss something so obvious, which of course makes me doubtful.

Thanks for your time to answer.

Kate
At Mon Jan 26, 11:15:00 AM 2009, Heather said…

I'm 36 weeks preg and last week started suffering from itchiness. I have had some tests which found a slightly raised ALT (72), today the maternity unit referred me for an ultrasound which found some small gallstones but he also wasn't too concerned about them, he also wasn't familar with OC. Reading websites has confused me. Is it likely OC could haqve caused the gallstones or is it likely the gallstones could be causing the itchiness and raised ALT and for me not too have REAL OC. The other confusing thing is I have also had instances of gluclose in my urine and are now tracking blood sugars just in case I might also have diabetes which also looks like it maybe linked to gallstones can it also be linked to OC?
At Tue Jan 27, 09:06:00 PM 2009, H C said…

I would really like your advice because I'm concerned that I'm not being taken very seriously by my OB. I am currently 29 weeks and 3 days pregnant with my first child and I was diagnosed at 26 weeks with ICP. My bile acid levels at that time were at 48, but my liver function test was normal. I was told to take Benadryl and later Atarax (neither helped, of course), when I complained about my severe itching. I broke down in sobs when I was describing it to the doctor--I had scratched and itched EVERYWHERE until I bled--I even put gloves on my hands and I still scratched until I bruised. The itching was so intense it's practically impossible to describe. I had been awake for days straight and was so exhausted that I was having trouble breathing and walking around without my legs buckling. I did some research on ICP and asked about being put on UCDA, but was not put on the medication until just last week. I have found out today that my bile acid levels last week were at 96 and my liver function test was elevated, too. However, my doctor did not want to test my bile acid levels this week at all when I went in for my appointment and did not do so. Should he be more concerned about my condition? He has talked about inducing labor by 37 weeks, but after finding out that my bile acid level of 96 is fairly severe, I'm worried that I might not make it to 37 weeks without the baby being harmed. Am I just overreacting? At my last 2 ultrasounds the amniotic fluid had a lot of cloudy stuff in it and they weren't sure what it was. Could it be meconium already? Should I push to be delivered sooner than 37 weeks? Is there a bile acid level at which you really out to be delivered regardless of lung maturity? I'm terrified to lose this baby. I'd really appreciate any advice you might have. Thanks for your time.
At Thu Feb 12, 02:51:00 PM 2009, Anonymous said…

dr. t-
i am 31 weeks pregnant and i have had severe itching in my lower legs and ankles for a while now. it is so bad at night. i wake up with raw bloody ankles. no lotion helps. i did some reserch and found out about OC. everything i read says ask ur dr. for a blood test to be sure. so i called her today and asked for one. she made me feel like a paranoid hypocondriac that looks online for things to be wrong with me. after a heated discussion she finally agreed to the test. i am affraid that my test levels may come back normal at this point even though something may still be wrong. i know she will not agree to do them again. what should i do? if i listen to her and something bad happens to my baby i cant blame it on her for not listening to me. ultimatly this is my responsibility.... -mandy
At Tue Apr 07, 06:18:00 AM 2009, Anonymous said…

This is my fourth preganancy. I have had severe all over night itching in my 2nd, 3rd and 4th pregnancy. The doctor ran a liver enzyme test in my 3rd pregnancy and said I did not have OC. I am 34 weeks and the itching started at night so intense I cannot sleep. Should I be tested again?
At Thu Apr 09, 07:33:00 PM 2009, helena said…

Hi. I had OC with my second pregnancy and was induced at 37 weeks (now healthy 2 year old). I did not have any problems with my first pregnancy. I just found out I am pregnant with my third. I am extremely worried, I read the comments regarding a low fat diet which is what lead me to this article. In all that I have read so far, I cannot seem to find anyone who did not have it with first pregnancy, but ended up getting it with a subsequent pregnancy. Do you have any thoughts on this??
At Fri Apr 17, 08:02:00 PM 2009, Pamela said…

Dr. Trofatter,

What a great site with amazing information, thank you so much for taking your precious time to do this!

I have a 3 year old son and developed OC early in the third trimester of my pregnancy. That pregnancy was also complicated by gestational diabetes and I was on a fairly high dose of Effexor, the anti-depressant, throughout the pregnancy. I didn't actually have any lab testing done to confirm the diagnosis but my OB treated me for OC based on clinical presentation of severe itching and lack of rash. I was scheduled to be induced at 37 weeks exactly but my water broke spontaneously at 35 weeks 6 days. My son was born weighing 6lbs 11oz, received supplemental oxygen for less than 24 hours but had severe hypotonia. He spent a total of 26 days in the NICU,mainly due to the hypotonia and severe feeding difficulties. He is now three years old and markedly delayed both physically and intellectually,he functions at an 8-month-old level. To date no one has been able to pinpoint the cause of these problems but everyone agrees it is likely neurological,originated in the central nervous system, and his disabilities are serious and permanent. Of course my first question for you is whether there have been other reported cases of this outcome with OC pregnancies?

Currently I am 17 weeks pregnant with my second child, a girl. At 11 weeks I had a bile salts test done as my OB wanted a baseline for this pregnancy. Lo and behold they are already elevated, and I began experiencing itchiness about 2 weeks ago. I began the Urso today, although my OB isn't sure if that is the right course of action since he says that OC doesn't actually pose a risk to the fetus until 32 weeks, but I can't find any literature to support that claim. So that is my second question....does OC not affect the fetus until 32 weeks?

Also, you have talked a lot about fetal monitoring...at what gestational age should that start? Is it too early for that to start now at 17 weeks?

Thanks again for all of your help,
Pamela
At Tue Apr 28, 01:25:00 PM 2009, Anonymous said…

I had OC with my last pregnancy. It wasn't discovered until about 37 weeks and they let me go full term. I delivered my son on my due date. I'm now 7 weeks pregnant with a different father. This does not run in my family. Is there a chance that I might not get it this time since I have a different father.
At Thu Apr 30, 01:33:00 PM 2009, Justin said…

My wife has had a very healthy, complication free, pregnancy her 34th week. Then she started itching. After a few days, she told me that the itching was getting really bad. Everyone kept saying "That's natural, your skins stretching, your swelling, etc." I looked it up and low and behold I find ICP. We called our midwife who had us in to do LFT along with Amylase and Lipase testing. I asked for Serum Bile Acids testing but was snottily told that the tests she prescribed were "more accurate." Our Dr. saw the results the next day and made us drive all the way back to do the SBA. The LFT was normal, but her cholic acid came back at a 9.4. Since that test, we've had to switch to the Dr. as we're now high risk, but the Dr. just wants to test once a week and let her go to full term. He says if her itching doesn't get worse, then we shouldn't worry. Is that accurate? At while SBA levels should we be looking for a more enlightened Dr.

Thanks for your time and advice!
Justin
At Tue Sep 22, 10:27:00 AM 2009, Anonymous said…

Hello...I am a 36 year old mother of 5. I have had about everything there is so far...fisrt child vaginal delivery w/Nubaine, second vaginal delivery w/no meds (not happily I will add) third failed ninduction leading to rushed c-section, 3 miscarriages (13 weeks, 5.5 weeks, 5 wks), VBAC induction 4 weeks early, 25 week induction (long story..) lost her about an hour later, last was c-section 5 weeks early due to cholestasis. I have considered (slightly lol) having another baby, but am concerned. With my last pregnancy I was constantly dehydrated. I in fact was so dehydrated I ended up in the hosptila and gained 10 pounds in 8 days from being that much so (at least my dr says so lol). The cholestasis was miserable. I ended up drawing blood from scratching with my fingernails...that was after a hairbrush! I also ended up with PIC line in with TPN because I was so sick everytime I ate (never had that before either). I read that the TPN could have been something that lead to the cholestasis, and my dr told me I have no risk with another pregnancy of developing this. My blood levels of whatever it was were pretty high and he had nonstress tests frequently. My DD came 5 weeks early, thanks goodness...she was already 6lb14oz!! My dr took her via c-section because he said it would be safer for her and my thought was...easier than induction! I was due to have surgery on the 15th and he did it 2 days earlier because my husband (love him dearly) told the dr if he didn't take her before the scheduled date, he wouldn't have to cut my stomach to get her out! What might my risks be with another pregnancy? I am going to leave my email address which I hope maybe you cna delete from my post. I don't know if I will find this site again. Can you email the reply to me? I seek an opinion beyond my dr. I am treated as high risk already....
lpuschel@bright.net
At Thu Oct 01, 04:51:00 AM 2009, Anonymous said…

I have had 4 children, all induced or arrived naturally by 37 weeks due to cholestasis. Raised LFT's and bile acids/ Severe itching etc. This time - no itch, normal LFt and bile acids. Am 36 weeks and finding it strange that it hasn't happened this time. Have been taking some chinese medecine from acupuncturist and high dose Vit E. Lots of water, low fat diet and yoga etc. - all this is different from my previous pregnancies. Still concerned that could have cholestasis somehow with no symptoms? Can you advise?
At Wed Oct 07, 11:34:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sep 22: Sorry, but I really can't send a message to your email nor am I able to delete it from your comments. Did you have the itching you describe with any of the other pregnancies you carried? If not, I would have to agree with your doctor that this is not true "obstetric cholestasis", however, whatever reasons you had the hyperemesis could possibly recur and again lead to cholestasis for whatever reason it occurred the last time. If you are not pregnant now, it might be a good time to have your liver and gall bladder reassessed to see if there is any underlying chronic condition of your hepatobiliary tract that set you up for both the hyperemesis and the cholestasis. Thanks for writing. Good luck!
Dr T
At Wed Oct 07, 11:39:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Oct 1: You might simply have stumbled on the right combination of ingredients to hold the condition off in you! Without the itching, it would be hard to establish the diagnosis of "cholestasis" but if you are still concerned, ask your doctor to order fasting bile acids and liver function tests. If you have that done, please let me know the results and the specific details of you diet and herbal remedy! Thank you so much for writing.
Dr T
At Wed Oct 07, 07:02:00 PM 2009, Steve and Hannah said…

Hello! I was wondering if you could offer a little advice. My mother and sister both had Cholestasis with their pregnancies, so I do not a bit about it. For the past several weeks my hands and feet have been itching, so when I saw my OBGYN I brought everything up with her. She did not seem too concerned, but she tested my bile acid anyways. My results are a total of 11.1 for bile acids. According to what I have found on the internet, that is a mild case, but she says it's normal results and she is not concerned. Is my research incorrect? I'd appreciate any information you can give me. Thank you so much!
At Wed Oct 07, 09:13:00 PM 2009, Anonymous said…

Hello, I have a question or two regarding Cholestasis. With my second pregnancy I developed an itchy rash on my abdomen, the Dr said it was PUPPS and left it at that. The itching progressed and they started running blood work and that is when they realized that my liver enzymes were extremely high, they never did the Bile test. Was induced at 39 weeks, had a healthy but jaundice baby boy. Third pregnancy the itching and rash again, had blood work every two weeks, induced at 37 weeks to a lethargic jaundice baby boy, he began breathing after cpr. I am now pregnant with my fourth. The itching began before I even got my positive, I told my husband I think I am pregnant because I was itching myself raw. I am now 21 weeks and am going in tomorrow for a complete liver function test and bile serum test. My question would be, is it possible to have this but to also have a rash. I am itching from head to toe, my feet itch so bad that I drag them across the carpet for relief, but I still have the red bumps on my abdomen. My Dr is convinced this is all in my head and that I just have PUPP because of the rash. I still itch everywhere, but the rash is getting them. The rash looks nothing like PUPP and it usually only appears after I have been scratching. They look like tiny red dots filled with a clear/yellow liquid.

For my liver, my enzymes never regulated after my second pregnancy. I have had a biopsy, ultrasounds etc done and the Doctors can never figure out what is wrong. Could this also be contributing to the problem? Thank you for your help.
At Fri Oct 09, 10:03:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Steve and Hannah: You didn't tell me how far along in the pregnancy you are. With that family history, your current itching, and bile acids > 10 at this point, you may well have ICP! Both you and your doctor are correct. That result may be normaal, but with a bile acids > 10, you meet criteria for someone who has or is at risk for ICP! Best wishes and let us know how things turn out.
Dr T

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Intrahepatic Cholestasis of Pregnancy - A Bitch of an Itch

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