Clinical Value of Maternal Bile Acid Quantification in Intrahepatic Cholestasis of Pregnancy as an Adverse Perinatal Outcome Predictor

Abstract

Aims: To evaluate the correlation between perinatal outcome and bile acid levels in intrahepatic cholestasis of pregnancy (ICP), and to evaluate variations in the mean bile acid level when stratifying by maternal and perinatal factors. A comparison between mild and severe ICP was made. Methods: A prospective observational study was performed in pregnant patients who underwent blood tests for bile acids due to persistent pruritus. Based on bile acid levels, maternal and neonatal data were obtained and were compared between patients presenting with ICP and gestational pruritus (normal bile acid level). Results: A total of 145 patients were included, 47 of whom were diagnosed as ICP (52 newborns) and 98 as gestational pruritus (102 newborns). The ICP group had a higher rate of NICU admission (14/42 vs. 6/98, p < 0.001) and global neonatal morbidity (13/42 vs. 9/98, p = 0.002), but these differences were no longer seen after adjusting for gestational age, singleton pregnancies and induction of labour. Patients presenting with severe ICP (maximum bile acids levels above 40 µmol/l) showed a higher rate of meconium-stained amniotic fluid (0/28 vs. 4/14, p = 0.009), NICU admission (9/34 vs. 11/17, p = 0.01) and neonatal global morbidity (5/32 vs. 8/17, p = 0.02). Conclusions: ICP patients have higher rates of adverse neonatal outcomes when compared to those with gestational pruritus. Some of this neonatal morbidity may be secondary to late spontaneous preterm deliveries, multiple gestation and a policy of elective induction of labour after 37 weeks of gestation. A comparison of outcomes among patients with mild and severe ICP shows that the severely affected group has higher rates of meconium-stained amniotic fluid and neonatal morbidity.

ACG Clinical Guideline: Liver Disease and Pregnancy

“…Maternal outcomes are excellent, however, there is a risk of fetal distress, preterm labor, prematurity, and intrauterine death (41)(42)(43)(44)(45). Early delivery at 37 weeks is encouraged, because intrauterine death is more common in the last month of pregnancy and few deaths occur before 37 weeks ( 46 ).…”

Bile acid levels and risk of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy: A meta‐analysis

“…The derivation of the relevant studies included in the present meta‐analysis is shown in Figure . Of the 368 publications initially found in PubMed, nine involving about 1928 patients were included in this meta‐analysis . The major characteristics of the nine eligible publications are described in Table .…”

“…Two studies were designed as prospective case–control studies six studies were retrospective observational studies; and one study was a prospective cohort study . Three studies were conducted in Europe three in the USA; and three in Asia . Sub‐group analysis was performed with stratification by region and study design (Table ).…”

“…Recently, more studies have been published and have yielded different and controversial results. Several studies have reported a positive relation between elevated TBA levels and increased risk of perinatal fetal outcomes, suggesting that the maternal bile acid level is an important predictor of fetal risks . Conversely, other studies have concluded that maternal clinical and laboratory features, including elevated TBA, do not appear to be significant predictors of fetal complications in gravidas with ICP .…”

Intrahepatic cholestasis of pregnancy: maternal and fetal outcome and its correlation with serum bile acid levels

“…Present results were also contrary to those of Glantz A et al who conducted a meta-analysis and found that maternal elevated bile acid levels are significantly associated with increased risks of overall adverse perinatal outcomes, PTB, MSAF, and asphyxia or RDS. 13,14 The earlier gestational age at delivery, particularly an increase in the number of iatrogenic preterm deliveries could be explained by the fact that patients were managed actively during pregnancy after an established diagnosis of ICP.…”