The risk of infant and fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age

Anela Puljic; Elissa Kim; Jessica Page; Tania Esakoff; Brian Shaffer; Daphne Y LaCoursiere; Aaron B Caughey

doi:10.1016/j.ajog.2015.02.012

The risk of infant and fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age

Am J Obstet Gynecol. 2015 May;212(5):667.e1-5. doi: 10.1016/j.ajog.2015.02.012. Epub 2015 Feb 14.

Authors

Anela Puljic¹, Elissa Kim², Jessica Page³, Tania Esakoff⁴, Brian Shaffer⁵, Daphne Y LaCoursiere², Aaron B Caughey⁵

Affiliations

¹ Department of Reproductive Medicine, University of California, San Diego, School of Medicine, San Diego, CA. Electronic address: apuljic@ucsd.edu.
² Department of Reproductive Medicine, University of California, San Diego, School of Medicine, San Diego, CA.
³ Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT.
⁴ Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.
⁵ Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR.

PMID: 25687562
DOI: 10.1016/j.ajog.2015.02.012

Abstract

Objective: The objective of the study was to characterize the risk of infant and fetal death by each additional week of expectant management vs immediate delivery in pregnancies complicated by cholestasis.

Study design: This was a retrospective cohort study of 1,604,386 singleton, nonanomalous pregnancies of women between 34 and 40 weeks' gestation with and without intrahepatic cholestasis of pregnancy (ICP) in the state of California during the years of 2005-2008. International Classification of Diseases, 9th version, codes and linked hospital discharge and vital statistics data were utilized. For each week of gestation, the following outcomes were assessed: the risk of stillbirth, the risk of delivery (represented by the risk of infant death at a given week of gestation), and the composite risk of expectant management for 1 additional week. Composite risk combines the risk of stillbirth at this gestational age week plus the risk of infant death if delivered at the subsequent week of gestation.

Results: Among women with ICP, the mortality risk of delivery is lower than the risk of expectant management at 36 weeks' gestation (4.7 vs 19.2 per 10,000). The risk of expectant management remains higher than delivery and continues to rise by week of gestation beyond 36 weeks. The risk of expectant management in women with ICP reaches a nadir at 35 weeks (9.1 per 10,000; 95% confidence interval, 1.4-16.9) and rises at 36 weeks (19.2 per 10,000; 95% confidence interval, 7.6-30.8).

Conclusion: Among women with ICP, delivery at 36 weeks' gestation would reduce the perinatal mortality risk as compared with expectant management. For later diagnoses, this would also be true at gestational ages beyond 36 weeks. Timing of delivery must take into account both the reduction in stillbirth risk balanced with the morbidities associated with preterm delivery.

Keywords: expectant management; intrahepatic cholestasis of pregnancy; stillbirth.

MeSH terms

Adult
Cholestasis, Intrahepatic / therapy*
Cohort Studies
Disease Management
Female
Gestational Age*
Humans
Infant
Infant Mortality*
Infant, Newborn
Male
Perinatal Mortality*
Pregnancy
Pregnancy Complications / therapy*
Premature Birth*
Retrospective Studies
Risk
Stillbirth / epidemiology*
Watchful Waiting*
Young Adult

Supplementary concepts

Intrahepatic Cholestasis of Pregnancy