Intrahepatic cholestasis of pregnancy and bile acid levels

Abstract

life-years than treatment according to "wait and see" strategy, depending on overall pancreatitis incidence (assumed to be 0.05%, 0.1%, 0.15%, or 0.2%/year) 3-5 and pancreatitis mortality (assumed to be 2.5%, 5%, 7.5%, or 10%). [6][7][8] In 6 of 16 possible scenarios, mortality during 10 years' follow-up proved to be reduced, but only in 4 of 16 possible scenarios life-years were gained by prophylactic cholecystectomy, because surgical death occurs early, whereas gained lives occur later. Further data on incidence and subsequent mortality of pancreatitis (as well as other complications) in asymptomatic gallstone carriers are clearly needed, and further cost-benefit analyses with full-scale economic evaluations are required to determine total costs and potential benefits of prophylactic cholecystectomy versus "wait and see" strategy in the different scenarios.NIELS G. VENNEMAN KAREL J. VAN Intrahepatic Cholestasis of Pregnancy and Bile Acid LevelsTo the Editor:We read with great interest the study reported by Glantz et al. 1 Although the authors should be congratulated on the data collected, we would nevertheless like to comment on their conclusions. Because these researchers had prospectively detected no increase of fetal risk in intrahepatic cholestasis of pregnancy (ICP) patients with bile acid levels less than 40 mol/L, they proposed to manage these women expectantly to reduce the costs of medical care. 1 We offer two reasons why this approach should be treated with caution.First, the pathogenesis of intrauterine fetal death (IUFD) in ICP remains unclear. 2 It has only been speculated, and never demonstrated, that bile acids may be the cause of IUFD in ICP. Moreover, it has never been demonstrated that they are solely responsible for IUFD in ICP and that other parameters do not play a role. 3 Second, among the three IUFDs that were reported by Glantz et al. during the observation period, one occurred while bile acid levels were less than 40 mol/L (27 mol/L). 1 Moreover, there was a slight increase in meconium staining of amniotic fluid, placenta, and membranes when bile acid levels were between 10 and 39 mol/L compared with normal controls. Although not statistically significant, these facts may be clinically significant.As the authors themselves report, "the low incidence of IUFD (0.4%) was due to increased attention devoted to ICP and its symptoms during the study which had led to high rates of induction of labor and planned cesarean section" (25% distributed as follows: 21% when bile acid levels were less than 10 mol/L, 24% when bile acid levels were between 10 and 39 mol/L, and 32% when bile acid levels were greater than 40 mol/L). 1 Therefore, why should obstetricians abandon active management, which is currently the only method that could reduce IUFD? 4 The policy of active management usefulness has been reinforced recently by the findings of Williamson et al. 5 These authors assessed the clinical outcome of 227 ICP patients. Among singleton pregnancies, 20 IUFDs were found. The median gestation...

Pregnancy and liver disease

“…They divided IHCP into mild (10-39 μmol/L) and severe ( 40 μmol/L) forms based on serum bile acids and found that there was a significant risk for fetal complications with serum bile acids greater than 40 μmol/L. Whether one can advocate changes in obstetric management based on serum bile acids in IHCP remains to be seen; however, this study supports the importance of monitoring serum bile acids in IHCP [11].…”

Intrahepatic Cholestasis of Pregnancy and Bile Acids Induced Lung Injury in Newborn Infants

“…Consequently, an active management has been suggested only for such patients which represent about 19% of the ICP pregnancies [1]. A wide discussion is now running on this topic and a randomised clinical trial to find the best perinatal management in ICP pregnancies with BA < 40 μmol/l is warranted [70,71].…”

La cholestase intrahépatique gravidique

“…Malheureusement, il ne s'agit pas d'un test de routine (test hors nomenclature) et même pour un laboratoire spécialisé sa mesure n'est pas réalisée quotidiennement mais le plus souvent que deux fois par semaine. Ainsi, le praticien disposera des résultats avec un délai pouvant aller jusqu'à trois jours, période pendant laquelle les acides biliaires peuvent doubler [19][20][21][22]. Par ailleurs, les techniques de dosage actuellement disponibles ne donnent pas toujours des résultats parfaitement reproductibles.…”