Cholestasis & The Rule of Threes!

One of the oddities and urban legends haunting the halls of medical schools and centers of learning is the theory that bad things often come in sets of three. It may be years before you see an ectopic pregnancy and suddenly you have three. Months go by and suddenly you have three clients in a week who have abnormal Pap smears. Some of us go a long time without having a set of twins in our practice and, then, there are three in one month. No explanation, probably coincidence, but perplexing all the same. The rule of threes has struck again! This past month in my practice I have three women, two of them with twins, who developed cholestasis of pregnancy. Cholestasis of pregnancy usually manifests itself in the third trimester of pregnancy with the symptom of intense itching usually on the belly. Cholestasis of Pregnancy Here is a reference to a relatively simple explanation of this disorder which has an incidence of about 1-2/1000 pregnancies. I thought I would use this blog to illuminate some of the research and thought for my colleagues and me. It is rarely predictable and the major theory is that high levels of certain pregnancy hormones slow or block the flow of bile from the gallbladder. This backup then causes some of the bile salts to be absorbed in the bloodstream and eventually deposited in the skin. Diagnosis is usually suspected by the symptom of a rashless itching and confirmed by laboratory testing. Treatment is discussed in the links I have provided and supplemental Vitamin K has been suggested for the mother while pregnant and nursing and for the baby after birth. There are numerous case reports in the literature of bad fetal outcomes from this disorder, and while not the norm, these have led to the suggestion that the treatment for cholestasis of pregnancy at term is delivery. (Not by cesarean section unless for other indications). Here are a few suggested links: Ursodeoxycholic acid in the treatment of cholestasis of pregnancy: a randomized, double-blind study controlled with placebo. In my practice, so far 2 of the 3 women have been delivered. One set of twins with elevated liver tests was fortunate to have Dr. Wu in Glendale induce her and have a vaginal birth of her vertex/vertex twins. Another was breech and, sadly, had no option of induction so had a primary cesarean section. The third client with twins is still holding on with stable labs, well informed consent and hopes of her home vaginal birth. I hope none of you ever experience this rare problem but am of the philosophy that being well informed is a good thing. Dr. F