Intrahepatic Cholestasis of Pregnancy - Outcomes and Management

Saturday, January 13, 2007

Kenneth F. Trofatter, Jr., MD, PhD

The other day we began a discussion of intrahepatic cholestasis of pregnancy, or obstetric cholestasis (OC). The post was prompted by the intrauterine death of an otherwise normal baby in a mother who had OC diagnosed late in pregnancy. Although women with OC can be absolutely miserable from the intense pruritus associated with this condition, they are at relatively low risk for serious complications themselves during the pregnancy. One maternal concern that has been raised is the possibility of increased risk for postpartum hemorrhage in women who have reduced blood-clotting factors secondary either to hepatic impairment or reduced intestinal absorption of vitamin K resulting from steatorrhea associated with OC, however, this rarely occurs.

Most women improve symptomatically within a month following delivery, but there is a recurrence risk as high as 90% with a subsequent pregnancy; and, about one-fourth of these women will develop intermittent pruritus, sometimes coinciding with stage of their menstrual cycle, or associated with oral contraceptive or other estrogen use. An excellent recent retrospective, cohort study out of Finland, looking at 10,504 women who had OC during the years 1972-2000, showed that these women also have significantly greater risk for developing complications related to hepatitis C virus infection, nonalcoholic liver cirrhosis, gallstones and cholecystitis, and nonalcoholic pancreatitis than case-matched controls (Ropponen A, et al., Hepatology 2006;43:647-9).

As part of the evaluation of OC, women should be screened for hepatitis C virus (HCV), since there is a higher prevalence of OC in HCV-positive individuals, and the virus infection itself is associated with short-term pregnancy, and long-term postpartum, complications. Other conditions that should be ruled out in OC are infections with hepatitis A and B, cytomegalovirus, and Epstein-Barr virus, and autoimmune hepatitis. With regard to the latter, antimitochondrial antibodies can be obtained to rule out primary biliary cirrhosis and anti-smooth muscle antibodies to exclude autoimmune chronic active hepatitis. Appropriate imaging studies should also be done to rule out obstructive cholelithiasis.

Although the pregnant woman herself is at fairly low risk for complications, it has been well-established that the baby is not. OC is associated with higher rates of spontaneous premature delivery, meconium passage in utero, fetal distress as assessed by heart rate monitoring, respiratory distress syndrome following delivery, intrauterine fetal demise (IUFD) and neonatal death (ND). Prior to the currently recommended therapeutic intervention of planned, early delivery, OC was accompanied by premature labor and delivery in 30-50% of affected pregnancies and IUFD, or ND, occurred in approximately 10%. In the 1995 report by the CESDI (Confidential Enquiry into Stillbirths and Deaths and Infancy) consortium in the United Kingdom, 5% of all term stillbirths were associated with OC. Since then, recommendations that women identified with OC are delivered, electively, no later 37-38 weeks, rates of IUFD associated with OC have been reduced to 0.5% or less. Of course, late preterm delivery can be associated with neonatal morbidity secondary to respiratory complications, but most pregnant women prefer this over the risk of losing their babies.

Management options prior to elective delivery are somewhat limited and inconsistent in their efficacy. Some providers routinely prescribe vitamin K (10 mg per day) orally once the diagnosis of OC is suspected, although the efficacy for this approach has not been proven in clinical trials. Absolute levels of serum bile acids do not reliably correlate with fetal outcome. Fetal heart rate (FHR) testing may provide some reassurance to providers and patients, but it is also not reliable in predicting fetal outcome. In our case that prompted these posts on OC, the baby had a beautifully reactive nonstress test and no FHR decelerations with maternal contractions to suggest any placental insufficiency within 12 hours of presentation with demise. Serial amniocentesis and transcervical amnioscopy (looking up through the cervix at the fetal membranes using a scope) have been used in OC patients to detect meconium and, if this is present, usually provides an indication for delivery, regardless of gestational age. Unfortunately, if meconium is not detected, this does not assure that the baby is not at risk.

Medications typically prescribed to relieve itching, such as diphenhydramine, hydroxyzine, and topical corticosteroids, seem to have very little effect on the pruritus associated with OC. Ursodeoxycholic acid (UDCA), taken in doses ranging from 500 mg to 2000 mg per day, seems to have the most consistent effect in relieving OC related symptoms. UDCA can take 2 to 3 weeks before an effect is noticed, but in some studies it has been shown to significantly reduce pruritus, serum bile acids, transaminases, and bilirubin. It has also been shown to reduce levels of bile acids in umbilical cord blood and amniotic fluid. Although the mechanism of action of UDCA is not entirely clear, it may protect hepatic and, possibly, placental cells from the toxic effects of bile acids and stimulate impaired hepatocellular secretion. Treatment with UDCA appears to reduce the risk for fetal complications related to OC and, as yet, has not been found to be associated with any short- or long-term fetal morbidity. High-dose dexamethasone therapy, may relieve some symptoms, but has shown inconsistent results in clinical trials and at this point, especially, in view of the recent concerns related to steroid administration and fetal growth and development, it cannot be recommended on a routine basis.

The primary question that remains unanswered in OC is why is the baby at such great risk? Do the elevated maternal serum bile acids cause damage to the placenta? To the fetal hepatobiliary system? To other organs, such as the heart? Do they stimulate the passage of fetal meconium directly? Or as the result of acute placental injury and ‘fetal distress’ secondary to reduced capacity of the placenta to transport oxygen or remove ‘wastes’? Or, is the mechanism of fetal compromise completely unrelated to the elevated bile acids? Once meconium has been passed, do some of the complications arise as the result of meconium aspiration before labor? If there is a genetic basis for OC, as there appears to be, does this put the baby at risk by itself for mechanisms that are unclear at this time?

Until we can elucidate a mechanism, and develop specific therapy to address that issue, or develop a specific test to identify the fetus at risk during an OC pregnancy, our best bet is UDCA and early delivery, knowing the occasional patient will still have a loss while under observation, or will lose a baby at term because OC was not recognized during the pregnancy….

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149 Comments:

At Sun Nov 18, 11:00:00 AM 2007, Anonymous said…

Hi Dr. Trofatter, I am in India. I am just 12 weeks pregnant have been diagnosed with ICP. I had my first child six years ago and during that pregnancy, I developed severed itching around the 32 week. However it was not diagnosed at that time at all. Since then I have had two miscarriages - 10th week and 5th week. This time everything looks fine except for this ICP. Given the accompanied sleeplessness, this has been very painful. Is there is a treatment for the itching. Also how risk is it for the fetus. Thank you.
At Fri Nov 23, 06:41:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Nov 18: It is VERY unusual to develop ICP this early in pregnancy. Do you know what your test results were that led to the diagnosis of ICP? Have you been screened for other causes such as viral hepatitis? Autoimmune conditions? Do you take any "herbal remedies" or prescription medications on a regular basis. Did anyone else in you family have problems with this during pregnancy? If you really have ICP and it has statred this early, your pregnancy might be quite hard. You can try ursodeoxycholic acid to help get rid of the bile acids; you may need both topical and oral steroids to control the itching. You might see if there are any foods that make the itching worse and avoid those during the pregnancy as well. Also, if this is ICP, your baby will have to be followed very carefully in third trimester. Infact, we are recommending delivery by about 37 weeks in most cases to avoid an 'unexplained' fetal death. Good luck to you.
At Sun Jan 27, 07:39:00 PM 2008, Anonymous said…

I was wondering what the correlation between the Epstein Barr virus and OC might be? I had (undiagnosed) OC with my first pregnancy. I started itching at 38weeks and my OB induced me 2 days later after much encouragement. I had mono when I was younger and diagnosed with EBV in 2003. I was given Vitamin B shots once a week for 10 weeks to treat that. So, I was just wondering what the connection between the two might be. Thank you in advance for your response.
At Sun Jan 27, 07:44:00 PM 2008, Anonymous said…

I had (undiagnosed) OC with my first pregnancy 3 years ago. I started itching at 38 weeks and was induced 2 days later. I had mono when I was younger and then EBV in 2003. In your article, you mentioned a connection between EBV and OC. I was wondering what the connection is between the two conditions? Thank you in advance for your response.
At Mon Jan 28, 06:00:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Jan 27: Epstein-Barr virus, which a herpes family virus that causes infectious mononucleosis, can cause mild abnormalities of liver function tests and mimic obstetric cholestasis. The fact that you had EBV many years ago (as most folks do, since it is frequently known as the "kissing disease" that people get when they first begin to share saliva) should not be a cause for concern now with regard to obstetric cholestasis. If you really had OC, you developed symptoms rather late in the pregnancy, so there might have been another cause for your itching rather than one of the genetic conditions that leads to recurrent episodes of OC with each pregnancy. Hopefully, it will not recur. thanks for reading. Dr T
At Sat Feb 02, 01:47:00 PM 2008, Anonymous said…

Thank you so much for the response. You mentioned that there may have been a different cause for the itching that occured in the last weeks of my pregnancy since it occured so late. I was wondering what they could be.
At Thu Feb 14, 04:48:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Feb 2: Itching during pregnancy is a very common complaint. Most itching is NOT related to a serious condition or to a condition such as pregnancy cholestasis that may place the baby in jeopardy. Obstetric cholestasis usually begins in third trimester, but in my experience, most cases do not start at the very end of pregnancy and the itching is usually quite intolerable. The diagnosis of pregnancy cholestasis can usually be ruled out late in pregnancy if your liver functions studies and bile acid levels are normal. More common causes of itching include simple stretching of the skin and dilation of the blood vessels that can occur even in the hands and feet under the influence of pregnancy hormones - estrogen and progesterone. Some women develop very dry skin during pregnancy and others may have an increased sensitivity to allergens, soaps, and deoderants that they may use. Mild cholestasis can also occur as the result of gall bladder problems, hyperlipidemia and hepatitis (of various forms) during pregnancy. Some women also become senistive to their prenatal vitamins. Hope that helps and also hope you really don't ever have true obstetric cholestasis! Dr T
At Mon Feb 18, 07:21:00 PM 2008, Emily said…

Thank you for your articles-- I had terrible cholestasis with both of my pregnancies and thankfully had two healthy children. I am now experiencing intermittent pruritis, and have identified antibiotics and oral contraceptives as triggers. Is there any research that indicates what other things can cause the recurrence? Do prenatal vitamins, for instance, because of the heavy mineral content, overload the liver and cause cholestasis? Also, should I just consider myself to have a weaker liver and follow the guidelines for general liver health? Thanks again for your articles and help!
At Sat Feb 23, 10:26:00 PM 2008, Anonymous said…

Hi Dr. Trofatter,
Thank you for writing on this topic! Your articles give the most consise info for me. I am 34 weeks pregnant w/ my 6th child and was diagnosed at 32 weeks w/ OC based on elevated liver enzymes, elevated serum bile acids and the classic intolerable soles and palms itching, which has since spread. I was recovering from the flu when it started. I had similar severe intolerable itching for weeks 37-40 of my 3rd pregnancy (MD told me "it's normal" and perhaps he was right) but for no other pregnancy. I am on urso 300 BID, getting twice weekly NSTs and labs drawn. Questions: At what level of elevated enzymes or serum bile acids is immediate action required, if ever, for the baby's sake/mother's sake? Does the mother have permanent liver damage after a certain point of elevated labs? The plan at this point is induction at 37 weeks. Is there any way other than amnio to determine fetal lung maturity prior to induction? Amnio sounds risky for both of us. Thank you in advance for your thoughts.
At Wed Feb 27, 08:34:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Feb 23: The risk for the baby is linear and does appear to be correlated with the level of bile acids, i.e., the higher the bile acids, the greater the risk (in general). But there is no specific "cutoff" above which all patients should be delivered and some babies get into trouble with only mdestly elevated maternal serum bile acids. I think the key is related to the effect of these on the baby, directly and by impairing placental function. As far as I know, there is not usually any permanent liver damage associated with OC. The amnio is VERY safe for both you and the baby that late in the pregnancy. The OC risk is much gretaer than the risk of the procedure and, if meconium (fetal stool) is present in the fluid at the time of the amnio, that alone is an indication to push on with delivery. Remember, fetal monitoring alone is NOT a good predictor of fetal outcome with OC. Good luck and I hope things turn out well. Thanks for writing and let us know how you and the baby do. Dr T
At Thu Feb 28, 04:45:00 PM 2008, Anonymous said…

Dr Trofatter, In 1999, I was diagnosed with ICP while carrying my (thankfully, healthy) twin daughters. Immediately upon returning home following almost two months of hospitalization with pre-term labor, I had what I have since self-diagnosed as gallstones - excruciating pain behind the bottom of my right rib cage whenever I ate what was my (usually) only meal of the day, fried eggs and toast. The only test I was offered was an x-ray and I was not comfortable with that as I was breastfeeding. But the circumstances and symptoms seem to match those for gallstones. My thought is that there may be some correlation to the cholestasis. I had just stopped taking Actigall(?) immediately prior to going home and the beginning of the pain. Might there have been a correlation? Karyn
At Thu Feb 28, 06:56:00 PM 2008, Anonymous said…

Hi - With my first pregnancy, I itched for about a month (all over) until I finally said something to my doc at 34wks. He did the bile blood test and it came back normal, but still diagnosed ICP. I also had severe swelling & protein in urine, so he diagnosed preeclampsia as well, and I had c-section at 37 weeks. I am now 27wks pregnant with second child and noticed itching last week (again, all over). Went to doc and he diagnosed ICP again, although he did not perform any blood tests this time. Is it normal to diagnose ICP as he did in my situation (1st preg. bile tests were fine, this preg. no test at all, but still ICP diagnosis). He has prescribed the URSO Acid 900mg per day. At this point I am showing no signs of preeclampsia.
At Fri Feb 29, 06:56:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Emily Feb 18: It's not the minerals in the vitamins that stresses your liver, it's the fat soluble vitamins, A. D, and E! Your liver is the primary means by which these vitamins and their breakdown products are metabolized and excreted. I am not sure what a "weak liver" is but if you have a genetically based form of cholestasis or have damage to your liver from some other source, this may make it so that it gets overloaded by work when asked to process certain vitamins, fats, and medications and that leads to 'congestion' and accumulation of bile acids that precipitate your symptoms. Dr T
At Tue Mar 04, 06:57:00 AM 2008, Regina said…

Dr. Trofatter, 19 years ago I was pregnant and had ICP but was not diagnosed. My son was born at 39 weeks and had merconium staining upon delivery. My question is what health conditions do babies have long term?
At Tue Mar 04, 06:29:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Karyn Feb 28: An X-ray shpould not cause any problems with your breastfeeding, but the diagnosis of gallstones can usually be made with a simple ultrasound which should not be an issue at all. tell your doctor about your symptoms and find out what's going on. It's not likely to be a more serious problem, but why take any chances?!? Good luck and let us know what they find. Dr T
At Tue Mar 04, 06:33:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Regina March 4: Usually none, but if there was meconium aspiration into the lungs, this may cause respiratory complications following delivery that can be associated with increased risk for asthma or respiratoy tract infections. Why? What sort of problems has he had? And, did he have any problems in the immediate postpartum period? Dr T
At Tue Mar 04, 06:42:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Feb 28: Pregnancy history tends to repeat itself, even if we are not smart enough to figure out why. With all that said, it might not be a bad idea to repeat your bile acid screen and to get baseline liver function tests, a complete blood count, and a 24 hour urine to check for protein and creatinine clearance. You are probably at increased risk for recurrence of your preeclampsia as well and this might be the first sign this is happening again. Probably not a bad idea to check the growth of the baby by ultrasound as well at this point. Best of luck and let us know how things turn out! Dr T
At Tue Mar 18, 06:51:00 PM 2008, itchymomof3 said…

I have had ICP with all three of my sons. Their ages are 7,6 and 3. Two and a half months after having my third son, I had to have my gallbladder removed. I am now having left side pain (under left rib) similar to the pain I was having with my gallbladder. A couple of doctors seem to think it is my spleen. I have researched to see if there is a link between ICP and spleen problems, and have been unable to find anything about it. Could you help me with this? Any thing you know that you can share regarding this will be greatly appreciated. Thanks.
At Thu Mar 20, 07:10:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To itchymomof3: As far as I know, there is no association between obsteric cholestasis and splenic problems. However, you might have some adhesions from your cholecystectomy that are causing your abdominal discomfort or there could be a completely unrelated problem. I will be curious to know what you find out. Dr T
At Sat Apr 12, 05:57:00 AM 2008, Anonymous said…

Thank you for all the helpful information on your site. I am 36 1/2 weeks pregnant and started itching around 34 weeks. My liver and bile acid levels were tested. My bile acid was in the normal range but my liver functions were high, but upon retesting a week later (after monitoring my diet by limiting bad fats) they were normal again. This past weekend, i neglected my diet and started itching badly again. The liver functions were high once again, but two days later, after watching my diet, they are back to normal and the itching has decreased. My question is, am i still at risk for ICP even though watching my diet is seeming to help? Is my baby in any harm if i carry him to term, or is an induction still recommended because of the symptoms i am showing? Doc has me monitored 2x a week, just in case, but i know you can never be certain. Thanks.
At Mon Apr 14, 08:59:00 AM 2008, martina said…

I delivered my 2nd daughter 2 weeks ago. Shortly after delivery it was noticed that she had a distended stomach, so was taken to the neonatal unit. Her liver funtion tests came back with results that were outside the normal range, and initially the doctors suspected hypothyroidism or possibly hyperthyroidism. An Xray indicated a slightly enlarged liver, and enlarged tongue. After about a week, they started to back away from that prognosis and think she is OK now, although I have to return in 4 weeks time to repeat the tests.

I had two episodes late in pregnancy that I thought were my ulcer returning, but on talking to my doctor, she believed they were gallbladder attacks. I also had very itchy feet late on in pregnancy. I am only now beginning to put the pieces together and see these incidents as related. I also was recovering from a bad bout of the flu when this happened (in common with some of your other readers).

My daughter's stomach is still a bit distended, but she is feeding and sleeping well. My main concern is the possible long-term effects on my her. Is this something you could shed any light on? Many thanks.
At Tue Apr 15, 07:25:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Apr 12: you have an atypical picture for obstetric cholestasis, but I sure as heck would recommend sticking to your diet. One of the things you might discuss with your doctors in view of their concerns and the unreliability of fetal monitoring in preventing fetal deaths in utero with OC, is to have an amniocentesis to assess fetal lung maturity sometime next week. If it appears the baby's lungs are ready to work or if there is meconium in the amniotic fluid, then there is reason to push on and to get you delivered early rather than taking any chances. Good luck and please let us know how things turn out! Dr T
At Tue Apr 15, 07:30:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Martina: I think the answer to your question lies in what they find out about what caused your daughter's problems. If you had 'flu-like' symptoms then it is possible the baby had a congenital viral infection such as cytomegalovirus (CMV). If you were treated with certain medications for your gall bladder problems, then perhaps that caused her problems as well. Of course, there is the possibility that she has something else wrong (a structural defect in the bowel or abdomen, or a genetic, syndromic, or chromosomal abnormality). I am so very curious abot this. Can you please let us know what you find out. Dr T
At Sun Apr 27, 01:13:00 PM 2008, Anonymous said…

If a woman is exhibiting symptoms of ICP late in pregnancy, but all lab work returns in the normal ranges, what are the risks to the baby? I've read that it can take weeks for lab work to show any abnormalities. What if the OB was reluctant to treat the symptoms as ICP with no actual proof of the disease and the pt. was approaching the end of the pregnancy? Would it be safe to proceed as a "normal" pregnancy given the lab values were normal? Is there still substantial risk to the baby if labor is not induced? Thank you in advance for your response.
At Tue Apr 29, 07:40:00 PM 2008, Anonymous said…

I am a mother to 10 children and have had terible itching with all 10 pregnancies. I never heard of ICP and my OBs never mentioned that the itching could be anything. I have never had any testing( other than normal pregnancy testing) and all my babies were born healthy at 41-43 weeks.

I started having gallbladder issues a year ago(gallstones diagnosed via MRI) but still have my galbladder. I have occassions where th area of my liver is tender to the touch and it feels like it's swollen (not sure how else to descibe it)I have wondered if this is due to the gasllstones.

My question is would having gallstones now and the tender liver area up my chance of ICP especially with my past history of inense pregnancy related itching?

I am not currently pregnant, but the possibility is there that I will be soon.

Thank you.
At Tue Apr 29, 07:48:00 PM 2008, Anonymous said…

I just sent a message but forgot to ask about diet. Since finding out I had gallstones I changed my diet completely and now eat a low fat vegan diet. Can eating a diet such as this prevent ICP? Could diet hide the symptoms of having ICP, cauing one to go undiagnosed?

Thanks again.
At Wed Apr 30, 05:31:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Apr 27: Have you had any pregnancies before and had the same problems? Regardless, the "normal" lab tests are reassuring, but do not absolutely rule out ICP. There are conditions associated with pregnancy that cause itching that are not related to ICP. It is impossible from what you have told me if your baby is at increased risk, but if there has been normal growth of the baby, no evidence of other medical complications in you, and all your laboratory studies are normal, you probably do not need to be delivered, electively, before 39 weeks and if you think you should be, I would recommend an amniocentesis to assess fetal lung maturity in the absence of any other indication for delivery. Good luck and thanks for reading. Dr T
At Wed Apr 30, 07:47:00 PM 2008, Anonymous said…

This is from anonymous April 17. I developed unbearable itching, mostly on palms and soles, in my 38th week of my first and only other pregnancy. I had lab work done the same day the itching started and the abnormalities then were ALK Phos. 206, protein 5.9, and albumin 2.7. I did not have the SBA test done and was induced 2 days later because of my concerns in regards to the possibility of ICP and terrible itching. This pregnancy has been "normal" aside from preterm labor since week 30. I was given steroid injections at 31 weeks just in case. My ultrasounds and measurements have been right on so far. I am now 36 weeks and have some itching, but nothing like last time. I just had LFT and SBA test done last week, however I don't have the results yet. I was just concerned that if the lab work came back within normal range my OB would be reluctant to treat as ICP and there would be a threat to the baby if it actually were that. Why do you suggest induction at 39 weeks? Is that just if I choose to for my own peace of mind? Thank you so much for your time and responses.
At Thu May 01, 07:19:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anaonymous Apr 29: If you had severe itching with all of your prenancies, you could have the real problem of ICP. What is your nationality and ethnic background? Are you in a part of the world where ICP is very common? True ICP will not be cured by removal of your gall bladder, although in your case, if you are having thoses kinds of symptioms, you might consider having that done BEFORE you get pregnant again. ICP involves a defect in your liver function and it is stressed by conditions, diet, medications and the like that add stress to your liver's ability to do its job. Other women with ICP have benefitted by weight reduction and low-fat diets, and in your cae, that would be worth a try. If you do get pregnant again, and develop symptoms of ICP, I would suggest you have your bile acid levels and liver function evaluated. True ICP is assoviated with a high risk of 'unexplained' and unexpected fetal loss. The usual recommendation is early delivery at 36-37 weeks in women who are documented to have the real disease rather than taking the risk of waiting, since routine antepartum testing is very unreliable in predicting outcome under these circumstances! Good luck and thanks for writing.
At Thu May 01, 10:35:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Apr 30: Hello again. I suggested 39 weeks for your peace of mind, your physician's peace of mind, and because there should be no issues related to "fetal lung maturity" at that time. I guess, my other concern would be that I am always a little uncomfortable under circumstances wherein it is difficult to make a definitive diagnosis and the outcome can be so tragic. By the same token, if you clearly have ICP, I would suggest delivery no later than 37 weeks. Best of luck again. Dr T
At Thu May 08, 07:42:00 PM 2008, Anonymous said…

Dr. T., I will try to make this as short as possible. This is my 4th pregnancy and I have never had ICP in the previous 3 that I am aware of. But I have been having many complications with this one. From around week 8 I have had pain in upper right quadrant, vomiting, and on and off lack of hunger. Doctors have checked everything possible that is safe during pregnancy with no luck. At around week 25-26 I started itching all day but worse at night. I didn't think anything of it I just ignored it for 3 weeks until I ran across info online about ICP. I had a follow up with a GI specialist who had done an ultrasound and blood workup a few days prior so I brought info to the appt. They diagnosed me with ICP because of the itching and elevated AST (46)and ALT (119). They started me on Actigall and took my bile salts and other hepatic panel a few days later which came back normal. I saw my OB a few days ago and he doesn't seem concerned. I am 31 weeks now and OB said since my levels are back to normal I don't need any follow up blood work and he will start nonstress test around 36 weeks. I asked if the baby should be delivered early he said no. I am not sure if I have true ICP or an underlying problem but I feel my OB is being to lax about the situation. Am I being too dramatic about being concerned?
Thanks for your advice!
Lindsay
At Fri May 09, 08:38:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Lindsay: It is hard to say because if you have true ICP, you have had a very unusual history for the same. Usually it recurs wih each pregnancy. Did they look for any oher possible causes of the elevated LFTs? Hepatitis viruses, autoimmune hepatitis, gallstones, medications such as tylenol, etc? I think your OB is "lax" because he/she is having a hard time accepting the diagnosis. If you have the 'real deal' it is nothing to be lax about and many specialists are recommending routine delivery at 36 weeks with true ICP. Good luck and please stay in touch to let us know how things turn out. Dr T
At Sat May 10, 09:06:00 AM 2008, Anonymous said…

The OB hasn't done any further testing. The ultrasound I had showed sludge but no gallstones. I was taking tylenol before this all started because of severe headaches from a sinus infection. But that was about a month before I had the blood tests done. I also had other symptoms at the time the itching started (which was about 5 days after starting augmentin for sinus infection). Very dark urine for 2-3 weeks and lack of appetite for about 2 weeks. I have only gained about 5-6lbs this whole pregnancy due to either being sick or just not wanting to eat. Should I recommend to my OB to get some other testing done? Thank you so much! Lindsay
At Tue May 13, 06:41:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Linsay: The studies I suggested in my previous response could all be considered. Write them down and ask either the gastroenterologist or your OB doctor. I would also suggest being screened for Epstein-Barr virus and cytomegalovirus if you have been "tired all the time" out of proportion to your other pregnancies. They can both cause abnormal liver function tests. Good luck! Dr T
At Wed May 21, 02:14:00 AM 2008, Anonymous said…

HI my name is amanda i had a unexplained stillbirth at 36wks in sept 07 and i am now 17 weeks pregnant again and i have servre itching on my arms feet hands and legs i also have a pain in my right side and have gallstones as they were diagnosed in my previous pregnancy.do you think i have icp i have had blood tests done and they have come back negative but i cant seem to control the itching i have tried all kinds.thank you
At Sat May 24, 12:55:00 PM 2008, Anonymous said…

I am anon Apr 29 with the 10 children. Thank you for your reply above. I am probably going to be having my gallbladder out soon anyhow and I hope things settle down after that. I will definitely be aware if we do have another baby and if I start any itching I will be mentioning ICP to my MW.
At Sun May 25, 05:29:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Amanda May 21: This is a little early in pregnancy for ICP, but you may have some degree of cholestasis related to the gallstones. Even if your blood studies are normal, I would recommend a low fat, high fiber diet and you can ask your doctor about starting ursodeoycholic acid. If the gallstanes are really the cause of your problem, it is not too late in the pregnancy to consider having your gallbladder removed. Best of luck and let us know what happens! Dr T
At Tue May 27, 08:02:00 AM 2008, Rahha said…

Dr. Trofatter,

I am a patient of Dr. Moore's and had ICP with first child and now 33 weeks with my second and the itching has started getting really bad the past 4 days. My labs from 2 weeks ago came back normal but I am miserable. I tried to get a consult with you but it looks like you are a very busy man the appt. is for 2 weeks from now. I see Dr. Moore on Friday and I was wondering if I should see one of your partners and if so who knows as much as you?
By the way your articles are very informative I appreciate what you have done for the woman like me that feel like it is all in "our head".
At Tue May 27, 05:21:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Rahha May 27: I am sorry, but I have been VERY busy lately because I was appointed interim Chair of the deaprtment at a VERY busy time in the medical center's history. Hopefully, the 'search committee' will work quickly because I truly have missed the time I spend with patients and the job has cut into that substantially. Any of my partners should be able to help if you need to be seen sooner and Drs Mabie and Dacus have a special interest in ICP. If you do come in sooner (and you probably should), have them call me when you have been seen. I love to meet my readers! Dr T
At Mon Jun 02, 02:54:00 AM 2008, MN said…

I am right now up in the middle of the night AGAIN with terrible itching. It started a little over 3wks ago, and I am now approaching 33wks gestation. I have never had this severe itching in previous pregnancies, but I did have intense itching on the tops of my feet for the last few pregnancies. Never thought anything of it, though, because of everything you read about itching being normal in pregnancy.

Anyway, I have tried benadryl, claritin, hydrocortisone cream, oatmeal bath, etc. and NOTHING is relieving this. It is EXTREME at night, and I am not sleeping for more than a few interrupted by scratching hours at night. I had liver function and SBA test done last week and SBA was 6 and liver function normal. So doc says it is not ICP. I have been searching for any other explanation, but cannot find anything except how closely my symptoms match the ICP description. The "rash" I get only comes from the scratching, and subsides once I stop and I have sores all over my arms and legs from the skin being a little "raised" from the irriation and the higher parts get more scratching and bleed. My itching is mostly on my neck, ears, arms, and legs. I have no itching on my trunk.

Due to the "normal" lab results, do I accept that this is NOT ICP, or is it still potentially ICP. We have lost two children in infancy (w/ uncertain diagnosis but suspected mitochondrial disorder), and I'm fearful of another loss. I am getting more and more sleep deprived, and really starting to lose it more mentally. I'm also already overwhelmed as the 2nd child who died only died 8mths ago and this pgcy was a shock and am having some difficulty with coping with all of it, now no sleep and terrible agony with itching is driving me truly insane!

As a side note, I also have been having discharge that is bloody (not bleeding, just blood in the discharge) for nearing a week now, and exam found only 1+ cm dilation and still thick. I am hoping for insights and if it is reasonable to request steroid shots and early delivery based on these symptoms, without substantiating lab results. Or what other plan could you suggest? TIA!
At Tue Jun 03, 06:45:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To MN June 2: This could still be intrahepatic cholestasis. If you have any sort of rash at all, you might consider consultation with a dermatologist. I would still consider treating you as if you had ICP - begin ursodeoxycholic acid and perhaps hydroxyzine; recommend a low fat diet; consider discontinuing your prenatal vitamins; if you are completely miserable, a tapering course of oral prednisone might be appropriate as well on a trial basis. All of these are relatively safe to take during pregnancy. Feel free to discuss these options with your doctor. Good luck and let us know how things turn out. BTW, I would be very curious to know what "mitochondrial disorder" affected your children and would aske the question, could this be contributing to your problems?
Dr T
At Wed Jun 04, 08:27:00 AM 2008, Anonymous said…

I am 35 weeks pregnant and this is my 2nd child, I started itching 2 days ago, went to the doctor yesterday, he just told me it is normal. I did not have any problems with my first pregnacy, can you still develop ICP if you don't develop with your previous pregnacies?
At Wed Jun 04, 07:34:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous June 4: You can, buttrue ICP usually recurs with pregnancies. There are lots of other causes of itching and cholestasis in pregnancy and, hopefully, since this is starting so late in your case, it is nothing to worry about as your doctor says. Did he/she send and liver function tests or bile acid studies? Best of luck and hope you can get some rest! Dr T
At Tue Jun 17, 10:22:00 AM 2008, Anonymous said…

Hello. I am 36 weeks pregnant and started itching around 33 weeks. I spent the night in L&D Sat. as I went to the hospital fed up with the itching. They drew labs and did an ultrasound Sun. morning. I was discharged with the diagnosis of suspected ICP. Now I'm having NST 2x week with BPP once a week until my bile acids come back. My OB talked with my perinatologist (already seen by peri. for a hx of 34 week ptl/rupture/delivery) and they agreed to my request for amnio and induction if the lungs show maturity at around 37 weeks. My questions are: should I be taking Actigall before my results come back? What should I do if my bile acids come back normal(LFTs were normal on Saturday) as I've heard symptoms can precede the rise in bile acids? Am I correct in my understanding that you can have normal labs and still have ICP? I'm wondering if I should still ask for amnio and induction if SBAs are normal since it's kind of late in the game and it could be too late to wait and see if my bile acid levels start to rise. Also, the baby's growth has been "sluggish" (not IUGR), not sure if that is a sign of ICP. I get a growth scan every 2 weeks.Doppler studies have always been normal. Thanks!
Carrie in GA.
At Fri Jun 20, 09:31:00 PM 2008, Anonymous said…

hey there im kia veal they said i was 7 weeks wan they diagnosis me with Intrauterine fetal death cause they didnt heart an heart beat an they went off my last period an said they i will past my baby by the weekend ,they also said my baby was to small to be 7 weeks {what can i do?} is they right please help me at kia.veal@yahoo.com
At Sat Jun 21, 05:22:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Carrie: I would suggest you reduce the fats in your diet and consider starting ursodeoxycholic acid (Actigall) even if the bile acids are normal. At times an antihistamine or oral steroids might help, but rarely are they much benefit in ICP. Let me know what your laboratory studies show and then I might have some other ideas. Best of luck. Dr T
At Fri Jun 27, 10:53:00 PM 2008, Anonymous said…

The hospital LOST my bile acids!!! And I did start URSO just a few days later so now we'll never know what my initial bile acids were. They were drawn again after they realized this Weds. Anyway. Didn't induce on Weds. (37 and 1, LMP) because amnio came back with immature lungs (L/S 2.0, Caution Mature; PG 0.1). Didn't shock me as by my dates I was more like 36 and 3 (I was doing BBT charting and using OPKs the cycle we conceived, so my date shouldn't be off more than a day or two, I usually ovulate on CD 19, and have never ovulated earlier than CD 18). So the plan now is to MAYBE repeat the amnio this Weds. and see if it's mature and induce Thurs. if it is (they left this up to me). Otherwise, without repeating the amnio the plan is induce July 7th (38 and 1 by my dates and 38 and 6 by theirs, so 39weeks following ACOG guidelines for induction based on LMP). They ended up giving me the steroid shots to speed up lung maturity since I had pPROM in my 1st pg. and if I did rupture unexpectedly the baby would almost certainly go to NICU, that's what they said anyway. Plus it will help her out when we do induce. I'm really leaning toward the amnio on Weds. because we could possibly be able to induce at 37 and 4, my dates, making me feel better regarding the OC risks, plus I'm assuming the steriod shots should help. Do you know if any benefits from the shots will translate to the FLM report of L/S ratio and PG level??? So, next week I'll be doing 2 NSTs and a growth scan as well. I am so ready for this to be done and hope to get her here safe. My symptoms have eased a bit after one week of URSO. They were rather mild in comparison to what I've read some others experince, I'm really hoping that that means my bile acids were less than 40, (if it's indeed ICP, may never know now, everyone, peri., OB, diagnosed based on symptoms but I still feel that there's a chance it's something else, best to be cautious in the presence of lung maturity I guess. I wouldn't feel comfortable inducing immature lungs as I just don't have all the classic symptoms and LFTs were normal). I don't feel particularly comfortable waiting until 39 weeks by my dates because of the risks but am nervous about even inducing on the 7th without an amnio as I really don't want my baby in the NICU, been there, done that, with my first baby. Do you think based on my FLM report from Weds. that the lungs will be mature by the 7th (so 25th June to July 7th, 12 days)? What effect would the steriod shots have on this? I desperatly want to induce this week but if the amnio isn't mature again it will be the 7th but without an amnio before. Well, any comments are greatly appreciated. I am so confused and scared for my little girl. Thanks!

Carrie in Atlanta
At Sun Jun 29, 07:35:00 PM 2008, Anonymous said…

The hospital LOST my bile acids!!! And I did start URSO just a few days later so now we'll never know what my initial bile acids were. They were drawn again after they realized this Weds. Anyway. Didn't induce on Thurs. (37 and 2, LMP) because amnio came back with immature lungs (L/S 2.0, Caution Mature; PG 0.1). Didn't shock me as by my dates I was more like 36 and 3 (I was doing BBT charting and using OPKs the cycle we conceived, so my date shouldn't be off more than a day or two, I usually ovulate on CD 19, and have never ovulated earlier than CD 18). So the plan now is to MAYBE repeat the amnio this Weds. and see if it's mature and induce Thurs. if it is (they left this up to me). Otherwise, without repeating the amnio the plan is induce July 7th (38 and 1 by my dates and 38 and 6 by theirs, so 39weeks following ACOG guidelines for induction based on LMP). They ended up giving me the steroid shots to speed up lung maturity since I had pPROM in my 1st pg. and if I did rupture unexpectedly the baby would almost certainly go to NICU, that's what they said anyway. Plus it will help her out when we do induce. I'm really leaning toward the amnio on Weds. because we could possibly be able to induce at 37 and 4, my dates, making me feel better regarding the OC risks, plus I'm assuming the steriod shots should help. Do you know if any benefits from the shots will translate to the FLM report of L/S ratio and PG level??? So, next week I'll be doing 2 NSTs and a growth scan as well. I am so ready for this to be done and hope to get her here safe. My symptoms have eased a bit after one week of URSO. They were rather mild in comparison to what I've read some others experince, I'm really hoping that that means my bile acids were less than 40, (if it's indeed ICP, may never know now, everyone, peri., OB, diagnosed based on symptoms but I still feel that there's a chance it's something else, best to be cautious in the presence of lung maturity I guess. I wouldn't feel comfortable inducing immature lungs as I just don't have all the classic symptoms and LFTs were normal). I don't feel particularly comfortable waiting until 39 weeks by my dates because of the risks but am nervous about even inducing on the 7th without an amnio as I really don't want my baby in the NICU, been there, done that, with my first baby. Do you think based on my FLM report from Weds. that the lungs will be mature by the 7th (so 25th June to July 7th, 12 days)? What effect would the steriod shots have on this? I desperatly want to induce this week but if the amnio isn't mature again it will be the 7th but without an amnio before. Well, any thoughts are greatly appreciated. I am so confused and scared for my little girl. Thanks!

Carrie in Atlanta
At Fri Jul 04, 06:51:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Carrie: The two safest options would be to simply deliver you a week after that last amnio without another one or to repeat the amnio and then deliver. With the L/S ratio of 2.0, your baby has a very small chance of significant repiratory problems already. This will be over soon so please let us know how things turn out. Best of luck! Dr T
At Wed Jul 23, 08:51:00 AM 2008, Anonymous said…

Hi Dr. Trofatter,

I am currently 27 weeks along in my first pregnancy and have been struggling with rashes and itchiness for about 4 weeks. There were visable rashes initially under my arms and on my forearms - these resembled contact dermatittis and have since gone away. There remains some itchiness on my underarms and breasts (the rash has diminished), and occasionally my belly, but there has been improvement as the weeks have gone on and I am managing by taking oatmeal baths, using powder to prevent chaffing, etc. My doctor had me take a blood test to assess bile salts and liver functions as a precaution - results are not back yet. Does this sound like ICP? Should I have a repeat of my blood tests in a few weeks if they come back normal, given that ICP does not always show up immediately in the tests?

Thank you.
At Wed Jul 23, 01:38:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous July 23: If the rash came before the itching, it is probably a primary dermatologic condition rather tha ICP. There are some conditions that are very specific to pregnancy (such as PUPPS) and that may be associated with occasional poor pregnancy outcomes. I suggest you ask for a referral to a dermatologist if the rash persists. Good luck! Dr T
At Sun Jul 27, 04:57:00 PM 2008, Anonymous said…

Hi Dr. Trofatter! I just wanted you to know that I delivered a healthy little girl (Norah) on July 2nd at 37.5 weeks(38 LMP). Another perinatologist in the practice that I talked to after my maturity amnio after hours, because I was upset and scared about not delivering that week, changed my appointment to see him the next week (very strange situation as I was supposed to see my peri. on Weds. but they called my OB to tell them my appt. had been changed to Tues. to see this perinatologist whom I had never seen, only talked to this once. He came in and said that if my amino results were what I had told him the previous week that he didn't see the need to repeat the amnio and that I could start induction that night! (My other peri. wanted to wait until 39 weeks). He was so nice and very responsive to my point that the risks of RDS were less at that point than the risk of stillbirth and therefore based on statistics I should be delivered (I've noticed how much perinatologists love statistics). I also pointed out that there were no bile acid results on which to base management decisions, and therefore that we had to assume the worst as far as bile acids and pursue active, or more aggressive, management. I am so glad to have gotten her out of there as starting on the previous Monday I experienced a sudden increase in itching! I cannot believe how bad I itched, absolutely intolerable and it was EVERYWHERE except my face. My bed sheets were streaked with blood I was itching myself so hard. I also noticed that the day before this happened my urine got really dark again. So, I am kind of glad that I went through that as I now have no question in my mind that I had ICP; in the absence of the bile acid results I was always doubting, even though I did have all the symptoms, they just weren't AS severe as others had posted. Actually my palms and soles were the last to start itching in those last couple of days, although once they did it was severe. In the beginning I mainly itched on my arms, legs, neck and chest, back, and hands and fingers. This got better after a week on Actigall but then that sudden onset returned with an absolute vengeance like I described earlier. Symptoms went away within a couple of days after delivery. So, thank you for your input and for helping us try to understand this quite puzzling condition!!!
Carrie in Atlanta
At Mon Jul 28, 04:31:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Carrie: Congratulations and thanks for the update. Now for the real question: How many more times are you going to go through this?!? Have fun with the baby. Dr T
At Wed Jul 30, 05:54:00 AM 2008, Anonymous said…

Hi Dr. Trofatter,

I had written previously, but now have my test results and wanted to get your thoughts. I am currently 28 weeks pregnant, and the itching that I had for several weeks has pretty much gone away. It did start with a rash. My liver enzymes have come back normal, and my bile acids came back at 18.3, which my doctor labelled as "slightly elevated". I should note that I had my gallbladder emoved several years ago due to a gallstone. My question is whether there is a linear relationship between bile acid level and fetal risk (some studies I read found no risk at levels below 40). Additionally, I am wondering if you would recommend continued monitoring of my levels, or other follow-up monitoring. Thanks in advance.
At Sat Aug 02, 06:26:00 AM 2008, Anonymous said…

I am 36 weeks in my 3rd pregnancy. I did not have ICP in my first but was diagnosed with it at 35 weeks with my second. I am not having significant itching right now. My SBA results are normal (tested at 35 weeks the results were 6.4). I am wondering if I should be induced because of my previous pregnancy with ICP even if I am having no symptoms. I would love to let this baby come on his own but I worry we will miss something and the worst will happen. Thank you for your article and input.
At Sat Aug 02, 07:32:00 AM 2008, Target Widow said…

Dr. Trofatter, I was diagnosed with ICP based on elevated SBA at week 36 during my last pregnancy and induced at 37 weeks (no itching during my first preg, but meconium staining). I am now 11 wks pregnant and wondering what steps I should take to monitor for ICP. Should we wait to take tests until I start itching? Or should I request lab work on a regular basis. I have been a little itchy, but I think its mostly just me being paranoid at this point, nothing like before. I have a doctors appt coming up and would like to know what the protocal is for someone who has had ICP in a past pregnancy. Also, I thought I would mention, that although my sister has not had ICP she does have autoimmune hepatitis and I would love more information on the genetic connection between the two. Thanks, Target Widow
At Thu Aug 07, 12:08:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous July 30: If your itching has completely resolved, it is unlikely that you have true obstetric cholestasis - there are many other causes of itching (and of cholestasis) in pregnancy. There does seem to be a linear correlation between symptoms and bile acid levels, but there alos seems to be very low risk to the baby until that threshold level of 40 is reached. However, as you probably know, nothing is 100% certain in this business. If your symptoms return, I would recommend repeating the bile acid and liver function studies; if not, you are probably at no great risk. Good luck and please let us know how things turn out! Dr T
At Thu Aug 07, 12:11:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 2: I am not s sure you have (had) true obstetric cholestasis. With your bile acids that normal, and your absence of symptoms this late in your current pregnancy, I doubt you or the baby are at much risk. So, other than perhaps, routine antepartum testing, I do not see a need for early delivery at this time. Best wishes and let us know how you do! Dr T
At Thu Aug 07, 12:17:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To targetwidow: True obstetric cholestasis is a genetic condition that usually does not declare itself until late in second or during the third trimesters. You probably do not need any evaluation until you develop some degree of recalcitrant itching! Autoimmune hepatitis can associated with cholestasis but not obstetric cholestasis. If your sister has an autoimmune condition, however, you might be at increased for one yourself since these do tend to run in families! I have had several request for information regarding autoimmune hepatitis and pregnancy, so I will probably devote a whole post to the subject sooner or later. Regards and best wishes for the pregnancy! Let us know how you do. Dr T
At Thu Aug 14, 12:06:00 AM 2008, Anonymous said…

Dr. Trofatter I am 31.5 weeks pregnant with twin boys and I have really itchy hands and feet only at night. I also have really dark urine. I went to the doctor 3 weeks ago and she did an ultrasound and they ultrasound teck said to my doctor there was alot of sludge. My doctor then was confident it was icp and tested me for it. All my labs came back normal my doc sid the bile acid levels are normal also. I have two little girls and never had this with them. I don't really itch any where else, nothing out of the normal, my belly itches maybe a little once in a while and but it is really is growing. I am so confused - my bile levels where 9 the first time she checked the and then the next time they where 5 and before the first result came back she had already put me on meds. Now I stopped taken the meds and the itching seems to get worse, I ate at burker king yesterday and drank a lot of milk, it is 2:00 am in the morning and I am awake because of the itching, but now that I am up the itching is better but not gone. I have used everything I can think of to relieve the itching like benadyl and nothing helps but to get up and after awhile it gets better. I have treally no problems with itching during the day. I had my doc check me for hep c and that was good. I go to the doctor today at 4 pm. Some advice, I need some sleep. I am on prozac and prenatals.
Thanks alot, Jessica
At Thu Aug 14, 12:32:00 AM 2008, Anonymous said…

Hi there again! I am the one pregnant with the twin boys and wanted to tell you that, I am contracting all the time. I have contractions everytime I move around. When I stand up and stuff like that. Lately I have noticed a huge difference in how strong they have gotten but when I go in I am the same - one cm and my cervix is still long but it is soft, but I do have funneling but my doctor doesn't seemed concerned because I still have a long cervix and it has only thinned out a little. That's what they tell me.I haven't had them measure my cervix for a few weeks they just do an exam. I have been going crazy. I hate driving all the way to the doc it is 45 minute drive and with two little girls and I watch a couple others it is so hard. I go any ways. I tend to try to ignore the contractions but the make very uneasy. I have at least 40+ Bh contractions a day. One day a 3:00 pm I had them every 4-5 minutes apart and it lasted until 8pm and after that they spaced out to every 10 minutes like clock work. By 11 pm they slowed down pretty much completely and I went to bed and the next day I went to the doc and there was no change in my cervix. I have been having BH contractions since 14 weeks but I really started getting them more at around 20 weeks.
I also notice that when I really am itchy my breast seem to leek a little more then normal. I am 31.5 weeks pregnant and have gained 20 lbs so far. At 30 weeks the boys weighed 3lbs 15 oz each. My BP is good and No other problems. I don't know if that info is helpful in anyway... I really hope you get this post!!!
Please I need some advice!
Thanks again, Jessica
At Sat Aug 16, 07:23:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Jessica: Your doctor might try a mild sedative - even something like phenobarbital at night toe help you rest. I wish I could help with the contractions, but some people just contract all the time and feel every single one of them. Your docs could try a drug like procardia to see if that helps decrease the frequency and intensity of them. Srry I can't be of more help...but the pregnancy won't last forever! Dr T
At Wed Sep 17, 01:02:00 AM 2008, Anonymous said…

Dear Dr. Trofatter, I come from Switzerland and had a first ICP pregnancy. I had preterm labour starting at week 26 and didn't tolerate the 2 first oral medications (no effects during hours and then all effects at the same time). My OB finally gave me a shot of another medication by intra-veined (Tractocyl) which stopped my contractions but then I directly started to itch and diagnosed with ICP (at week 32). I had an healthy boy induced at week 37 on January 26th, 2008. I'm now 11 weeks pregnant and no sign of ICP yet. I have a feeling that medication were the trigger for ICP in my case, what do you think? If this is the case, which medication should I ask this time if I have preterm labour again to avoid ICP?? Or am I wrong and preterm labour is the first symptom of ICP (before the itching)??? Many thanks in advance for your help.
At Wed Sep 17, 08:45:00 AM 2008, maria alvarez said…

My name is Maria, I'm from Mexico. I am 22 weeks pregnant and started itching mildly two weeks ago. I called my ObGyn but he doesn't seem to have any experience on this. After a week itching I went to do lab test, the Liver Function test came back normal and the Bile Acid is not ready until saturday (it takes two entire weeks). Sometimes I don't feel itchy at all, and have never itch in my palms or soles, but in the rest of the body, but I have felt some discomfort in my upper right abdomen. I am not sure ICP is my problem, but I don't want to risk it.
Are there any other causes for mild itching in pregnancy that can rule out ICP?
At Thu Sep 18, 01:29:00 PM 2008, Anonymous said…

I was diagnosed at 30 Weeks and 3 Days with ICP based on my bloodwork showing serum bile acids of 40. With the exception of two nights, I have barely itched, maybe once or twice. I am currently taking 600 of Urso a day and go for non-stress tests twice a week and a biophysical once a week. I am pushing my doctor to run another serum bile level test; however, last time it took two weeks to come back. The idea that it should take so long seems ridiculous. Do you have any suggestions? Also, I presently have a cerclage in place and when I am 35wks, 6 days they will be removing it. I would like to have an amnio at this time and then get induced at 36wks if it shows lung ( I had steroids at week 28) maturity or mostly lung maturity. I do know that getting the bloodwork done to check the levels will help, but if I need to wait two weeks for results it seems impossible to get the most current and accurate number. I do not want to risk going into 37 weeks or even 38. Any opinions regarding that?
At Tue Sep 23, 07:18:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 17: We have no experience in the U.S. with Tractocyl except in a few research studies. It is interesting that you itching started after you were given that medication. Your doctors might consider the use of indomethacin and nifedipine if you have preterm labor with your current pregnancy. Fortunately, if you had ICP, it usually does not start until later in pregnancy. I am curious, did the itching continue until you had your last baby at 37 weeks or did it go away after the treatment for your preterm labor was stopped? Best wishes and please let us know how things turn out this time! Dr T
At Tue Sep 23, 07:20:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Maria: Itching is a VERY common complaint during pregnancy. It can come about from simply stretching the skin. Hopefully, you do not have ICP because it can make you absoluetely miserable. You might try reducing the fats in your diet to see if that helps. Good luck and let us know how things turn out. Dr T
At Tue Sep 23, 07:23:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 18: I wouldn't bother repeating the bile acids under those circumstances either! Simply continue the Urso and fetal monitoring and have the amnio for fetal lung maturity at the time they remove the cerclage. That sounds like a great game plan! Good luck and I hope thing turn out well! Dr T
At Sat Oct 25, 03:13:00 PM 2008, Ginger in Az said…

I was so glad to read your article. I have had ICP 4 times and I am now pregnant with my 5th ( we lost one to SIDS) and started itching about 3 weeks ago. This is the first time I've been taken seriously and am being treated with URSO. My question....in your article you mentioned CMV(cytomegalovirus). I am carrying a baby that tested positive through an amnio for this virus. Will this further complicate the ICP or vice versa?
At Sat Nov 01, 04:47:00 PM 2008, Anonymous said…

Hello,
I had a quesstion about Actigall dosage. I had undiagnosed ICP with my first pregnancy, and have just been diagnosed at week 23 of my 2nd pregnancy. I've been taking 600mg per day of actigall for 1 week and it has not seemed to help my iching. Just wanted to know what the common dosage is, and if it is increased, will it affect the baby?
At Thu Nov 06, 07:33:00 PM 2008, Monique said…

Dr. Trofatter,
I would love to be able to visit with you. My water broke with daugter # 1 and I had itcy palms and feet starting a few days prior- not bad just noticable. I was induced at 36 weeks 5 days. No diagnoses of ICP and No problems for me or baby. Baby #2 --I noticed the itching at 37 weeks. I thought hmm I wonder if this is a symptom of labor. Researched and suspected ICP. Labs were elevated and with persistance I was induced. I did not want to lose this baby after 3 years of infertility. Both me and baby did fine. Baby #3 - 4 days after house flooded 7 feet (Katrina) at 35 weeks labs were done and again high liver levels. So high that my dr. couldn't believe how good I felt. (I felt great) Mild itching of hands just started and were my only symptom. In fact, lab levels came back elevated before I had this symptom. When I told them I have had ICP even the liver specialist thought possibly I had fatty liver. My Dr. later said she feared that both baby and I had 50% chance of surviving before delivery. She had only seen liver levels that high in a 70 year old man who had been an alcoholic his entire adult life and his liver was about to shut down. My baby's lungs were not mature and he spent 10 days in NICU. My labs dropped down to normal in just a few days.
Question??? could we have waited longer to deliver even with such high labs?,-- was our risk that great?, does ICP get worse with each progressive pregnancy?, and does maternal age factor in? I just turned 34. Also, how about stress can I blame the hurricane for my levels getting high sooner? I am contemplating baby #4 and leaning towards no, but I want to make an educated choice.
Thank you so much. Your knowledge is such a blessing.
At Wed Nov 12, 09:55:00 AM 2008, Anonymous said…

Dr. Trofatter,
Thank you for answering these posts!!! I need urgent advice on whether it's advisable to request that my c-section be done tomorrow or the next day (Thurs. Nov 13, or Fri Nov 14) instead of Monday the 17th.

I'm week 37 with my first child, 44 yrs old. Just started itching badly in late week 35, with scabs all over now. OB said it was likely a food allergy or new laundry detergent. Had to ask my doc for a blood test last Fri. after learning online about cholestasis. Monday's blood test results were botched (they did not freeze it)and had to be redone yesterday, so I'm still waiting on bile acid levels. But the ALT and AST levels were high enough this last Monday Nov 10th, to prescribe 500mg daily Urso.

I am already scheduled for amniocentesis tomorrow (Nov 13) to check lung maturity for a previously scheduled c-section on Monday Nov 17th (for unrelated reasons...multiple fibroid removals in 2006 - myomectomies(sp?)

Is it wise/advisable to request they move the c-section up to tomorrow or Friday, dependent on the lung maturity results from amnio tomorrow? I won't likely get my own OB, who's on vacation. I'm going to request that they check for meconium in the amnio tomorrow... is there anything else I should have them check for??

Sorry for so much info and urgency. I feel a little helpless, and at 44, losing my first and only child is unthinkable.

Thank you--
Lauren
At Fri Nov 21, 11:38:00 PM 2008, Anonymous said…

Hi Dr. Trofatter,

I am 36.5 weeks pregnant and started having all over itching about a month ago but didn't think much about it until recently when I found out about ICP. I mentioned to my doctor last week and ran the liver enzyme test and bile acid test. According to my doc the liver enzyme test elevated a little bit but normal for pregnant women. still waiting for the bile acid test. I asked my doc if ICP could pose a risk to my baby and he said "not at all" other than the mom is being uncomfortable from the itching. He didn't think ICP is dangerous at all and wouldn't consider induction. How do I convince him that ICP can be very dangerous if not treated? Does the itching in ICP have to be constant and severe? I have all over itching (not on my palms and rarely on my soles) but not constant. It gets worse at night and more of annoyance sometimes kept me awake at night. I didn't scratch myself till I bled. I have this "spasm" where I have strong urge to itch in one area, the next seconds, i feel it in a different area. What should I do considering that I am already 36 weeks and by the time the test comes back i will be over 37 weeks. I am so worried. Thanks
At Sat Nov 22, 02:07:00 AM 2008, Anonymous said…

I am the one at 36.5 week pregnant. I forgot to mention that I have gestational diabetes (no insulin though)and so far have been able to manage my sugar levels well. You mentioned that itching at the late stage of pregnancy is not normal. Why is that?
Thank you.
At Sat Nov 22, 06:32:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Ginger Oct 25: Sorry for the delay in my response, but I just received your comment in my mailbox yesterday. Why did they think your baby had CMV and then do the amniocentesis? Anyway, CMV can affect your liver, but this is usually more of a problem with primary (first time) infections with the virus and so it could potentially worsen your cholestasis problems, but most of the time it does not. I am very curious to see how the pregnancy turns out, so please stay in touch if you get this response after such a long delay! Best wishes. Dr T
At Thu Nov 27, 04:13:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Lauren: I am so sorry, but I JUST got your comment - I will be so glad when they fix blogger. Anyway, if you ever get back to this site, please let us know how things turned out. I hope they went well. Best wishes. Dr T
At Thu Nov 27, 04:20:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Nov 21/22: If your bile acids returned abnormal then you probably have ICP and it certainly CAN be dangerous and very unpredictably so for your baby. There are many specialists who recommend delivery in such cases at 36-37 weeks even without documenting fetal lung maturity because antepartum testing does not necessarily mean the baby will be okay. However, there are also many other causes of intense itching in pregnancy - usually as women get into the third trimester - and even though they may be less serious with regard to fetal risks, it has been found that pregnancies in which itching occurs for any reason appear to be a increased chance for fetal and maternal complications. I hope things turn out fine. Please let us know how you do! Dr T
At Fri Nov 28, 12:03:00 AM 2008, Martina said…

Hi Dr Trofatter,

Martina here just updating you, following my post from April 2008. Following your post, my daughter was tested for CMV and it came back negative. My bile acid levels were tested, with my own GP, and came back elevated. None of my healthcare providers here seem to think that my elevated bile acid results and my daughter's initial problems were related. My daughter still returns to her paediatrician, and will have her next visit in about 6 months, if no problems at that then she will be discharged completely. She is doing fantastically well now, she is clever, alert, responsive, mobile etc. Her tummy is still a bit rounder than I think is normal, but the medical profession seem happy with her. Because we didn't get to the root of the initial problem, I do tend from time to time to worry that there is something, such as a tumor, as yet undiagnosed. Just thought I would give you update, I really really appreciated your advice at the time. Thank you very much.
At Tue Dec 02, 12:09:00 AM 2008, Anonymous said…

Dr. Trofatter - My wife was diagnosed with Cholestasis late in her pregnancy. She delivered through C-section with no complications at 38 weeks but it has now been 10 days since delivery and the symptoms have not subsided. Anti-itch medications, including steroids, have not been effective. Do you know any experts in this condition in the Los Angeles area?

Thanks.
At Tue Dec 02, 05:35:00 PM 2008, Anonymous said…

Hi Dr.T My daughter age 18 how is 28 weeks pregnant and has been diagnosed with ICP this is her fist child and her bile acid level was 98.6. She is very itchy and worried. The ob put her on pills. could the baby have birth defects or is she just going to be itchy
At Tue Dec 02, 10:59:00 PM 2008, Anonymous said…

My itching started about 21 weeks, lead to sleepless nights about 23 weeks, and I had blood tests done at 24 weeks. My LFT and Bile Acids were in the normal range, but my OB said she thought it was ICP. She agreed to start me on Urso (900 mg/day) and said "If this helps, then it is definately ICP". After a week, my itching went away with occasional itching here and there, but over the last couple of days, it's slowly returning. I'm going in for repeat tests this week (28 weeks), so we'll see if the levels have risen. Ok, so my questions are:
1) Is my OB correct that if the Urso worked, it is ICP?
2) Will the Urso dosage lose effectiveness as the pregnancy progresses?

Thanks!
At Tue Dec 09, 09:31:00 AM 2008, Anonymous said…

Dr. Trofatter,

I am have had two previous ICP pregnancies, am currently 35 +5 weeks pregnant with baby #4, experiencing the same issues and my OB is acting like most in refusing to acknowledge that this is a serious concern for me. (she is the same OB who diagnosed me last year when I was pregnant with my son, provided excellant treatment with frequent monitoring and early induction. This pregnancy she just brushes off my complaints as "of course you are itchy, you have the same kind of pregnancy you had last time, see you in two weeks" comments). No SBA testing, no LFT, no NST, no nothing. I am livid that I am recieving non-care from a doctor who is aware of the condition and has experience with the recommended treatments.

My problem is that she IS the high risk OB in a very small, rural community, thus my only real option and this late in the game I feel that I am "stuck" with her. It would take forever to get referred out to a MFM and even then, that would require some travel. Anyways, my real question (yes it took me a while to work into it lol) has to do with "natural" induction methods.

Since it is recommended that we follow a low fat diet, what would be the impact on the liver if I were to take castor oil? Or even Evening Primrose Oil? (I am definately favorable for induction, 3cm, 50% effaced)

Thank you in advance. I can't tell you how reassuring it was to be directed to your blog and to find that there are doctors out there who are aware of this condition, and concerned for the well being of their patients not just physically but the emotional aspect.

Dustie
At Sun Dec 28, 09:51:00 PM 2008, Tara in MN said…

Hello, I am 19 weeks and 5 days and have recently been diagnosed with ICP at about 18 weeks. My itching started around 14 weeks. This is my third pregnancy since 2006 (first baby born 2/20/06, second 8/15/07 and due 5/20/09). My doctor seems fairly laid back so far (I have not met with him since 16 weeks besides a few short phone calls and will not see him until 21 weeks) and I'm wondering what I should expect/push for as far as monitoring goes. I have been prescribed Ursodiol since I went in for lab work at 17 weeks. The dose has just been increased from 500mg to 600mg twice a day due to no relief from itching thus far. Am I at any higher risk due to being diagnosed earlier than average? How often should lab work be done and how closely should the baby be monitored and when should that start? What is the highest dose of Ursodiol I can be prescribed? I'm assuming that because the itching is still so terrible, my levels must still be high but perhaps not. I will have more labs done at my ultrasound appointment this week, to be discussed at my appointment next week with my doctor. Thank you so much for any information you have!
At Wed Jan 07, 02:19:00 PM 2009, Anonymous said…

I'm 35 weeks pregnant, and for the last 3 nights have woken up with severe itching on the soles and sides of my feet (and a bit on my hands), that keeps me awake for an hour or two, then subsides. During the day, I'm kind of itchy all over, but can't tell if it's just normal dry skin itchiness or not (the night thing is NOT normal for me).
My midwife seems to think it's not a big deal if it's only at night and no rash. But if it's still there at my 36 week appointment, they'll do blood work.
Since it only just started, and seems mild compared to some itching I've read, is it OK to wait to do the test to check for ICP?
Thanks.
At Fri Jan 09, 06:13:00 AM 2009, Anonymous said…

Hi Dr. Trofatter. My husband and I are considering a third child but I am concerned about possible ICP which was not diagnosed with my other two. I do not remember unbearable itching with my first but I remember the feeling nagging pain in my liver area which I went to the doctor's for a few months afterwards. LFT showed high protein and alkaline phosphatase, but doc thought that was just due to normal pregnancy. Retested a few months later and numbers were fine. Second pregnancy I developed unbearable itching all over, esp. hands & feet in third trimester but didn't express to ob how bad it was. The same liver pain came back post-delivery with my second as well. It takes several months for it to completely go away. I should mention my mother died of primary liver cancer (she did not drink much or have hepatitis) at age 48 and I now am worried that i may have liver issues, though pregnancy is the only time I have this problem. I'd love a third child but do not want to cause any damage to myself or my baby. Do you have any recommendation?
At Sun Jan 11, 07:51:00 PM 2009, Anonymous said…

Hi Dr. T! This is Carrie with baby Norah from some June and July posts. Norah is now 6 months old. She stopped gaining weight at around 4 months and so they decided to run some blood work at 5 months which showed elevated AST and ALT. She has been retested 3 more times with the same results. And of course she is undergoing a through workup to determine the cause. So far all we really know is it's not cystic fibrosos. Her liver ultrasound was also normal. Plasma and urine amino acids were normal as was fecal fat. Her CK was just slightly elevated but her gi ped. said that wasn't unusual with elevated LFTs. Her bilirubin is normal and she is not at all jaundiced. So...do you know if this can have anything to do with my having OC? She is otherwise happy, healthy, and developmentally normal. My AST and ALT were still elevated 8 weeks postpartum so clearly this thing can have residual effects...I just don't know if they've ever studied the residual effects in babies. Thanks!
Carrie
At Wed Feb 04, 10:56:00 AM 2009, Helen said…

I was diagnosed with choleostasis last week. I am now 30 weeks +4 and have been given URSO tablets to take.

The doctors will take my bloods again in 3 weeks time when I next see them - is that regularly enough? Everything I've read suggests monitoring bloods and baby weekly?

At the moment my ALT is 144 and Bile Acid 23. Is that not really that high? Can't find anywhere that gives 'normal' ranges.

So worried about my baby. Please reply.

Thanks
At Thu Feb 05, 06:44:00 PM 2009, Anonymous said…

Dr. Trofatter,
I was diagnosed today with ICP at 33 weeks; I had developed severe itching on my palms and feet last week. This is my 5th pregnancy (1st and 3rd resulted in healthy kids, 2nd was a late miscarriage due to Turner's Syndrom, 4th was an early miscarriage). I have never had these symptoms before. I was given a dexamethasone shot today and am receiving another tomorrow; I was also prescribed cholestyramine. I have been reading on line that UDCA is the better treatment, can you help me understand this and also know what else to be asking my doctors? I am really concerned about vitamin k deficiency; I am already anemic because I have thalessemia trait, although previously no bleeding disorder. Thanks for the help, Katherine
At Fri Feb 06, 03:53:00 PM 2009, sneak peak said…

Dr. Trofatter, Are you still recommending treatment for ICP/OC as you have written in this article from Jan. 2007? Has anything changed or is there further information? I am currently 35 weeks pregnant with Serum Bile Acids more than double the norm and Liver Funtion Tests more than double the norm. I am on 1200 mg. Actigal (doctor won't prescribe more as needed) with levels still this high. Should I consider being delivering baby at 37-38 weeks gestation as you have suggested? Any further information is very much appreciated. Thank you.
Renee (Oregon)
At Tue Feb 10, 03:38:00 PM 2009, Anonymous said…

I was dignoised at 22 weeks with ICP. I have been given the drug URSO but I am really nervous about taking a drug that seems to have very little research with long term effects. I am most concerned about what this is doing to the babies development? Are there any abnormalities for the baby?
At Thu Feb 19, 01:53:00 PM 2009, Michele Acker said…

Dr. Trofatter,
I would appreciate your input on cholestasis.

I had ICP with my first pregnancy which was undiagnosed despite my complaints of excessive itching for 4 weeks. After bringing in a MEDLINE search my doctor drew liver enzymes and bile acids, send me to the hospital the next day, the perinatologists diagnosed ICP and saw signs of fetal distress so my son was delivered via c-section at 34 weeks. His lungs were not mature but he is fine and wonderful.

7 years later I am in my second pregnancy, 41 years old. It has gone relatively well. I am currently 35 weeks. At 32 weeks some signs of perterm labor (regular contractions and 1 cm dilated) and am on Procardia with NSTs weekly. 33 weeks my hands and feet started itching. 1 bile acid tests came back in normal range since thena nd itching did not progress until last might when it was unbearable and all over. Bile acid from 4 days ago came back in normal range so my doctor is unconcerned. I am concerned because of history and itching. I think the NSTs are not going to predict fetal demise. I don't want another premature baby but I really don't want a dead one. My questions--
Do bile acids change within a 3-4 day window (i.e., could they be normal on Monday and elevated on Thursday)? Could this still be ICP with normal bile acids? Should I insist on referral back to perinatalogists at hospital in your opinion?
Thank you for your advice.
At Fri Feb 20, 03:27:00 AM 2009, Anonymous said…

I am currently 27 weeks pregnant. I have been concerned throughout because I developed severe non stop itching around 4-5 weeks. I have told my midwife repeatedly that I think I may have a serious underlying problem that is not just a common pregnancy rash. Hepatic problems are highly prevelant in my family. My dad has liver disease. I also have problems with my gallbladder. What should I do? Should I look into internal medicine or a gastroentrologist? (Spelling)
At Fri Feb 20, 11:40:00 AM 2009, anxious-mom said…

Hi Dr. Trofatter,

I am 32.5 weeks and began itching 4 days ago. I do not have itching on my palms or feet; rather the itching started along my arms and seems to have spread down my sides on the front and back (none down the middle of the trunk). I had blood drawn today and have not yet been diagnosed with ICP. I have none of the other symptoms associated with ICP. Even the doc. who ordered the blood work didn't know about ICP or that I needed an SBA to confirm/rule out ICP. Would you be able to tell me the likelihood of my actually having ICP without lab work results? I understand the SBA test results take a while to come back; besides following a healthy diet (which I have done anyway, even before the pregnancy), what else could I do in the meantime? What could my doctor/midwife do while we all wait? I don't want to worry needlessly, but I want to know if I should be worried.
At Thu Feb 26, 06:33:00 PM 2009, Jennifer said…

Hi Dr. Trofatter, I just lost my baby girl 3 weeks ago as result of ICP. I developed the unbearable itch at 38 weeks and my blood work confirmed I had developed ICP. I went into the hospital to be induced 3 days later and gave birth to what we all thought was healthy baby girl. While I was holding my baby she began to spit up blood and mucus. At that point they took her to the NICU to be examined. There were no signs of an infection so there were no concerns. She did require oxygen and NCPAP because she had trouble breathing. The very next day she began hemorrhage and began to expire. It all happened so fast and there were no test results that indicated the cause. All they said was that she was a very sick baby but we don't know why. Doctors need to take ICP more seriously and there should be some way to treat or prevent this tragedy from happening. They say this is so rare but it's truly not. My heart is broken and I have so many questions that I want answered. I would like to have another baby in the future but I don't want to go through the loss of another child. What should be done to prevent this from happening again? Should I not have any more children? I am going to see a specialist in a few weeks to get my liver checked out. Thank you and I hope more can be done so that other expecting moms don't have to live the pain that I am living.
Jennifer
At Wed Mar 25, 11:58:00 PM 2009, Nick and Lexie said…

I am 32 weeks pregnant with my first baby. I have had severe itching for almost three weeks now, all over my body, but worse on my hands and feet, and worse at night. My doctor agreed with me in thinking that it could be cholestasis. I have done labs twice. The first time, my liver enzymes were elevated but my SBA test was at 7, within the normal range. The second time, a week later, my liver enzymes had raised quite a bit (from approx. 50 to 90 and 90 to150). My OB seemed concerned, but said she could not make the official diagnosis of cholestasis. My SBA came back, just as 8, so I am really confused. She also tested me for Hepatitis, just in case, but there was nothing there. We are doing monitoring for the baby twice a week just in case, but I am just frustrated because I don't know what the diagnosis is. I also am exhausted and the itching seems to get worse. She prescribed me hydroxizine for the itching and sleeping, but it doesn't really seem to help. And she won't prescribe the USD until I have an official diagnosis. She has referred me to a specialist because I think she is confused as well. Any helpful advice or information would be great. I just want to make sure I am doing everything right so that there are no risks for my baby.
At Sat Apr 04, 12:51:00 PM 2009, Anonymous said…

Hi Dr Trofatter,
I see the last post was November and wonder if you are still answering questions, but I have nothing to lose to try right?
I am currently 24 weeks pregnant with triplets and developed severe itching several weeks ago, on a hunch my maternal fetal specialist tested me for cholestasis. The Liver came back fine but not the bile, Thus I have it and it is very early. I am very scared about it, since I did get it so early. I am wondering if results are worse for women who get it so early? I have very bad digestion as it is so really eat almost no sugar at all, I think my diet is pretty good, but have no appetite, I am hoping the medication will change that. I have also been having discolored stools, I had them 2xs, then it went back to normal, now after starting the medication it is back (light yellowish)...is this a worrying symptom? Any input would be so much appreciated.
Best, Alex
At Wed Apr 15, 03:42:00 AM 2009, Anonymous said…

Hi Dr. T,
I was diagnosed with OC yesterday by my OBGYN. I am 27 weeks pregnant, and after many blood tests, they have determined that this is what I have. My OB didn't seem concerned in the least at this point. At the moment I don't have any of the symptoms like itching or yellowing of the skin, (the blood test results is what she is going by), and she has said that she wants to see me in 3 weeks from now. She wants to check my liver enzymes once a month, and that if I develop itching than she can prescribe medication. I am a little alarmed as to her attitude towards this. I have read numerous things stating that the baby is in serious danger, and that induction is necessary between 35-37 weeks. Should I be looking for another doctor?? I live in Canada, and I don't know if it's possible for me to request an elective induction at 37 weeks? Please help I am very concerned. Thank you!
At Sat May 02, 11:29:00 AM 2009, jess said…

Dr. Trotter, I don't know if you're still monitoring this blog, but I hope that you are.

I wanted to know your thoughts on women presenting with what would seem to be classic, clinical ICP but not showing abnormal labs.

My feet first began to itch about 4 weeks ago, but it was mild and intermittent, occuring mostly as I would prepare for bed. I laughed it off as a fluke. It progressed to the legs, and in the last two weeks has become absolutely unbearable, keeping me up (or waking me up if I've taken hydroxyzine to get some sleep) all night. I have excoriations covering every inch of my legs (where the pruritis is worst) and nothing has worked thus far (hydroxyzine, methylprednisolone dose pack, benadryl, wide variety of OTC topicals).

Also in the last two weeks, I have displayed intermittent light-colored bowel movements and consistent dark-colored urine (despite rule-out of dehydration via IV fluids).

These things would suggest ICP/OC, but on having AST/ALT/SBA/Bili checked, they all came back within normal range.

I am now 29.5 weeks. In the last few days, I noted increased contractions, though they seemed disorganized and weak--until last night. So I charted. First they were 10 - 12 minutes apart, then 8-10, that's when I paged my doctor (after about 2 hours of contractions). When the doctor ordered Terbutaline, my contractions were 4 - 5 minutes apart. Luckily my cervix knew better than my uterus and remained closed, so I was sent home once the contractions had broken up.

But with this newest development as yet another indicator of a problem, and one that would agree with an ICP diagnosis, do you think it wise to continue to proceed with a suspicion for ICP or do the normal labs automatically rule it out?

And if it does warrant futher suspicion of and testing for ICP, would there be any reason to not begin UDCA (if nothing more than as a shot in the dark attempt to alleviate the incessant itching)?

I've just strongly suspected ICP since it's the ONLY fit I can find for my symptoms, and was honestly dismayed when my lab results came back normal. At least if it's ICP, it's known, it can be managed. But without the labs, there is no diagnosis--and with no diagnosis, there is no hope of or path to relief/management!

I'm so frustrated. I just feel like with the contractions last night, I can't afford to ignore it if it is ICP... What would you recommend?

Thank you so much.

- Jessica
At Sun May 03, 02:14:00 PM 2009, Anonymous said…

Hi. My son is 7 years old. I had ICP when I was pregnant with him. It was a severe case. He was born with two fingers joined together and had to have surgery to separate them. We just found out that he has enamel displacia on his teeth. Could these two things be a result of me having ICP when I was pregnant with him?
At Thu May 28, 03:00:00 PM 2009, Anne W. said…

Hello, Thank you for your help with this area. A little history first: Pregnancy #3-- I started breaking out in severe hives everywhere but hands and feet. My OB said at first Mast Cell Dz but later changed to PUPPPS. He never drew blood to check ICP b/c of the itching not affecting hands, etc. But did state it was the worst case he had ever seen. I went to Dermatologist who was concerned about it not being PUPPPs b/c it was such an atypical presentation (timing, rash less severe on abdomen) He placed me on Prednisone after two trials of Dose Packs didn't resolve the rash. I was on those from 20 weeks to 4 weeks postpartum, at times up to 60mg! I did deliver a healthy baby boy at 40 weeks (April 1, 2008)spontaneously.
Now I am on pregnancy #4. At 8 weeks gestation I broke out in severe hives again (this time literally head to toe). On Easter Sunday my husband took me to the ER because my face and mouth began to swell from the hives. ER MD tested Liver Panel (normal) but not bile salts. Also gave prednisone dose and benadryl injection. (I had already been taking leftover Hydroxyzine tabs, benadryl, zyrtec and OTC H2 blockers with little to no effect on the hives.)
The next day I had an appointment with a new OBGYN that immediately began Ursodiol treatment after seeing the rash and hearing my history. Within two weeks of starting the Urso, my hives were completely gone. I still have some breakthrough itching but continue to take the Urso and Zyrtec.
My question is, do some people have hives with elevated serum bile acids? I was suspicious because my older sister had a gallbladder attack recently and broke out in severe hives along with it.
Thank you again for your time.
At Tue Jun 30, 03:28:00 AM 2009, sarah said…

hi i am 26 weeks pregnant. i have had itching on the soles of my hands and on the palms of my feet since week 18 of pregnancy. when i get hot or eat salty or greasy food (i.e a cheese and onion pasty) it gets worse. my hands have a thin red line on each palm where i have been scratching and i have given myself a few blisters there, as well.

i had a blood test done at around 18 weeks when the itching first started and my level of bile acids came back at 11.

since then my midwife doesn't think that there is any need to do anything else.

im really scared and i am really hating this pregnancy.
At Thu Jul 02, 07:00:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Sarah June 30: Oh Sarah, don't hate the pregnancy. This is probably NOT cholestasis of pregnancy, especially if you did not have the problem with another pregnancy, but it may well be some other dermatologic condition that can be helped. Why don't you find a local Dermatologist who will take a look at you and make some recommendations. Let us know what you find out and best wishes...
Dr T
At Wed Jul 15, 09:21:00 PM 2009, Anonymous said…

Dear Dr. Trofatter,

I believe that I had an undiagnosed case of OC 9 months ago. At around 30 weeks I developed severe itching to my palms, soles of my feet and all over my body including my chest/back. This episode only occurred at night. They were so bad that I had difficulty sleeping. I would ask my husband to scratch me as well using a comb or a brush every night. I cannot remember having any dark urine or pale stools, but I was not thinking the worst then. I became concerned about the condition and mentioned it in passing to my OB who chalked it up to skin dryness and sensitivity normal in pregnancy. I had an u/s done on Sept. 17, which showed good movement and heartbeat of our baby and then on Sept. 21, I felt no movement and no heartbeat found on u/s. Our baby looked normal. Autopsy report showed no reason for baby's death. I have mentioned the fact that I itched weeks prior to the stillbirth to my OB, family doctor and a high-risk OB, and I am frustrated by the fact that they seem to be brushing off my concerns.

I am currently 21 weeks pregnant and am being followed up at a high-risk facility. I have no pruritus so far; however, I had baseline LFTs that were mildly elevated but were shown to be going down during a second test. I am being checked for placental insufficiency, but my 16-week test showed no abnormalities and my 20-week u/s showed a normal growing baby.

I am very frustrated that my current high-risk OB would not deal with my concerns appropriately should they arise in the latter part of my pregnancy. I asked him what his thoughts are on OC, and I felt that he does not put much stock on it being dangerous for the baby. I do not like feeling like it is all in my head but I do believe that I did develop OC which cost the life of our baby.

I just want to post this message to get some validation and to caution all other pregnant women out there re: the dangers of this condition and that we have to be actively involved in the medical care we are receiving. Thank you so much for listening.

J
At Fri Jul 24, 08:08:00 AM 2009, Lina Vergara said…

Hi Dr. T, My name is Lina. I am 20 weeks into my first pregnancy. I am currently awaiting the results of my Liver function test. As of a week ago I have been experiencing rashless itching all over my body, including my palms and soles of feet. The itching gets much worse at night. Also I don't know if this is related but I have a sore mouth and tongue. (At night this also gets wore as my tongue seems to itch!) After doing some research and learning about ICP I made an appointment to see my OB right away. Even though I mentioned both the Bile Acid Test and the Liver Function test, my OB only ordered the LFT. I know that it is very early in my pregnancy to have ICP, but I am still very worried and confused as to what is causing my symptoms and the negative affects to my Baby. I wanted to ask your opinion as to what other tests I should do and what other diseases this could be? Also I am hispanic (Colombian), and do not know of anyone having ICP in my family. Any info and advice you have would be SO appreciated. - Thank You.
At Fri Jul 31, 10:44:00 PM 2009, fargol said…

Hi Dr. Trofatter,
at about 34 wks i had severe itching and went to the dr. to be diagnosed with ICP. I was recommended to do an amnio at 36 wks to make sure lungs were matured then induced but i am so worried about what could be happening to my baby in the meanwhile. It seems the drugs may have decreased the itching a little. ALso what are the risks of doing an amnio that late in preg?
Thank you,
FR.
At Sun Aug 09, 09:36:00 PM 2009, Anonymous said…

Hi Dr. T. These posts are great. I have been trying to do my own research on ICP for a while now. 18 months ago I delivered my daughter at 33 weeks. I was diagnosed with ICP at 29 weeks and hospitalized and placed on an antepartum ward to be closely monitored. I was diagnosed with autoimmune hepatitis when I was 11 years old, but have had the it under control for most of my life. I also have high cholesterol. I am wondering if having autoimmune hepatitis and cholesterol intensified the ICP in my case and if it should have been anticipated. Perhaps it just added to the complexity of my "case". I am also wondering if I should discontinue using estrogen based BCPs. I do not feel an ICP symptoms while on them, but wonder if it silently harming my liver.
I was induced earlier than many other mothers with ICP, and my IUGR baby was 3 pounds 6oz, She is now a happy, healthy 18 month old. We feel so blessed to have her. A diagnosis of ICP can be a fearful thing, but have faith!
At Tue Aug 11, 11:41:00 PM 2009, shylebgal said…

hi doctor im 16,5 weeks pregnant with my 4th..with my first she was born 40w2d and i had no problems with her...i fell pregnant straight after she was born but also developed gallstones..wen i was 35 weeks pregnant with my 2nd i was told i had ICP but the doctor did not prescribe any meds even though i had severe itching in which i tore my skin off and my daughter was born on her due date..i did mention to the doc about stillbirth but he said theres no such evidence that wil happen but thankfully my daughter was born healthy..i then had a m/c a few months later at 5 weeks and now im 16.5 weeks pregnant with my 4th and im scared its happening all again,,im goin in for blood tests in the next few days but was wondering is there any medications i can take to help if i do have ICP that dont put the baby at any risk and reduce the rate of having a stillborn..ive read a lot of sites saying not to go past the 37week but wat if the doctor doesnt agree wat can i do then..thanks..Mary
At Wed Aug 12, 12:29:00 PM 2009, Diane73 said…

I was thrilled to see your article this afternoon. I am a 35 year old, healthy mother of two and 34 weeks pregnant with my third child. When I was pregnant with my first child, when the itching started my mother was the only one who understood. She said she had the same condition during her first pregnancy, but after having her gallbladder removed due to stones, she never experienced the symptoms in her next 3 pregnancies. In each of my three pregnancies I've developed the same symptoms during my third trimester. Now I know what to look out for. Yesterday I noticed my urine was unusually dark during the middle of the day, despite being well hydrated, then the dreadful itching began during the night. It only itches on the soles of my feet, and the palms of my hands. Dipping them in cool water helps. The problem is, I have a doctor that doesn't seem to think it's important, because I've had two perfect previous pregnancies, and a great pregnancy so far. How do I stress to the doctor how serious this can be to the baby? I delivered my first at 37 weeks (by the way, she had meconium in her fluid), and my second at 39 weeks. I've been told I have precipitous labor. I dilated from 0to 10 in 45 minutes with my first, and about 15 minutes with my second! It made for a very dramatic birth experience for both myself and my nurses! Please tell me if I should be concerned and any advice you may have. Thank you.
At Thu Aug 13, 03:28:00 PM 2009, shylebgal said…

hi diane 73, im no doctor but from everything ive read and it has mainly been research so they are more factual then just a website, this condistion ICP can be very dangerous if left untreated...a lot of babies have died due to the mother being undiagnosed and not receiving proper treatment,,with treatment the rate of stillbirth is the same as the normal rate if u didnt have the condition, so geting blood tests to measure ur levels are very very important and getin started on treatment is as important..my doctor is kinda clueless or thinks this condition is not serious..im so thankful all went well with my daughter who was born 40 weeks..because this is a serious conditon i would b concerened and i would nag and nag and nag and nag until the nurses or ur doctor or the OB do something..if u have severe itchiness and ur urine is darker they are symptoms, the medication causes no harm to the baby and sometimes a rise in levels coould take many weeks to show up, so u could have the condition but all tests are coming bak negative and that is very common...i know one lady who had severe i mean severe itchiness at 20 weeks , her results were all negative until she reached 30 weeks and they were very high at that time and the doc straight away put her on the medication, but reasearch has shown if tests are negative and u stil have really bad itchiness and/or other symptpms ur doc or OB needs to put u on meds straight away to decrease any chances of fetal distress and other complications..my email is marymoufferrige@hotmail.com
feel free to email me and i wil send u the links i have of current research but please dont delay geting blood test and asking for medication.all the best

mary
At Mon Aug 17, 05:24:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To J July 15: Keep pushing your concerns with your doctors. For goodness sakes, I would hope they would also be concerned. OC can be a dangerous condition for the baby, but it's greatest risk is its UNPREDICTABILITY. Most women will still do well, but even with regular antepartum testing one can have the unexpected loss of a baby who otherwise is normal in all respects. That is why many leaders in Maternal-fetal Medicine now delivery women with true OC at 36-37 weeks. And, because you have unfortunately lost one baby already, you are at even greater risk. I wish you the best of luck with both your pregnancy and your doctors.
Dr T
At Mon Aug 17, 05:30:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Lina July 24: It is a little early in pregnancy, but I have seen cases this early, particularly in Hispanic women. Your doctors should really check yyour fasting bile acids. That is the best way to establish the diagnosis. This might not be OC, but any persistent itching during pregnancy appears to be associated with greater risk for adverse pregnancy outcome. By the way, you might consider changing or stopping your prenatal vitamins because sometimes this might help. good luck and let us know how things turn out.
Dr T
At Mon Aug 17, 05:37:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To FR July 31: The risk of an amnio at 36 weeks is very low and if there are any significant complications, they can just go ahead and get you delivered. Odds are the baby would do just fine. In true OC, many MFM providers are proceeding with delivery at 36-37 weeks without even bothering to document fetal lung maturity. If the diagnosis is in question, however, it is better to do so. Good luck and tell us what happens!
Dr T
At Mon Aug 17, 05:41:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 9: Thank you for sharing your story. If you are tolerating your OCPs, I would suggest continuing them rather than risk another pregnancy until you are REALLY ready to face that. You might just ask your doctors to recheck your LFTs now that you have been on the pills for awhile. Your underlying autoimmune condition could certainly exacerbate OC and may lead to other problems that could complicated your pregnancies such as IUGR and preeclampsia. Thanks for writing and best wishes.
Dr T
At Mon Aug 17, 05:47:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Mary: If you truly have ICP, then ursodeoxycholic acid may help lower your bile acids, improve your symptoms, and decrease your risk for still birth. It does not mean you will be completely 'safe' and delivery is still appropriate at 36-37 weeks. You can always ask your doctor for a 'second opinion' with a specialist in Maternal-Fetal Medicine. Best wishes.
Dr T
At Mon Aug 17, 05:50:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Diane73 Aug 12: See my response to J immediately underneath your comment. OC can be dangerous and it is unpredictable. You can always request a consultation with a specialist in Maternal-Fetal Medicine if your doctor doesn't agree. Good luck!
Dr T
At Tue Aug 18, 06:09:00 PM 2009, Bill and Melissa said…

Dear Dr.,
thank you so much for taking the time to address this issue. I am 34 weeks and have raised bile levels. My history - infertility treatments for 8 years, 2 early miscarriages. I have been itching and just not feeling right at night since about 20 weeks. Last week the itching started and has not stopped resulting in the diagnosis. My Dr. put me on cholestyramine three days ago. the itching is getting much worse and I am terrified that my baby is in great danger. I feel as if I am begging my Dr. for information. I do love him when we have no problems, but I am really scared. He wants to check me once a week and will deliver at 38 weeks. Yours thoughts? Should I ask to see a specialist?
At Sat Aug 22, 01:28:00 AM 2009, Marj said…

I was diagnosed with ICP and gave birth very shortly after that (at almost 37 weeks) to my twin boys. They are very healthy now, 3 weeks old. However, I am still itchy. They have given me prendisone, but taken me off the actigal because I am nursing. I still have rough itching episodes though. Do you have any reccomendations? I have heard herbal supplements like Milk Thistle or Dandelion root can help?
Also, is it normal for my bile acid levels to be higher now than when I was pregnant? My levels were only ever slightly elevated, but they are not going down, they are going up.
At Sat Aug 22, 02:26:00 AM 2009, carriebc said…

Hi Dr. T!

I delivered a healthy baby (ICP pregnancy) in July of '08, (I posted a couple of times on here, not sure on which post though). My baby was dx with elevated liver enzymes at 5 months after they decided to do some precautionary blood work because of her weight being on the low end, though they wrote in the chart that they suspected it was just a genetic predisposition to being small (I'm 5'1" and around 100lbs, and was petite as a baby too). Do you think that her liver problems could be attributable to my pregnancy with OC? The ped GI has determined it was some sort of neonatal hepatitis which is kinda an umbrella term and basically means liver disease of unknown origin because all test results were normal, inc. CMV, CF, etc. She (baby) had a full workup including genetic testing and nothing came back abnormal besides some organic acids (but ped. genticist said this was likely due to liver dysfunction). All seems to be well now; her LFTs are back to normal. I"m just curious about this because it's not like all babies get a CMP done in their infancy and perhaps ICP babies may have liver dysfunction that goes undetected because they are mild. My baby was always very healthy looking and acting with no jaundice or liver enlargement; you would have never guessed that her liver enzymes were elevated.

~Carrie in Atlanta
At Sun Aug 23, 03:03:00 AM 2009, Diane73 said…

Thank you, Dr. Trofatter. I did take your advice and called a Maternal-Fetal Specialist, on Friday. I asked to speak to him on the phone and told him exactly what was happening. He saw me the very same morning and diagnosed me with Cholestasis of Pregnancy. Finally someone listened! I am scheduled to be induced Tuesday, pending the results of my amnio tomorrow. If the baby's lungs are not ready, then his recommendation is that I be induced no later than the following Monday, at 37 weeks.

Again, thank you so much for your suggestion, I didn't even realize there was a specialist in this field. My advice to others, is to seek a second opinion if you truly believe you need to.
At Mon Aug 31, 03:56:00 PM 2009, A. Cheng said…

Hello Dr. Trofatter.

I am 29 weeks pregnant with my first child and have developed all-over itching in the past few days.

The palms of my hands and soles of my feet are about the only places I DON'T
itch.

The itching is not deep/intense - if I scratch the spot it doesn't itch anymore
but it will move somewhere else. So it's not severe, it's just widespread.

I do not have a rash.

Does ICP usually start out mild like this and then get worse? I started taking
an antihistimine to see if that would relieve my itching so I figured I would
give that a few days and see if I still itch.

Since this is my first pregnancy I am very concerned and scared that I might
have ICP. At 26 weeks I went to the ER complaining of upper left quadrant pain
which was later determined to be cartilage inflammation from my ribs stretching
as my uterus grew. But during the course of trying to diagnose me they did blood
panel tests which included liver panels, etc and I got a CT scan with contrast.
My liver enzymes at that time were normal but they found a 1 cm mass on my liver
which the radiologist said he believed was benign. They recommended a follow-up
ultrasound to confirm the benign diagnosis. The ultrasound techs were unable to
photograph the mass clearly enough to have the radiologist give me a definite
diagnosis but he did say he thought it was a cyst. They have recommended a CT
liver scan after I deliver to confirm. My regular doctor assured me if they were
concerned about malignancy or something bad they would have recommended an
immediate test. Before the ultrasound my OB told me he believed the mass was probably a hepatic angioma, which some women get during pregnancy (esp. pregnant with girls) or while taking oral contraceptives due to the increased hormones. This eased my fears but now that I have discovered ICP has to do
with the liver I am worried they might be connected.

I have already called my OB and spoken to a nurse but she gave me the standard "Take Benadryl, if that doesn't help go to a dermatologist" runaround so I don't think they know of ICP.

What do you think?
At Tue Sep 01, 05:24:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Bill and Melissa: The possibility of ICP should never be taken lightly. At the least you should have fasting bile acids and liver function tests done, assessment of the fetal growth, and well-being. There are other causes for itching, but ICP should be ruled out. Interestingly, itching in general is associated with a greater risk for pregnancy complications but usually not the serious and less predictable complications seen with ICP. There are many specialist providers who recommend delivery with ICP at 36-37 weeks due to the unpredictability and lack of efficacy of usual "fetal testing" in the presence of ICP. Best wishes and let us know how things turn out.
Dr T
At Tue Sep 01, 05:27:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Marj: You probably have something else instead of true ICP. I would be concerned that you might have infectious or autoimmune hepatitis or perhaps a gallbladder or pancreatic condition that is causing your cholestasis and persistent itching now that you have delivered. Please see a doctor about this. Best wishes and please let us know what they find out.
Dr T
At Tue Sep 01, 05:29:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Carrie: I don't know, but perhaps she too will have ICP when she gets pregnant!!! Tell her to let me know if she does. Best wishes and I am glad everything turned out okay in the end! Regards,
Dr T
At Tue Sep 01, 05:32:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Diane73: Yep there are specialists and you are correct, many women do not even know we exist. That is one of the primary reasons I keep writing. Hope things turned out okay and thanks for letting us know what happened!
Dr T
At Tue Sep 01, 05:35:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To A Cheng Aug 31: In true ICP, antihistamines are usually not much help. You need to take something to reduce the level of bile acids and although there is no ideal drug for that, ursodeoxycholic acid does help many women and may reduce the risks for the unpredictable pregnancy complications related to ICP - specifically, unexpected fetal death. Many specialist providers now routinely recommend delivery with ICP at 36-37 weeks. I wish you the best and please let us know how things turn out.
Dr T
At Thu Sep 03, 09:56:00 PM 2009, Anonymous said…

In 1987, I was diagnosed with severe intrahepatic cholestasis of pregnancy in my 7th month of my first and only pregnancy. The worst itching was on my ankles and wrists, but it spread to almost everywhere. Soaking in cold water helped. Back then, I was given cholestyremine (which didn't help) and phenobarbitol, which helped a lot. I was told that phenobarbitol "sped up" my liver and wouldn't harm the baby (and might help me sleep). Since then, I haven't read about this treatment being used. BTW, I had a healthy baby by C-section at 38 weeks, followed by a tubal ligation and since have had no problems. I am of Scandinavian heritage and wonder if this increases the chance that my daughter will inherit this condition.
At Fri Sep 04, 12:59:00 PM 2009, Diane73 said…

Great news! I delivered a healthy, beautiful 7 lb 9oz baby boy this week, at 37 weeks. It's been two days since delivery and I'm still slightly itchy, but bearable. We are incredibly happy and feel very grateful for the careful attention I received in the last two weeks of my pregnancy.
At Tue Sep 08, 09:13:00 AM 2009, Anonymous said…

Hello, I was admitted into the hospital 3 weeks ago. I am 31 weeks. I had a slight fever and my liver function test were elevated. My urine protein was 1300.They gave me antibiotics for several days and the fever was gone. My blood pressure was high for only 1 night or so. I tested positive for CMV in my blood. They did a avitity test and said it showed a very low avitity. After a few weeks they checked the bile and it was high. They started giving me urso 300MG twice a day. In 5 days my liver enzymes are all normal and my urine protein dropped to 540. I have had very little itching and my blood pressure has been perfect for weeks. 120/60 most of the time. They are still confused and are hanging on preclamsia since the protein is still a little high. What do you think?
Jennifer/Atlanta
At Thu Sep 17, 10:32:00 AM 2009, Anonymous said…

Hello Dr. T,
My name is Beci, I'm glad to see there are specialists in this area. I am currently on my fourth pregnancy. severe OC diagnosed with #1 @22 weeks. Water broke @ 32 wks and I didn't realize it. Ended up with infection, fever, preeclampsia, and later hemmorhaged severly. 1st son was okay, delivered @ 34 wks very jaundiced first week in NICU, breathing issues and weight gain slow. 2nd two boys no itching w/ until 35 wks & tests showed only moderate lft elevation. Water broke at 38 wks with #2, & 4 days past due date with #3. The delivery went well except for VERY blue babies when born, as well as a couple times immeadiatly after birth they just didn't take a breath on their own, turned very blue all over and the nurses wisked them away temporarily. They were fine after we left the hospital. Now @ almost 8 weeks on this 4th pregnancy started itching, not as bad as the 1st time, but much worse than with 2nd and 3rd. My Ob said my first liver test came back normal, 9. We are waiting on test two to come back. I'm still itching, a little more now- distrubs my sleep much more now. My grandmother, aunt, and mother had multiple unexplained miscarriages and stillbirths (delivered at or close to birth but baby was not living or died soon after birth). I haven't been able to find out any more info on them than that. I don't know my parents much and my Grandmother passed away before I was married. When I was young I remember my mother talking about her losses, but that is all I know. I am concerned because of how early the itching has started and my first experience with delivery.
I'm at 13 weeks and have watched my diet closely since week 7. Do you have any thoughts or recommendations on this 4th pregnancy? I've had wonderful OB's, but they didn't know very much about OC, as they told me they didn't know much about it.
Thank you! Beci
At Sun Sep 20, 12:47:00 PM 2009, Anonymous said…

Hi Dr Trofatter-
My daughter was just induced 2/2 ICP and delivered a healthy 37 1/2 wk child. Now,4 days postpartum, she complains of RUQ pain. FOur years ago she delivered her first child ( healthy) but developed cholecystitis 2 months postpartum. Is there a concern for this new pain? Could it be a problem with the CBD,etc? Should this be investigated further? Her LFTs were improving when labs were drawn on day 2 post delivery. Thanks for your help
At Sun Sep 20, 02:14:00 PM 2009, Anonymous said…

Hi Dr T- a friend with ICP just delivered/induced at 37 weeks and was discharged on day 2. As soon as the labs were back she went to the hospital and after overnight monitoring without event, was induced the next day. Of course she was seen by the pediatrician a couple of times during her stay and both mom and baby were ready for discharge on day 2 as with a normal pregnancy. The literature notes concern for preterm delivery, fetal death etc but is there concern for any other short term or long term consequences to the baby's health? Thanks for your help-
At Tue Sep 22, 01:39:00 PM 2009, Anonymous said…

Dr. T - I noticed that you are still checking this blog as recently as September, I'm hoping you come back again!

I just have a question regarding Bile Acids and the lab tests that are run. When I had my daughter 5 years ago (diagnosed ICP) the range the lab used was 0-8 and the doctor diagnosed anything over 8. My first results came in at 15 umol/L

With my current pregnancy (I'm 31 weeks). The lab has now changed the range to 4-5 to 24.6. I am seeing a new OB and she says they will not diagnose until I hit the upper limits of 25. The lab is still measuring in umol/L.

My question is this....at what point do YOU diagnose? After a ton of research, it seems most doctors say 10 umol/L is an ICP dianosis, and become more dangerous as they reach upwards of 40.

Can you confirm?

~Laurie
At Mon Sep 28, 08:30:00 PM 2009, concerned mom/gramma said…

Dr.T, Please advise...28y.o. daughter @35 wks, hypoglycemic pre-preg, now w/gestational diabetes, on glyburide, most recently (few weeks now) c/o itchy hands and feet. OB states probable sensitivity to sulfa in glyburide (was pre-existing sensitivity)will change to metformin. Also c/o recent onset of nose bleeds and increased bleed time in minor scrapes or cuts, extreme fatigue and onset of increased swelling in extremities, currently twice weekly fetal stress tests and biweekly obgyn visits w/ultrasound... blood drawn recently (no bleeding issue)for "testing" unsure of what testing to be done (military based ob care, generally no explanation of testing until results are in. Symptoms seem to be coming quickly, your take on this very much appreciated...
At Tue Sep 29, 03:58:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sep 3: I have not heard of anyone trying phenobarbital for ICP but the logic for its use may be sound! If you have the genetic form of ICP, your daughter could inherit the genes that lead to it as well. This is certainly seen in areas where ICP affects a high percentage of pregnant women - it is not just diet and environment that contributes to its expression! Thanks for writing and the insight!
Dr T
At Tue Sep 29, 03:59:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Diane73: Congratulations and have a lot of fun with your baby!
Dr T
At Tue Sep 29, 04:06:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Jennifer Sep 8: This is not behaving like a typical case of preeclampsia. I am more concerned that you may well have had a primary CMV infection during the pregnancy that has affected your liver and kidneys and probably the placental function as well. I have seen other primary virus infections present as "preeclampsia" and then the preeclampsia improves as immunity is established to the virus and the infection subsides. Within 48-72 hours after delivery, it will be important to screen your baby's urine for CMV and if a congenital infection is documented, the baby should have regular hearing and vision checks and be evaluated for any evidence of developmental delay. I wish you the best and would very much appreciate it if you would let me know how things turn out!
Dr T
At Tue Sep 29, 04:32:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Beci Sep 17: It is very unlikely that the itching this early in pregnancy is ICP. In fact your history of itching during pregnancy is not very typical for the true genetic condition, although you might have other reasons for it. You might just try an antihistamine now to see if that helps and empirically try ursodeoxycholic acid if the antihistamine doesn't! Good luck to you and thanks for writing.
Dr T
At Tue Sep 29, 04:36:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sep 20: Her LFTs were normal 2 days after delivery but what were they 4 days after delivery when she developed symptoms? Did they take out her gall bladder when she had the cholecystitis?
Dr T
At Tue Sep 29, 04:42:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sep 20 0214: I am not aware of any long-term complications unless there is a heritable underlying metabolic disorder that could cause complications for the baby eg., an abnormality of fatty acid metabolism. The primary deleterious affect of maternal ICP on the baby during pregnancy is not entirely clear but the bile acids may lead to placental dysfunction.
Dr T
At Tue Sep 29, 04:45:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

Laurie: Your last paragraph sums up the range of values I was taught to be concerned about. A value of at least 10 is required to establish the diagnosis and the level of concern rises with the level of the bile acids. More than 40 is considered to be very high risk. Thanks for writing!
Dr T
At Wed Sep 30, 11:18:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To concerned mom/gramma: This could be simply late pregnancy common 'complications' or something more serious such as ICP or preeclampsia. Is this her first pregnancy; if it isn't did she have any of these problems with a previous pregnancy? Is the baby growing normally or is it big or small? Is her blood pressure normal? Are her liver function tests, platelets, and fasting bile acids normal? Have the doctors done a 24 hour urine for protein and creatinine clearance? Let me know and I will tell you what I think! Best wishes to you and your daughter!
Dr T
At Thu Oct 01, 09:10:00 AM 2009, Anonymous said…

Dr.T, This is Beci from previous post. I have tried antihistamines and they do nothing. I have had cholestasis confirmed w/ other pregnancies. The first one being the worst. The itch I've had with this is not like allergies and it doesn't go away. It is much worse at night and nausea increases with the increase in the intensity of itching. I itch close to menstrual cycles every month when not pregnant. What else could it be if not cholestasis? I still itch, mostly hands and feet, but all over as well- now at 15 1/2 weeks.
At Thu Oct 01, 09:28:00 PM 2009, Christina said…

I wasnt sure if you were still reading comments on this post so I posted on another thread. Your responses here have been GREAT. I am currently on my 7th pregnancy and it is my 5th ICP pregnancy. My 2nd pregnancy was when I started itching but was told I had PUPPS and went the full 40 weeks. 3rd pregnancy no ICP. 4th pregnancy I was diagnosed with ICP and went into labor around 37 weeks. 5th pregnancy I was diagnosed with ICP and given URSODIOL and induced at 38.5 weeks. 6th pregnancy I was seeing a midwife but had an OB diagnose me and prescribe URSODIOL and I delivered at home at 40 weeks.
I have had healthy babies with each pregnancy regardless of when they were delivered.
I am currently 36 weeks pregnant and have been diagnosed with Cholestasis again and was prescribed URSODIOL by my family practioner. As with the last pregnancy the lab results for the Serus Bile Acid Test take WEEKS to get back so my midwife and I have not even run that test at this point. We have been doing weekly liver function testing. 2 weeks ago my levels were normal and then shot up. My AST/SGOT was 139 and my ALT/SGPT was 245. How high would the number have to be to be considered to be severely dangerous? The elevated levels were when I was unmedicated and not following a low fat diet. We should have the next round of liver function results back in a few days. As of right now I am on 300 mg of URSODIOL twice daily, following a strict low fat diet and taking Milk Thistle and Dandelion Root supplements. Like I said before, I am seeing a midwife and planning a home birth so induction isnt in the plan for me. Also neither my midwife or family doctor seems to know much if anything about Cholestasis so I am in a sense acting as my own doctor. I have read that if ICP is treated and levels are stabilized the risk of stillbirth is less than 1%. Can you confirm that? Also what should I be avoiding food and supplement wise so that my liver is not stressed anymore than it already is? I do take quite a few supplements at this point such as, multi vit, vit c, cal/mag, alfalfa,evening primrose oil, fish oil, flaxseed oil, dandelion root, milk thistle, fiber tablet,folic acid and ligaplex. What would the levels have to rise to, to warrant an increase in the dosage of Ursodiol?
Sorry for all the questions, you are the first knowledgable medical professional I have ever heard of regarding cholestasis. Thanks SOO much
At Wed Oct 07, 11:47:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Beci Oct 1: You might consider stoppin (or changing) your prenatal vitamin, start on a VERY low-fat diet, and drinking 7-8 glasses of water per day. You might also try Vitamin E but do NOT take an excessive amount of this or any other fat soluble vitamin. In some countries a low-dose of phenobarbital is prescribed. This stimulates the production of certain liver enzymes that just might help you faster metabolize other 'wastes' that you might be processing slowly and that might be leading to cholestasis. None of these things are PROVEN to work, but in general, this is a relatively safe approach to therapy and as an adjunct to ursodeoxycholic acid. Good luck and let us know what happens!
Dr T
At Wed Oct 07, 11:55:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Christina: I would completely agree with the low-fat diet and urso Make sure you are drinking lots of water as well. But my concern is that we will not know if you are responding to this without knowing the actual level of your fasting bile acids. I suppose if your itching improved, you could take that as indirect evidence that they are lower. If it doesn't you are taking your chances by not delivering a little early. Current professional recommendations with true ICP are delivery at 36-37 weeks because, even if the fetal loss rate is only 1%, it is very unpredictable who that 1 in 100 will be! Anyway, I wish you the best and please let us know how things turn out.
Dr T
At Wed Oct 07, 02:07:00 PM 2009, Christina said…

Dr. Trofatter,
I would love to have the SBA testing done weekly also but in the previous pregnancies the results take WEEKS to come in. Is there any way to avoid the wait or do you know of any labs that can do it quickly? I use Westcliff and they have to send it out for the results. Last pregnancy we had it done and it took over 3 weeks for tyhe results to come in. Also would it be advisable to up my dosage of Ursodiol to be "safe". Right now I am on 300mg 2 times daily. Would adding a third dosage do any harm? Thanks.
At Fri Oct 09, 10:00:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Christina: Even if you took two to three times the dose you are currently taking, that would be very safe in pregnancy. If you have to really wait 3 weeks to get the fasting bile acid test results, they aren't worth using for follow-up management. Good luck.
Dr T
At Sat Oct 10, 11:12:00 AM 2009, CartersMommy said…

I was so happy to read your article which spoke about itching periodically after pregnancy based on menstrual cycles. I seem to fall into the 25% of women who continue to suffer after pregnancy! Although I was never diagnosed with ICP, I am sure that I had it during my last trimester. I was up all night in tears dragging my feet across the carpet and felt abandon by my doctor as she never took my itching seriously. My son is now 16 mos., and I still experience itchy feet about 2 weeks before I begin my period, and then goes away after I begin my period. What can be done about this? It is worth getting a liver function test? My doctor is unaware of ICP and fear she may think I’m crazy for coming to her wanting a liver function test. Thank you for your help! It’s too bad I didn’t know about ICP while pregnant!
At Fri Oct 16, 06:36:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To cartersmommy: I would start with the liver function tests, metabolic profile, CBC, fasting bile acids (at the time of month you have your itching) and perhaps a hepatitis profile and a gall bladder ultrasound. Once you have more information, it may be easier to decide who to consult with for your problems. Kind regards and thanks for writing.
Dr T

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Intrahepatic Cholestasis of Pregnancy - Outcomes and Management

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