Perinatal death by bile acid levels in intrahepatic cholestasis of pregnancy: a systematic review.

Background: Intrahepatic cholestasis of pregnancy (ICP) is characterized by the elevation of total bile acids (TBAs). The primary concern in women with ICP is the increased risk of stillbirth. ICP is generally considered as "mild" when TBA levels range from 10 to 39 micro mol/L and "severe" with levels greater than 40 micro mol/L, although levels of TBA >=100 micro mol/L have been also considered as a further threshold of severity.Objective: To quantify the association between different severities of ICP (TBA 10-39, 40-99, and >=100 micro mol/L) and perinatal death.Data sources: Medline, Embase, Scopus, Web of Sciences, and ClinicalTrial.gov were searched from the inception of each database to February 2019.Methods of study selection: Randomized, cohort, case-control, or case series studies reporting maternal and perinatal outcomes on women with ICP by the three prespecified TBA levels (10-39, 40-99, and >=100 micro mol/L) were included. We excluded multiple gestations and trials which included an intervention. The analysis was performed with Pearson chi-square and Fisher's exact test as appropriate. Continuous outcomes were compared using metaregression with inverse variance weighting using reported sample sizes and standard deviations. Pairwise comparisons used a Bonferroni correction to control for multiple testing.Tabulation, integration, and results: Six articles including 1280 singleton pregnancies affected by ICP were included in the systematic review. Out of the 1280 singleton pregnancies affected by ICP included, 118 had ICP with TBA >=100 micro mol/L. Perinatal death was more common in women with TBA >=100 micro mol/L (0.4% for TBA 10-39 mumol/L versus 0.3% for TBA 40-99 mumol/L versus 6.8% for TBA >= 100 mumol/L, p < .0001). Of the 8 perinatal deaths in the TBA >=100 micro mol/L group, 3 occurred >=34 weeks. TBA >=100 micro mol/L increased the risk of spontaneous preterm birth (PTB) (5.4% versus 8.6% versus 18.2% respectively, p < .0001) and iatrogenic PTB (10.8% versus 21.6% versus 35.8% respectively, p<.0001) as well as meconium-stained amniotic fluid (9.0% versus 18.4% versus 31.6% respectively, p < .0001).Conclusions: Maternal TBA >=100 micro mol/L is associated with a 6.8% incidence of perinatal death, most of which (5.9% overall) are stillbirths, while TBA <100 micro mol/L are associated with an incidence of perinatal death of 0.3%. It may be reasonable to consider late preterm delivery (at about 35-36 weeks) in women with TBA >=100 micro mol/L.

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