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

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 (Vastra Gotaland) were screened for ICP, defined as otherwise unexplained pruritus of pregnancy in combination with fasting serum bile acid levels greater than or equal to10 mumol/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 mumol/L of serum bile acids. Complementary analyses showed that fetal complications did not arise until bile acid levels were greater than or equal to40 mumol/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 >= 40 mu mol/L. No increase in fetal risk was detected in ICP patients with bile acid levels < 40 mumol/L, and we propose that these women be managed expectantly, which would significantly reduce the costs of medical care.