Cholestasis Of Pregnancy

What Is Cholestasis Of Pregnancy? What Is Obstetric Cholestasis?

Cholestasis of pregnancy, also known as obstetric cholestasis or intrahepatic cholestasis of pregnancy, usually occurs during the last trimester of pregnancy, and triggers severe itching, especially on the hands and feet. On rare occasions symptoms may appear before the third trimester. The condition is rarely of concern for the mother's long-term health, but may cause severe complications for the fetus baby.

Cholestasis is when the excretion of bile (from the liver) is interrupted. Bile is a fluid that helps the body process fat.

There are two main types of cholestasis:
  • Short and long term cholestasis (acute and chronic)

    • The one that comes on suddenly is known as acute cholestasis.
    • Long-term interruption in the excretion of bile is called chronic cholestasis.
  • Cholestasis outside and inside the liver

    • Extrahepatic cholestasis occurs outside the liver.
    • Intrahepatic cholestasis occurs inside the liver.
The term "cholestasis" comes from the Greek word chole meaning "bile" and the Greek word stasis meaning still.

Pregnancy is a possible cause of intrahepatic cholestasis. Apart from giving the patient intense itching, it does not usually cause any serious problems for the mother. However, it can be potentially dangerous for the fetus (developing baby inside the mother).

According to Medilexicon's medical dictionary:
    Intrahepatic cholestasis of pregnancy is "intrahepatic cholestasis with centrilobular bile staining without inflammatory cells or proliferation of mesenchymal cells; clinically characterized by pruritus and icterus; of unknown cause but associated with high estrogen levels.

What are the signs and symptoms of cholestasis of pregnancy?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.

The following signs and symptoms may be present when the mother has cholestasis of pregnancy:
  • Very intense itching, especially on the palms of the hands and soles of the feet.
  • Dark urine.
  • Light-colored feces (stools, bowel movements).
  • Jaundice - whites of the eyes, skin and tongue may take on a yellowish/orangey tinge.
It is not uncommon for the itchiness to be the only symptom, which tends to become much worse during the night.

Pregnant mothers who have any of the signs or symptoms mentioned above should tell a health care professional as soon as possible.

What causes cholestasis of pregnancy?

Experts believe that pregnancy hormones trigger the condition; but they are not sure.

What is bile? Bile is a yellow-green fluid that helps to digest fat. It is produced by the liver and stored in the gallbladder. From the gallbladder it passes through the common bile duct, into the duodenum.

Bile mainly consists of cholesterol, bile salts, and the pigment bilirubin.

Pregnancy hormones - these can affect the proper functioning of the gallbladder. On some occasions pregnancy can slow or even completely block the flow of bile. If the excess bile enters the bloodstream the condition is called cholestasis of pregnancy.

What are the risk factors for cholestasis of pregnancy?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.

We do not really know how many women globally develop cholestasis of pregnancy. According to The Mayo Clinic, USA, estimates vary from 1% to 15%. In Chile and Scandinavia records indicate that the risk of cholestasis of pregnancy is higher during the winter months.

The following factors may increase a woman's risk of developing cholestasis of pregnancy:
  • Having a close relative who had cholestasis of pregnancy.
  • Having had cholestasis of pregnancy before (up to70% risk of recurrence during the subsequent pregnancies).
  • Carrying multiple babies (twins, triplets, etc).
  • Having a history of liver damage.
  • Being pregnant as a result of in-vitro fertilization (IVF).

What are the possible complications of cholestasis of pregnancy?

The mother
  • The pregnant mother may have some problems with absorbing fat-soluble vitamins (vitamins A, D, E and K), as well as intense itching. However, within a few days after giving birth the problems resolve with hardly ever any subsequent liver problems.
  • The greatest complication for the mother is a very high risk of recurrence in subsequent pregnancies.
The baby
  • The risk of being born prematurely is significantly greater if the mother has cholestasis of pregnancy. Experts are not sure why.
  • There is also a risk of the baby inhaling meconium during childbirth, resulting in breathing difficulties.
  • The risk of fetal death during late pregnancy is also higher if the mother has the condition.
Doctors often induce labor early if the mother has cholestasis of pregnancy because of the potential serious complications for the baby.

How is cholestasis of pregnancy diagnosed?

The doctor will ask the patient questions related to potential signs and symptoms, such as urine and stool color, itchiness, etc. The mother will also be asked about her personal and family medical histories. A physical exam will also be performed.
  • Blood test - this may reveal how well the patient's liver is functioning. Blood levels of bile may also be measured.
  • Ultrasound scan - the aim here is to check the mother's liver (not the baby) for any abnormalities.

What are the treatment options for cholestasis of pregnancy?

There are two aims when treating a mother with this conditions: 1. To relieve the symptoms, mainly of itching. 2. To prevent potential complications.

Relief of symptoms
  • Ursodeoxycholic acid is a drug which helps relieve itching as well as increasing bile flow.
  • Corticosteroids - these will be in the form of anti-itching creams or lotions.
  • If the patient soaks the affected areas of skin in lukewarm water there may be some temporary relief.
Preventing potential complications
  • Blood tests - the patient's liver function and blood levels of bile will be closely monitored.
  • Ultrasound scans - these will occur more frequently to monitor the baby's health and development.
  • Non-stress test - the aim here is to check how often the baby moves in a given period. The baby's heartbeat in relation to body movements is also measured.
  • Induced labor - in most cases the health care professional will recommend inducing labor at about 38 weeks. If cholestasis is severe induction may occur earlier.


What is Cholesterol? What Causes High Cholesterol?

Cholesterol is a fat (lipid) which is produced by the liver and is crucial for normal body functioning. Cholesterol exists in the outer layer of every cell in our body and has many functions. It is a waxy steroid and is transported in the blood plasma of all animals. It is the main sterol synthesized by animals - small amounts are also synthesized in plants and fungi.

The word "cholesterol" comes from the Greek word chole, meaning "bile", and the Greek word stereos, meaning "solid, stiff".

What are the functions of cholesterol?

  • It builds and maintains cell membranes (outer layer), it prevents crystallization of hydrocarbons in the membrane
  • It is essential for determining which molecules can pass into the cell and which cannot (cell membrane permeability)
  • It is involved in the production of sex hormones (androgens and estrogens)
  • It is essential for the production of hormones released by the adrenal glands (cortisol, corticosterone, aldosterone, and others)
  • It aids in the production of bile
  • It converts sunshine to vitamin D
  • It is important for the metabolism of fat soluble vitamins, including vitamins A, D, E, and K
  • It insulates nerve fibers

There are three main types of lipoproteins

Cholesterol is carried in the blood by molecules called lipoproteins. A lipoprotein is any complex or compound containing both lipid (fat) and protein. The three main types are:
  • LDL (low density lipoprotein) - people often refer to it as bad cholesterol. LDL carries cholesterol from the liver to cells. If too much is carried, too much for the cells to use, there can be a harmful buildup of LDL. This lipoprotein can increase the risk of arterial disease if levels rise too high. Most human blood contains approximately 70% LDL - this may vary, depending on the person.
  • HDL (high density lipoprotein) - people often refer to it as good cholesterol. Experts say HDL prevents arterial disease. HDL does the opposite of LDL - HDL takes the cholesterol away from the cells and back to the liver. In the liver it is either broken down or expelled from the body as waste.
  • Triglycerides - these are the chemical forms in which most fat exists in the body, as well as in food. They are present in blood plasma. Triglycerides, in association with cholesterol, form the plasma lipids (blood fat). Triglycerides in plasma originate either from fats in our food, or are made in the body from other energy sources, such as carbohydrates. Calories we consume but are not used immediately by our tissues are converted into triglycerides and stored in fat cells. When your body needs energy and there is no food as an energy source, triglycerides will be released from fat cells and used as energy - hormones control this process.

What are normal cholesterol levels?

The amount of cholesterol in human blood can vary from 3.6 mmol/liter to 7.8 mmol/liter. The National Health Service (NHS), UK, says that any reading over 6 mmol/liter is high, and will significantly raise the risk of arterial disease. The UK Department of Health recommends a target cholesterol level of under 5 mmo/liter. Unfortunately, two-thirds of all UK adults have a total cholesterol level of at least five (average men 5.5, average women 5.6).

Below is a list of cholesterol levels and how most doctors would categorize them in mg/dl (milligrams/deciliter) and 5mmol/liter (millimoles/liter).
  • Desirable - Less than 200 mg/dL
  • Bordeline high - 200 to 239 mg/dL
  • High - 240 mg/dL and above
  • Optimum level: less than 5mmol/liter
  • Mildly high cholesterol level: between 5 to 6.4mmol/liter
  • Moderately high cholesterol level: between 6.5 to 7.8mmol/liter
  • Very high cholesterol level: above 7.8mmol/liter
  • Dangers of high cholesterol levels

    High cholesterol levels can cause:

    • Atherosclerosis - narrowing of the arteries.
    • Higher coronary heart disease risk - an abnormality of the arteries that supply blood and oxygen to the heart.
    • Heart attack - occurs when the supply of blood and oxygen to an area of heart muscle is blocked, usually by a clot in a coronary artery. This causes your heart muscle to die.
    • Angina - chest pain or discomfort that occurs when your heart muscle does not get enough blood.
    • Other cardiovascular conditions - diseases of the heart and blood vessels.
    • Stroke and mini-stroke - occurs when a blood clot blocks an artery or vein, interrupting the flow to an area of the brain. Can also occur when a blood vessel breaks. Brain cells begin to die.
    If both blood cholesterol and triglyceride levels are high, the risk of developing coronary heart disease rises significantly.

    Symptoms of high cholesterol (hypercholesterolaemia)

    Symptoms of high cholesterol do not exist alone in a way a patient or doctor can identify by touch or sight. Symptoms of high cholesterol are revealed if you have the symptoms of atherosclerosis, a common consequence of having high cholesterol levels. These can include:
  • Narrowed coronary arteries in the heart (angina)
  • Leg pain when exercising - this is because the arteries that supply the legs have narrowed.
  • Blood clots and ruptured blood vessels - these can cause a stroke or TIA (mini-stroke).
  • Ruptured plaques - this can lead to coronary thrombosis (a clot forming in one of the arteries that delivers blood to the heart). If this causes significant damage to heart muscle it could cause heart failure.
  • Xanthomas - thick yellow patches on the skin, especially around the eyes. They are, in fact, deposits of cholesterol. This is commonly seen among people who have inherited high cholesterol susceptibility (familial or inherited hypercholesterolaemia).

What causes high cholesterol?

Lifestyle causes
  • Nutrition - although some foods contain cholesterol, such as eggs, kidneys, eggs and some seafoods, dietary cholesterol does not have much of an impact in human blood cholesterol levels. However, saturated fats do! Foods high in saturated fats include red meat, some pies, sausages, hard cheese, lard, pastry, cakes, most biscuits, and cream (there are many more).
  • Sedentary lifestyle - people who do not exercise and spend most of their time sitting/lying down have significantly higher levels of LDL (bad cholesterol) and lower levels of HDL (good cholesterol).
  • Bodyweight - people who are overweight/obese are much more likely to have higher LDL levels and lower HDL levels, compared to people who are of normal weight.
  • Smoking - this can have quite a considerable effect on LDL levels.
  • Alcohol - people who consume too much alcohol regularly, generally have much higher levels of LDL and much lower levels of HDL, compared to people who abstain or those who drink in moderation.
Treatable medical conditions

These medical conditions are known to cause LDL levels to rise. They are all conditions which can be controlled medically (with the help of your doctor, they do not need to be contributory factors): Risk factors which cannot be treated

These are known as fixed risk factors:
  • Your genes 1 - people with close family members who have had either a coronary heart disease or a stroke, have a greater risk of high blood cholesterol levels. The link has been identified if your father/brother was under 55, and/or your mother/sister was under 65 when they had coronary heart disease or a stroke.
  • Your genes 2 - if you have/had a brother, sister, or parent with hypercholesterolemia (high cholesterol) or hyperlipidemia (high blood lipids), your chances of having high cholesterol levels are greater.
  • Your sex - men have a greater chance of having high blood cholesterol levels than women.
  • Your age - as you get older your chances of developing atherosclerosis increase.
  • Early menopause - women whose menopause occurs early are more susceptible to higher cholesterol levels, compared to other women.
  • Certain ethnic groups - people from the Indian sub-continent (Pakistan, Bangladesh, India, Sri Lanka) are more susceptible to having higher cholesterol levels, compared to other people.

How is high cholesterol diagnosed?

Cholesterol levels may be measured by means of a simple blood test. It is important not to eat anything for at least 12 hours before the blood sample is taken. The blood sample can be obtained with a syringe, or just by pricking the patient's finger.

The blood sample will be tested for LDL and HDL levels, as well as blood triglyceride levels. The units are measure in mg/dl (milligrams/deciliter) or 5mmol/liter (millimoles/liter).

People who have risk factors should consider having their cholesterol levels checked.

What are the treatments for high cholesterol?


Most people, especially those whose only risk factor has been lifestyle, can generally get their cholesterol and triglyceride levels back to normal by:
  • Doing plenty of exercise (check with your doctor)
  • Eating plenty of fruits, vegetables, whole grains, oats, good quality fats
  • Avoiding foods with saturated fats
  • Getting plenty of sleep (8 hours each night)
  • Bringing your bodyweight back to normal
  • Avoiding alcohol
  • Stopping smoking
Many experts say that people who are at high risk of developing cardiovascular disease will not lower their risk just by altering their diet. Nevertheless, a healthy diet will have numerous health benefits.

Cholesterol-controlling medications

If your cholesterol levels are still high after doing everything mentioned above, your doctor may prescribe a cholesterol-lowering drug. They may include the following:
  • Statins (HMG-CoA reductase inhibitors) - these block an enzyme in your liver that produces cholesterol. The aim here is to reduce your cholesterol levels to under 4 mmol/liter and under 2 mmol/liter for your LDL. Statins are useful for the treatment and prevention of atherosclerosis. Side effects can include constipation, headaches, abdominal pain, and diarrhea. Atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin and simvastatin are examples of statins.
  • Aspirin - this should not be given to patients under 16 years of age.
  • Drugs to lower triglyceride levels - these are fibric acid derivatives and include gemfibrozil, fenofibrate and clofibrate.
  • Niacin - this is a B vitamin that exists in various foods. You can only get very high doses with a doctor's prescription. Niacin brings down both LDL and HDL levels. Side effects might include itching, headaches, hot flashes (UK: flushes), and tingling (mostly very mild if they do occur).
  • Anti hypertensive drugs - if you have high blood pressure your doctor may prescribe Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin || receptor blockers (ARBs), Diuretics, Beta-blockers, Calcium channel blockers.
In some cases cholesterol absorption inhibitors (ezetimibe) and bile-acid sequestrants may be prescribed. They have more side effects and require considerable patient education to achieve compliance (to make sure drugs are taken according to instruction).




Avian Flu / Bird Flu

What Is Avian Flu? What Is Bird Flu?

Avian flu (commonly referred to as Bird flu) is used to describe the influenza viruses that infect birds - for example wild birds such as ducks and domestic birds such as chickens. In fact, birds appear to a natural reservoir of flu viruses - 15 subtypes influenza A virus are known to be circulating in bird populations.

Many forms of avian flu virus cause only mild symptoms in the birds, or no symptoms at all. However, some of the viruses produce a highly contagious and rapidly fatal disease, leading to severe epidemics.

These virulent viruses are known as 'highly pathogenic avian influenza' and it is these viruses that cause particular concern. One such avian flu virus is currently infecting chickens in Asian countries.

Why are scientists and governments so concerned about avian flu?

Until 1997 avian flu was believed to only infect birds, however in 1997 it was discovered that the virus can occasionally infect people who have been in close contact with live birds in markets or farms.

This rare ability of avian flu viruses to infect humans (known as 'species jumping') throws up a worrying possibility. It is possible that a highly pathogenic avian flu virus could merge with a human flu virus and create a new virus that could be easily passed between humans and was rapidly fatal.

If this happens, the result could be the next flu pandemic.

What is a flu pandemic?

When a new, highly infectious form of a flu virus is formed it can rapidly infect a large number of people. The result is a illness that rapidly spreads round the world and may cause widespread loss of life. An example is the Spanish flu pandemic of 1918-1919 which caused an estimated 40-50 million deaths worldwide.

How would an avian flu virus merge with a human flu virus to produce a new, highly infectious flu virus?

There are two circumstances in which an avian flu virus could merge with a human flu virus:

In humans - if a person who already has flu is comes into close contact with birds who have highly pathogenic avian flu, there is a tiny chance that the person could become infected with the avian flu virus.

If this happens, the person would now be carrying both the human flu virus and the avian flu virus. The two viruses could meet in the person's body and swap genes with each other.

If the new virus had the avian flu's genes that made it rapidly fatal and the human flu's genes to allow it to be passed from person to person, a flu pandemic could result.

In pigs - pigs are susceptible to both human and bird flu viruses. If a pig became infected with both viruses at the same time, it could act as a 'mixing vessel', allowing the two viruses to swap genes and produce a new virus.

Has such a new flu virus happened yet?

No. There is no evidence that the people who have been infected with avian flu have passed the disease on to other people. This suggests that a new, highly infectious, flu virus has not been produced yet.

However, every time an avian flu virus jumps from a bird to a person, the risk of a new flu virus being produced increases. For this reason, governments are keen to prevent the spread of avian flu among birds and this is why they are culling their poultry stocks.

How is the avian flu virus transmitted?

When a bird is infected with avian flu, it sheds the flu virus in its faeces, saliva and mucus.

Other birds become infected by eating or inhaling the virus. Very rarely, the virus can infect people who are in close contact with infected birds - for example by people inhaling dried faeces that have become trampled into dust.

People cannot catch avian flu from eating cooked chickens.

It is suggested that travellers to Asian countries affected by avian flu should avoid poultry markets and farms to minimise any risk of becoming infected.

What is being done to contain the spread of avian flu?

In the countries that have been affected by avian flu, governments have begun to cull affected poultry stocks.

By removing the potential for the virus to spread through the countries' chicken populations, it is hoped that the virus will be contained and removed from circulation.

What are the symptoms of avian flu in humans?

In humans, it has been found that avian flu causes similar symptoms to other types of flu: in severe cases of avian flu, it can cause severe breathing problems and pneumonia, and can be fatal.

Are there any treatments available for avian flu?

Antiviral medications used to treat human flu viruses appear to be effective in treating avian flu.

How dangerous is avian flu?

Avian flu appears to have a high mortality rate among people who get it. There have been a number of small outbreaks of avian flu since 1997:

Hong Kong 1997 - during this outbreak, 18 people were infected and 6 people died.

Hong Kong 2003 - in a family that had visited southern China, there were two cases of the disease and one death.

Far East 2004 - up to 10 deaths have been linked to this latest outbreak of the disease in a number of Asian countries.

What is the current travel advice for visitors travelling to Asian countries affected by avian flu?

The UK Department of Health (DoH) advises:

'Although there is no restriction on travel to any of the areas where avian flu is being reported, travellers are advised to take sensible precautions such as avoiding bird markets, farm or contact with live poultry.'

The US Centers for Disease Control and Prevention (CDC) advises:

'At this time CDC and WHO [the World Health Organisation] have not issued any travel alerts or advisories for the region in response to the H5N1 [avian flu virus] outbreak. However, travellers to countries in Asia with documented H5N1 outbreaks are advised to avoid poultry farms, contact with animals in live food markets and any surfaces that appear to be contaminated with faeces from poultry or other animals.'

Vigorous Exercise 3 Times Weekly Reduces Men's Heart Attack Risk By 22%

Vigorous Exercise 3 Times Weekly Reduces Men's Heart Attack Risk By 22%

Men who do vigorous exercise three times a week were found to have a significantly lower risk of having a heart attack, compared to those of the same age who did not, researchers from the Harvard School of Public Health wrote in the American College of Sports Medicine. The authors added that other important markers included hemoglobin A1c, apolipoprotein B and vitamin D.

Lead author, Andrea Chomistek, Sc.D. and team gathered data on activity levels and biomarkers from adult males from the Health Professional Follow-Up Study (HPFS). Included in the data were insulin sensitivity, cholesterol levels and markers of inflammation. The participants were asked to complete a questionnaire twice a year, in which they wrote about how long they spent each week on leisure-time physical activity.

Andrea Chomistek said:

"We studied vigorous exercise because of its stronger association with coronary heart disease. While we discovered that vigorous-intensity exercise decreases a man's risk of heart attack, we also were able to partially determine why. The benefits of exercise on a man's levels of HDL-C, or 'good' cholesterol, account for approximately 38 percent of that decrease. Other important markers included vitamin D, apolipoprotein B and hemoglobin A1c."

Blood samples were collected from 18,225 adult males, of which 454 had suffered a non-fatal heart attack or had died form coronary heart disease between 1994 and 2004, the period of the study. 412 of those with coronary heart disease were compared to 827 controls and matched for smoking status, age and date of blood donation.

Chomistek said:

"As expected, traditional cardiovascular disease risk factors were more common among cases than controls. Men who suffered a nonfatal heart attack or died from coronary heart disease had less 'good' cholesterol, more 'bad' cholesterol and were more likely to have high blood pressure, high cholesterol and diabetes."

Even though they had identified some biomarkers that could explain the link between physical activity and a lower chance of developing coronary heart disease, the authors stressed that further research on other mechanisms by which physical activity impacts on cardiovascular risk are needed.

Heart disease causes more premature adult male deaths in the USA than any other illness or condition, according to the CDC (Centers for Disease Control and Prevention). From 70% to 89% of all sudden cardiac events occur in males. Almost half of all men who suffer a heart attack before they are 65 years old do not live more than eight years.

In an Abstract in the journal, the authors wrote:

"Participating in 3 h•wk-1 of vigorous-intensity activity is associated with a 22% lower risk of MI among men. This inverse association can be partially explained by the beneficial effects of physical activity on HDL-C, vitamin D, apolipoprotein B, and hemoglobin A1c. Although the inverse association attributable to these biomarkers is substantial, future research should explore benefits of exercise beyond these biomarkers of risk."

Hemoglobin A1C is monitored to assess the long-term control of diabetes mellitus.

Apolipoprotein B, also known as APOB or ApoB is the main apolipoprotein of LDL (low-density lipoproteins or "bad cholesterol").

HDL-C, also known as high-density lipoprotein is what is often termed the good cholesterol. Higher HDL-C levels are generally associated with a lower risk of coronary artery disease.
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