INTRODUCTION: Intrahepatic Cholestasis of Pregnancy (ICP) is associated with intrauterine fetal demise (IUFD) and severity of disease is associated with higher rates of IUFD. Antepartum management of (ICP) is highly variable. Consensus in clinical practice is to encourage delivery at 37 weeks regardless of severity. We evaluated if standardizing the management of ICP based on bile acid level would affect maternal and neonatal outcomes. METHODS: Women diagnosed with ICP and delivered at our hospital were prospectively followed from 01/02/2012-01/01/2018. Maternal and neonatal outcomes were evaluated before and after institution of a standardized management protocol. A 6 month wash-out period was utilized. Statistical methods performed included the Chi Square test, Fischer exact probability test and the two sample t-test. IRB approval was obtained and standards upheld. RESULTS: Ninety-two patients were included in the analysis. The bile acid level was higher in the post guideline group 69 umol/L vs the pre guideline group 30 umol/L (p =0.002). No difference was noted in the cesarean rate (p=0.56), NICU admissions (p=0.075), or 5 minute APGAR (p=0.609). The rate of composite neonatal respiratory morbidity was higher in the post guideline group (p=0.0023). There was one IUFD in the post-guideline group that occurred at 28 weeks in the setting of a twin pregnancy and bile acids of 264. CONCLUSION: Induction at 39 weeks for pregnancies with bile acids 20 or less did increase composite neonatal respiratory morbidity. Guidelines and standardization of care for cholestasis of pregnancy would help reduce variability between providers and deliveries prior to 39 weeks.
OBJECTIVE: Prior analyses have demonstrated the cost-effectiveness of elective induction of labor at 39 weeks for healthy nulliparous people. However, elective induction is resource-intensive, and effective resource allocation requires a thorough understanding of which subgroups of patients will benefit most. We sought to determine whether induction of labor at 39 weeks is more cost-effective in patients with favorable or unfavorable cervixes. STUDY DESIGN: We constructed two decision analysis models using TreeAge software: one modeling 39-week induction versus expectant management for a group of nulliparous patients with unfavorable cervixes and the other for a group with favorable cervixes. Estimates of cost, probability and health state utility were derived from the literature. We assumed that women with favorable cervixes would have a lower baseline rate of cesarean delivery, lower induction costs and higher rates of spontaneous labor. RESULTS: Induction of labor at 39 weeks was cost-effective as compared to expectant management in both models. The incremental cost per quality-adjusted life year was 5-fold lower for women with unfavorable cervixes ($5,515 versus $27,060). In the group with unfavorable cervixes, induction of labor resulted in 2,726 fewer cesarean deliveries per 100,000 patients and 57 fewer stillbirths as compared to 1,161 fewer cesarean deliveries and 47 fewer stillbirths with labor induction for those with favorable cervixes. The models were most sensitive to the probability of cesarean section after induction of labor, the probability of hypertensive disorders, the degree of quality of life decrement with hypertension, the cost of induction of labor with unfavorable cervix, and the probability of spontaneous labor. CONCLUSION: 39-week induction of labor is cost-effective regardless of cervical dilation. However, given lower incremental cost per quality-adjusted life year in the group with unfavorable cervixes, health systems may wish to prioritize these patients for 39-week inductions, which may be opposite common practice.
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