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Kenneth F. Trofatter, Jr., MD, PhDPregnancy and Childbirth
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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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68 Comments:

  • At Sun Nov 18, 11:00:00 AM 2007, Anonymous 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, Blogger 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 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 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, Blogger 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 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, Blogger 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, Blogger 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 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, Blogger 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 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 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, Blogger 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, Blogger 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, Blogger 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, Blogger 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, Blogger 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, Blogger 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, Blogger 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 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, Blogger 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, Blogger 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, Blogger 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 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 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 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, Blogger 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 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, Blogger 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, Blogger 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 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, Blogger 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 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, Blogger 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 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 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, Blogger 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, Blogger 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, Blogger 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, Anonymous 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, Blogger 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 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, Blogger 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 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 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, Blogger 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 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 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, Blogger 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 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, Blogger 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 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, Blogger 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 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 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, Blogger 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, Blogger 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, Blogger 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, Blogger 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 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 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!!!