Objective
The objective of the study was to characterize the risk of infant and fetal death
by each additional week of expectant management vs immediate delivery in pregnancies
complicated by cholestasis.
Study Design
This was a retrospective cohort study of 1,604,386 singleton, nonanomalous pregnancies
of women between 34 and 40 weeks’ gestation with and without intrahepatic cholestasis
of pregnancy (ICP) in the state of California during the years of 2005-2008. International Classification of Diseases, 9th version, codes and linked hospital discharge and vital statistics data were
utilized. For each week of gestation, the following outcomes were assessed: the risk
of stillbirth, the risk of delivery (represented by the risk of infant death at a
given week of gestation), and the composite risk of expectant management for 1 additional
week. Composite risk combines the risk of stillbirth at this gestational age week
plus the risk of infant death if delivered at the subsequent week of gestation.
Results
Among women with ICP, the mortality risk of delivery is lower than the risk of expectant
management at 36 weeks’ gestation (4.7 vs 19.2 per 10,000). The risk of expectant
management remains higher than delivery and continues to rise by week of gestation
beyond 36 weeks. The risk of expectant management in women with ICP reaches a nadir
at 35 weeks (9.1 per 10,000; 95% confidence interval, 1.4–16.9) and rises at 36 weeks
(19.2 per 10,000; 95% confidence interval, 7.6–30.8).
Conclusion
Among women with ICP, delivery at 36 weeks’ gestation would reduce the perinatal mortality
risk as compared with expectant management. For later diagnoses, this would also be
true at gestational ages beyond 36 weeks. Timing of delivery must take into account
both the reduction in stillbirth risk balanced with the morbidities associated with
preterm delivery.
Key words
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Article Info
Publication History
Published online: February 13, 2015
Accepted:
February 9,
2015
Received in revised form:
January 17,
2015
Received:
November 15,
2014
Footnotes
The authors report no conflict of interest.
The racing flag logo above indicates that this article was rushed to press for the benefit of the scientific community.
Cite this article as: Puljic A, Kim E, Page J, et al. The risk of infant and fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age. Am J Obstet Gynecol 2015;212:667.e1-5.
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- The risk of infant and fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age: various objectionsAmerican Journal of Obstetrics & GynecologyVol. 215Issue 6
- Expectant management in cholestasis in pregnancyAmerican Journal of Obstetrics & GynecologyVol. 214Issue 1
- PreviewWe read with great interest the article by Puljic et al.1 The authors demonstrated that intervention at 37 weeks reduced the risk of either neonatal or intrauterine fetal deaths. Unfortunately the authors did not distinguish between mild and severe intrahepatic cholestasis of pregnancy. Severe form (bile acids >40) has been shown to have an increased risk of adverse perinatal outcome, which is difficult to prevent with antenatal fetal surveillance.2,3,4 Meconium has been shown to be an independent risk factor for adverse fetal outcomes (odds ratio 7.3) in these patients.
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- ReplyAmerican Journal of Obstetrics & GynecologyVol. 215Issue 6
- PreviewWe thank Professor Wensink for his letter to the editor regarding our article investigating the risk of stillbirth in patients with intrahepatic cholestasis of pregnancy (ICP).1 Based on our retrospective cohort study, we concluded that ICP was associated with an increased risk of stillbirth as compared to pregnancies without ICP. Furthermore, we found that delivery at 36 weeks’ gestation would minimize overall perinatal mortality. Professor Wensink’s main objections to our study were in regards to the validity of our composite mortality calculation, the fact that we claim that there is a lack of evidence regarding specific bile acid levels and correspondent fetal outcomes, and lastly, the turnaround time of bile acid results.
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- Induction for intrahepatic cholestasis of pregnancy: why we'll never knowAmerican Journal of Obstetrics & GynecologyVol. 213Issue 4
- The risk of infant and fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational ageAmerican Journal of Obstetrics & GynecologyVol. 213Issue 4
- PreviewWe read with great anticipation the report by Puljic et al.1 The authors presented data in support of a positive correlation between advancing gestational age in intrahepatic cholestasis of pregnancy (ICP)-affected pregnancies and risk of fetal demise.1 The authors controlled for the large number of disparities and confounding maternal variables, such as older age, member of ethnic minority, and the presence of cardiovascular disease, between the 2 study groups. However, we suggest the higher stillbirth rates identified in the study group are directly related to the prevalence of the confounders known to be risks for fetal demise.
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