Intrahepatic cholestasis of pregnancy: Relationships between bile acid levels and fetal complication rates

TLDR

Intrahepatic cholestasis of pregnancy (ICP) is marked by pruritus in late pregnancy and is associated with increased fetal risk. This study aimed to quantify ICP incidence and fetal complication rates and identify high‑risk patient groups. A prospective cohort of 45,485 Swedish pregnancies screened for ICP—defined as unexplained pruritus plus fasting bile acids ≥10 µmol/L—was analyzed. ICP occurred in 1.5% of pregnancies, fetal complications rose 1–2% per µmol/L bile acids, becoming evident only at ≥40 µmol/L, distinguishing mild (81%) from severe (19%) forms, and indicating that expectant management for bile acids <40 µmol/L could reduce costs.

Abstract

Intrahepatic cholestasis of pregnancy (ICP), characterized by pruritus in the second half of pregnancy, entails an increased risk to the fetus. This study was designed to determine the incidence and fetal complication rates in ICP, and to define groups at increased risk. In an prospective cohort study conducted between February 1, 1999, and January 31, 2002, all 45,485 pregnancies in a defined region of Sweden (Västra Götaland) were screened for ICP, defined as otherwise unexplained pruritus of pregnancy in combination with fasting serum bile acid levels > or = 10 micromol/L. Pruritus was reported by 937 (2.1%) women, and ICP was diagnosed in 693 (1.5%). Simple logistic regression analyses showed that the probability of fetal complications (spontaneous preterm deliveries, asphyxial events, and meconium staining of amniotic fluid, placenta, and membranes) increased by 1%-2% per additional micromol/L of serum bile acids. Complementary analyses showed that fetal complications did not arise until bile acid levels were > or = 40 micromol/L. Gallstone disease and a family history of ICP were significantly (P < .001) more prevalent in the group of ICP patients with higher bile acid levels. In conclusion, we found an incidence of ICP in our population of 1.5%. From complication rates recorded prospectively, we could define a mild (81%) and a severe (19%) form of ICP, the latter with bile acid levels > or = 40 micromol/L. No increase in fetal risk was detected in ICP patients with bile acid levels < 40 micromol/L, and we propose that these women be managed expectantly, which would significantly reduce the costs of medical care.