Intrahepatic Cholestasis of Pregnancy - A Bitch of an Itch
Wednesday, January 10, 2007
Kenneth F. Trofatter, Jr., MD, PhD
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…
100 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