Predicting Fetal Outcome in Intrahepatic Cholestasis

of Pregnancy: Is the Bile Acid Level Sufficient?

placental hormone production, chorionic vessel constric-
See Article on Page 467
tion and possibly fetal cardiac function.9 –11
The authors of the Swedish study have shown a corre-

L
iver disorders during pregnancy range from those
lation between serum bile acid levels and obstetric com-
being a benign nuisance to others of catastrophic
plications in ICP. The serum bile acid test remains
importance. While sailing comfortably through an
underutilized in cholestasis of any etiology. One reason
uncomplicated pregnancy, the parturient, her fetus, and
for such underutilization is the delay in getting the results.
her care providers may unexpectedly find themselves fac-
A quick survey of two national clinical chemistry labora-
ing an unforgiving tempest. This conundrum is exempli-
tories showed that the sample must be sent to a reference
fied by intrahepatic cholestasis of pregnancy (ICP), which
starts with modest itching and can end in intrauterine lab, where the determination is done either daily or three
fetal demise.1 times a week. Thus, the result will be returned in as little
The frequency of ICP among pregnancies in the as 2 or as many as 6 days.
United States is 0.1%. It is considerably higher in women The authors of this study used cardiotocography or
from Scandinavia or Chile, where the prevalence is nonstress fetal heart rate monitoring to ascertain fetal
roughly 1% and 10%, respectively. Family history is an well-being but found this test to be less helpful than the
important risk factor, as is a personal history of hepatitis serum bile acid measurement. The usual tool to predict
C.2 The diagnosis is typically based on clinical findings, uteroplacental insufficiency and identify fetuses at risk for
although a number of perturbations in aminotransferases, antepartum demise is fetal heart rate monitoring. How-
bilirubin, and bile acids can be detected. In a study from ever, antenatal testing, like adult cardiac assessment, in-
Sweden in the current issue of HEPATOLOGY, Glantz et al. volves more than one modality. The weekly fetal heart
demonstrate a correlation between fetal complications rate nonstress testing (used in this study) is the least sen-
and serum bile acid levels, but no association between sitive test when compared to the fetal biophysical profile
maternal symptoms and levels of serum bile acids in these (a sonographic in utero physical examination) and the
pregnancies.3 Indeed, ICP may be present in the absence fetal heart rate contraction stress testing.12 To date, no
of elevated bile acids.4 ideal method of fetal surveillance has been determined for
Adverse effects of ICP to the gravida include intracta- ICP,13 and fetal antenatal testing has had limited predict-
ble pruritus and its associated fatigue and discomfort, and ability in the setting of this disorder. Intended to recog-
can also include coagulopathy and postpartum hemor- nize a failing placenta, fetal cardiac monitoring cannot
rhage.5 The adverse effects of ICP on the fetus include forecast an acute event such as an umbilical cord entan-
increased risks of meconium stained amniotic fluid, pre- glement or a sudden fetal cardiac decompensation or ar-
term delivery, fetal distress and fetal death. The mecha- rhythmia. Such disparity is highlighted in a case where
nisms behind such untoward events are unclear. Elevated reassuring fetal heart rate monitoring had been docu-
sulfated progesterone compounds as well as impaired ex- mented within a short period before a fetal death.14 The
cretion of bile acids are found in pregnancies complicated unpredictability of antenatal testing in pregnancies com-
by ICP.6,7 Progesterone given to delay premature delivery plicated by ICP provides a challenge to the obstetric pro-
has been associated with ICP.8 High levels of maternal vider. Consideration is given to delivering the fetus a few
bile acids produce abnormalities in placental transport, weeks before the estimated date of confinement in an
attempt to reduce the risk of an in utero death.15 Prefera-
bly, the delivery is performed after fetal pulmonary mat-
Abbreviation: ICP, intrahepatic cholestasis of pregnancy. uration has been documented, but it may be sooner if
From the Division of Maternal Fetal Medicine and the Gastroenterology Divi- antenatal fetal heart monitoring is nonreassuring, a find-
sion, Hepatology Section, University of Tennessee Health Science Center, Memphis,
ing that warrants an expeditious delivery.16
TN.
Address reprint requests to: Caroline A. Riely, M.D., University of Tennessee Glantz et al. report that adverse perinatal outcomes in
Health Science Center, 920 Madison Ave., Suite 240, Memphis, TN 38163. pregnancies complicated by ICP are limited to those with
E-mail: criely@utmem.edu; fax: (901) 448-5338. increased maternal serum bile acids (⬎40 mmol/L); fur-
Copyright © 2004 by the American Association for the Study of Liver Diseases.
Published online in Wiley InterScience (www.interscience.wiley.com). thermore, they note that increasing bile acid concentra-
DOI 10.1002/hep.20347 tions correlate with worsening perinatal events. The
287
288 EGERMAN AND RIELY HEPATOLOGY, August 2004

authors conclude that directing focused surveillance on References

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