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Pregnant, have body itching, no sign of rash or reddening. Cause and tests to be done?

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Practicing since : 1999
Answered : 1677 Questions
Hi Dr. Raichle,

How are you? I am 36.5 weeks pregnant with 1 baby and I started having this itching yesterday night. It's all over my head, body, legs and arms. I was wondering could it be cholestasis? I know my friend had the cholestasis but her itching was mostly in the hands and feet. I can't really say my itching is concentrated in the hands and feet, it is evenly spread all over my body, face etc. I have no outside rash or reddening, it all seems to come from the inside. My family has no history of cholestasis.
Is it possible this is what I have and what testing should I do for it?
I know my friend had to be induced right away but she chose not to and then her baby was born stillborn 10 days later. If I have this, how fast do I need to be induced? Thanks
Posted Mon, 3 Jun 2013 in Pregnancy
Answered by Dr. Timothy Raichle 5 hours later
First of all, thank you for the question. I am sorry about the significant delay in responding. First I have a couple of questions:

1. Please remind me if this is your first pregnancy?
2. Have you had any issues with your blood pressure?
3. Where did the itching START - was it more on your belly?

Please answer and I will get back to you very quickly.
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Follow-up: Pregnant, have body itching, no sign of rash or reddening. Cause and tests to be done? 6 minutes later
Hello, yes this is my first pregnancy. I have always had low blood pressure - 90/60 or 100/70, not really higher than that.

The itch kind of started everywhere, maybe on my belly first, but I am not sure. I think I noticed scratching my belly first and then my hands, my head and face, my back. my legs, my butt. It kind of jumps around, but I have no redness on the outside or any rash. The itch just keeps moving every few seconds to a different place. I would say I don't really have it on the underside of my feet though or palms. Thanks
Answered by Dr. Timothy Raichle 2 hours later
Thank you for the followup.

First of all, I am terribly sorry about your friend. It is definitely a tragic reminder that 'intrahepatic cholestasis of pregnancy' in fact carries a very serious risk potential for the fetus. Thus the importance of making the diagnosis.

It usually starts with the development of itching, which may be intolerable. It is often generalized but predominates on the palms and the soles of the feet, and is worse at night. So from what you are telling me, it does not totally fit the picture of cholestasis, but it is extremely important to 'rule it out'.

The labs that are usually performed include:
1. Liver function tests (AST and ALT)
2. Gallbladder related labs (bilirubin and GGT)
3. Total bile acids

#3 might take up to a week to get back, but that is okay, because in most cases of cholestasis, induction of labor would probably not happen until about 38 weeks. So the timing to get this figured out right now is good!

There are other causes of itching during pregnancy, one of the most common being PUPPS (which you can google).

I hope that this helps - please tell me if you have additional questions!!
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Follow-up: Pregnant, have body itching, no sign of rash or reddening. Cause and tests to be done? 15 minutes later
Thanks Dr. Raichle, my doctor has not called me yet, so hopefully he takes that seriously. I googled PUPPS, the only thing is, I really have no bumps or rash or pimples, the itch is all from inside, there is nothing on my skin whatsoever. It even feels like it itches on the inside of my skin somehow.

However, just to be clear, cholestasis should be more on the palms and soles of the feet right? My friend said it was her whole body that itched, but also palms and soles. And I cannot really say I have anything on the soles of the feet, and very little on the palms occasionally. So hopefully it's not that...

If my doctor ignores it, which he might do, based on past experience, could I just go to triage and ask them to do the tests there? Or would that be a test that would not be done in the triage?

Answered by Dr. Timothy Raichle 11 minutes later
Yes, PUPPS almost invariably has a rash associated with it - all the more reason to consider that this could be something more significant.

We have had several patients over the last two years where we have made this diagnosis (one of which had it two pregnancies in a row). Their presentations were variable, and only one of them had the classic 'itchy palms'. They all had full body itching, no rash.

If your doctor 'ignores' this complaint, then something is wrong with your doctor. Even before you asked me this question, you were rather well informed about this as a possibility. You also have contact with someone who has actually experienced the worst possible outcome. It is one of those cases where you just have to be an advocate for yourself, at all costs. If they blow you off, then go to triage. I imagine that you will be evaluated appropriately in that setting, but if not, then you ask to change OB doctors and don't stop until someone does the labs.

Regardless, it sounds like you might need a new doctor anyway. If they don't listen to your concerns, then just imagine how they might be when you are in labor and it does not seem to be going well.

Again, I hope that this helps!
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Follow-up: Pregnant, have body itching, no sign of rash or reddening. Cause and tests to be done? 18 hours later
Thanks Dr. Raichle, my obgyn called me back and told me that he will give me the blood test requisition tomorrow during my appointment. While we are waiting for the results back, do you think I should be monitored through a non-stress test or some other way? Or is it ok to just wait for the results next week? Thanks
Answered by Dr. Timothy Raichle 5 hours later
Thank you for the follow up- this is great news.

In the setting of cholestasis, it is hard to predict which pregnancies are at greatest risk. Nonetheless, you need to assume that it could present. I would request:

1. NST and fluid volume tomorrow
2. NST on Monday

I hope that this helps!!
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