Intrahepatic cholestasis of pregnancy linked to poor outcomes

1. Higher bile acid levels were associated with preterm delivery, meconium-stained amniotic fluid and perinatal death.

2. Maternal bile acid levels were correlated with umbilical cord bile acid levels.

Evidence Rating Level: 2 (Good)

Study Rundown: Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease among pregnant women. The condition is characterized by pruritus and elevated bile acid levels; transaminase levels may or may not be elevated. Because the itchiness and lab abnormalities typically resolve after delivery, ICP is a relatively harmless condition to pregnant women and symptoms can typically be managed with ursodeoxycholic acid. However, ICP has more significant adverse effects on fetal outcomes. Prior work identifies associations with ICP and adverse fetal outcomes, including preterm delivery and intrauterine fetal demise. In the present study, authors found that severe ICP, defined as total bile acid levels ≥100µmol/L, was associated with lower birthweight, preterm delivery, meconium-stained fluid, and perinatal death. Additionally, authors found that severe ICP was correlated with umbilical cord bile acid levels. These findings suggest that maternal bile acid levels may be useful in predicting risk for adverse fetal outcomes for infants being born to mothers suffering from ICP. These risk predictions may be helpful in guiding testing and management to improve fetal outcomes.

Limitations of the study include retrospective design and small sample size, such that the incidence of adverse outcomes may be misrepresented. Future work should include larger, prospective cohort studies to confirm the findings observed here. If future studies yield similar results, more precise bile acid level cut-offs may be helpful in triaging pregnancies at high-risk for fetal demise or other adverse outcomes.

Click to read the study in AJOG

Relevant Reading: Intrahepatic cholestasis of pregnancy: molecular pathogenesis, diagnosis and management

In-Depth [retrospective cohort study]: This study evaluated the relationship between bile acid levels and adverse pregnancy outcomes in 215 women diagnosed with ICP by elevated total bile acids. ICP was classified as mild, total bile acid 10-39µmol/L (n=108); moderate, bile acid 40-99µmol/L (n=86); or severe, bile acid ≥100µmol/L (n=21). Outcomes of interest included mode of delivery, meconium staining of amniotic fluid, preterm delivery, postpartum hemorrhage, small for gestational age, NICU admission and death.

Severe ICP was associated with lower birthweight (p=0.009), preterm birth (p=0.03), meconium-stained fluid (p=0.003), postpartum hemorrhage (p=0.019) and perinatal death (p=0.009). Furthermore, every 10µmol/L was associated with increased likelihood for spontaneous preterm delivery (OR 1.15, CI 1.03-1.28) and meconium-stained fluid (OR 1.15, CI 1.06-1.25). The highest measured maternal bile acid level was positively correlated with umbilical cord bile acid levels (p=0.006).

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