Maternal and Foetal Outcomes in Early and Late Intrahepatic Cholestasis of Pregnancy and their Association with Maternal Serum Bile Acid Levels: A Prospective Cohort Study

Abstract

Introduction: Intrahepatic Cholestasis of Pregnancy (IHCP) also known as recurrent jaundice of pregnancy is a pregnancy specific benign liver disease presenting in the second and third trimester of pregnancy and is associated with increased perinatal morbidity and mortality. Aim: To study and compare the maternal and foetal outcomes in early and late IHCP and to evaluate the Serum Bile Acid (SBA) levels and its association with adverse maternal and foetal outcomes at a tertiary care hospital in New Delhi. Materials and Methods: This was an observational, prospective cohort study, conducted during September 2018 to March 2020 in the Department of Obstetrics and Gynaecology, ESI PGIMSR, Basaidarapur, New Delhi, India. A total of 196 antenatal women with clinical signs and symptoms suggestive of IHCP with deranged liver function tests were grouped on the basis of period of gestation as early IHCP ( diagnosed ≤32 weeks) comprising of 40 women, and late IHCP (diagnosed >32 weeks), comprising of 156 women. They were further divided into four groups A, B, C, D on the basis of the maternal Serum Bile Acid (SBA) levels between 10-19 mmol/L, 20-29 mmol/L, 30-39 mmol/L and ≥40 mmol/L, respectively. Maternal outcomes such as caesarean rates, instrumental delivery, postpartum haemorrhage, blood transfusion, hospital stay and foetal outcomes such as preterm birth, birth weight, Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score, Neonatal Intensive Care Unit (NICU) admission, intrauterine foetal demise and neonatal death were noted and association was found by Pearson’s Chi-square test or Fisher’s-exact test. Results: A total of 196 women (mean age 25.64±3.8 years, 40 in Early IHCP and 156 in late IHCP) were analysed for foetomaternal outcomes and were further divided into group A (n=138), group B (n=27), group C (n=13), and group D (n=18) on basis of maternal SBA. Adverse maternal outcomes such as high caesarean rates, instrumental delivery, postpartum haemorrhage, blood transfusion, prolonged hospital stay and adverse foetal outcomes such as preterm birth, low birth weight, low APGAR score, NICU admission, intrauterine foetal demise and neonatal death was more common in early IHCP in comparison to late IHCP (p<0.05). It was also observed that risk of adverse foetomaternal outcomes increased with increasing maternal SBA levels with maximum adverse outcomes seen in women with SBA ≥30 mmol/L i.e., Group C and D (p<0.05). Conclusion: Women diagnosed with IHCP at an earlier gestation ≤32 weeks have more propensity towards adverse foetomaternal outcomes and significantly higher rate of adverse outcome was observed in patients with SBA level ≥30 mmol/L.

Keywords

• foetomaternal outcomes
• liver function tests
• meconium staining of liquor
• ursodeoxycholic acid