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Pregnant. Used lotion for itching. Lab test showed elevated bile acids and elevated liver enzymes. Risk?

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My wife is 34 weeks pregnant with bile acid of 14.5, 109 sgot and 221 sgpt. We are getting mixed answers on this. She does not have itching or any symptoms of choleostasis, so we aren't sure what to think. What are your thoughts?Please tell me why she had these labs drawn if she has no symptoms?
She had itching for a week, changed lotions and she was fine, the itching ceased. A few weeks later she had mentioned this at a routine check up and her DR who then ordered these labs. The labs came back and the DR said she likely has choleostasis. She went back for more labs and the partner DR in the office said everything is normal with the results I gave you. We then got a call today saying they are concerned with the levels again, so we are very confused. Words like stillborn, being induced and high risk were thrown around, but we have lost confidence since the story changed.
Posted Tue, 19 Feb 2013 in Pregnancy
Answered by Dr. Timothy Raichle 6 hours later
Thank you for the followup. I am sorry about the delayed response.

Based on the symptoms of itching, elevated bile acids, and elevated liver enzymes, it seems as though she meets criteria for a diagnosis of cholestasis of pregnancy. The doctor who said everything is normal is completely "missing the boat" and assuming an uncertain risk. While she needs a full workup for other causes of liver disease in pregnancy, this seems like the most obvious diagnosis. Another common cause of elevated liver enzymes is related to preeclampsia, so this should be addressed as well.

I am sorry that there has been so much confusion. The bottom line is that there is little risk to your wife, but the potential for significant risk to the fetus.

As you already know, the main potential complications are:
1. Risk for fetal prematurity / risk of early delivery (confused by the fact that this is more common in twins and they deliver earlier)
2. Meconium stained amniotic fluid (this is common but can be an issue at time of delivery)
3. Intrauterine demise (I will touch on this later)
4. Increased risk for neonatal respiratory distress syndrome (which appears to be associated with bile acids entering the fetal lungs)

With regard to the most concerning issue, fetal demise (or death of the fetus before delivery), it rarely occurs before the last month of pregnancy (i.e. before 37-38 weeks). The cause is not understood.

You have been told that she should be delivered early. This is true. This decision is a balance between risks of prematurity and the risk of fetal demise. In general, and depending on her symptoms and concern for the fetus, most OB/GYN's would deliver her sometime between 37-38 weeks gestation. Leading up to delivery, she needs to be followed closely, likely with repeat labs (bile acids over 40 are of a greater concern) and with once or twice weekly monitoring of the fetus (though this is controversial whether this helps to prevent fetal demise).

The bottom line is that she needs to be treated on a "worst case scenario" basis, and delivery by 38 weeks seems like a reasonable balance between the different risks. This is a basic thought process that we have gone through, but the ultimate decision needs to be betweeen she and her doctor. Please do not take this answer as medical advice, but rather as continued education in the setting of a confusing situation with uncertain risks.

I hope that this helps. Please ask if you have any followup questions.
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