Abstract
(Lancet. 2019;393:899–909) Intrahepatic cholestasis of pregnancy has been associated with adverse perinatal outcomes, including preterm labor, fetal asphyxia, meconium-stained amniotic fluid, and stillbirth. Although studies have found an increased risk of these complications when the serum bile acid concentration is >40 µmol/L, there currently are no studies to indicate a specific concentration threshold that is predictive of fetal death. The purpose of this systematic review and meta-analysis was to quantify adverse perinatal complications in relation to serum bile acid concentrations and to determine whether specific concentration levels were associated with the risk of stillbirth and preterm birth.
Highlights
Intrahepatic cholestasis of pregnancy affects 0·1–2% of pregnant women;[1,2,3,4] it is diagnosed in women with gestational pruritus and increased serum bile acids, and can be complicated by preterm labour, fetal asphyxia, meconium-stained amniotic fluid, and stillbirth.[5]
Results from a large Swedish cohort showed that pregnancies in which the maternal serum bile acid concentration was of 40 μmol/L or more were more likely to be complicated by spontaneous preterm labour, meconium-stained amniotic fluid, and fetal asphyxia.[6]
Implications of all the available evidence Our study shows that clinical management of women with intrahepatic cholestasis of pregnancy with singleton pregnancies can be stratified according to the maximum serum bile acid concentration, with the majority of women having bile acids lower than 100 μmol/L and, unlikely to have a higher risk of stillbirth than the background population
Summary
Intrahepatic cholestasis of pregnancy affects 0·1–2% of pregnant women;[1,2,3,4] it is diagnosed in women with gestational pruritus and increased serum bile acids, and can be complicated by preterm labour, fetal asphyxia, meconium-stained amniotic fluid, and stillbirth.[5]. Added value of this study This study is the first to do individual patient data analysis of perinatal outcomes and bile acid concentrations for women with intrahepatic cholestasis of pregnancy to show a clear association between women with the most severe disease (bile acids ≥100 μmol/L) and increased stillbirth risk (in singleton pregnancies) compared with those with milder disease and the background population. Women with intrahepatic cholestasis of pregnancy should be managed according to their peak bile acid concentration, irrespective of treatment with ursodeoxycholic acid, provided repeated bile acid testing is done in women at low risk of stillbirth (ie, with bile acids
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