PDF herunterladen
Am J Perinatol 2025; 42(09): 1229-1234
DOI: 10.1055/a-2495-3553
Clinical Opinion

Simplifying Management of Cholestasis: A Proposal for a Classification System

Minhazur Sarker 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, California
,
Gladys A. Ramos
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, California
,
Lauren Ferrara
2   Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
,
Cynthia Gyamfi-Bannerman
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, California
› Institutsangaben
Funding M.S. was supported by an NIH T32 HD007203-42 grant. Funding bodies had no input in the clinical opinion being written.
› Weitere Informationen
Auch verfügbar auf
   Lizenzen und Reprints

Abstract

Given the stillbirth risk associated with intrahepatic cholestasis of pregnancy, management to reduce this adverse outcome has primarily involved planned delivery as early as 36 weeks gestation. While earlier planned delivery has decreased the incidence of stillbirth in this population, recently, there have been multiple published retrospective studies to better correlate the association of adverse outcomes with cholestasis severity. Despite these new data, the uptake of individualized management for cholestasis has been varied from provider to provider. In this opinion, we briefly review the current literature and evidence regarding cholestasis and adverse outcomes and propose a cholestasis classification system with subsequent algorithms for management.

Key Points

  • Recently, multiple studies have further characterized adverse outcomes with cholestasis.

  • Incorporation of severity-associated management into clinical practice is variable.

  • A cholestasis classification system will simplify and streamline management.

Keywords

bile acids - cholestasis - delivery timing - stillbirth


Publikationsverlauf

Eingereicht: 20. November 2024

Angenommen: 03. Dezember 2024

Accepted Manuscript online:
04. Dezember 2024

Artikel online veröffentlicht:
24. Dezember 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Lee RH, Incerpi MH, Miller DA, Pathak B, Goodwin TM. Sudden fetal death in intrahepatic cholestasis of pregnancy. Obstet Gynecol 2009; 113 (2 Pt 2): 528-531
    CrossrefPubMedSuche in Google Scholar
  • 2 Herrera CA, Manuck TA, Stoddard GJ. et al. Perinatal outcomes associated with intrahepatic cholestasis of pregnancy. J Matern Neonatal Med 2018; 31: 1913-1920
    CrossrefPubMedSuche in Google Scholar
  • 3 Sentilhes L, Verspyck E, Pia P, Marpeau L. Fetal death in a patient with intrahepatic cholestasis of pregnancy. Obstet Gynecol 2006; 107 (2 Pt 2): 458-460
    CrossrefPubMedSuche in Google Scholar
  • 4 Alsulyman OM, Ouzounian JG, Ames-Castro M, Goodwin TM. Intrahepatic cholestasis of pregnancy: perinatal outcome associated with expectant management. Am J Obstet Gynecol 1996; 175 (4 Pt 1): 957-960
    CrossrefPubMedSuche in Google Scholar
  • 5 Lee RH, Mara Greenberg, Metz TD, Pettker CM. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org. Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy: Replaces Consult #13, April 2011. Am J Obstet Gynecol 2021; 224 (02) B2-B9
    CrossrefPubMedSuche in Google Scholar
  • 6 Ovadia C, Seed PT, Sklavounos A. et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet 2019; 393 (10174): 899-909
    CrossrefPubMedSuche in Google Scholar
  • 7 Kawakita T, Parikh LI, Ramsey PS, Huang CC, Zeymo A, Fernandez M, Smith S, Iqbal SN. Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol 2015; 213 (04) 570.e1-570.e8
    CrossrefPubMedSuche in Google Scholar
  • 8 Brouwers L, Koster MPH, Page-Christiaens GC. et al. Intrahepatic cholestasis of pregnancy: maternal and fetal outcomes associated with elevated bile acid levels. Am J Obstet Gynecol 2015; 212 (01) 100.e1-100.e7
    CrossrefPubMedSuche in Google Scholar
  • 9 Cui D, Zhong Y, Zhang L, Du H. Bile acid levels and risk of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy: a meta-analysis. J Obstet Gynaecol Res 2017; 43 (09) 1411-1420
    CrossrefPubMedSuche in Google Scholar
  • 10 Sarker M, Zamudio AR, DeBolt C, Ferrara L. Beyond stillbirth: association of intrahepatic cholestasis of pregnancy severity and adverse outcomes. Am J Obstet Gynecol 2022; 227 (03) 517.e1-517.e7
    CrossrefPubMedSuche in Google Scholar
  • 11 Manzotti C, Casazza G, Stimac T, Nikolova D, Gluud C. Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy. Cochrane Database Syst Rev 2019; 7 (07) CD012546
    PubMedSuche in Google Scholar
  • 12 Kenyon AP, Tribe RM, Nelson-Piercy C. et al. Pruritus in pregnancy: a study of anatomical distribution and prevalence in relation to the development of obstetric cholestasis. Obstet Med 2010; 3 (01) 25-29
    CrossrefPubMedSuche in Google Scholar
  • 13 Kenyon AP, Piercy CN, Girling J, Williamson C, Tribe RM, Shennan AH. Obstetric cholestasis, outcome with active management: a series of 70 cases. BJOG 2002; 109 (March): 282-288
    CrossrefPubMedSuche in Google Scholar
  • 14 Sepúlveda WH, González C, Cruz MA, Rudolph MI. Vasoconstrictive effect of bile acids on isolated human placental chorionic veins. Eur J Obstet Gynecol Reprod Biol 1991; 42 (03) 211-215
    CrossrefPubMedSuche in Google Scholar
  • 15 Gorelik J, Harding SE, Shevchuk AI. et al. Taurocholate induces changes in rat cardiomyocyte contraction and calcium dynamics. Clin Sci (Lond) 2002; 103 (02) 191-200
    CrossrefPubMedSuche in Google Scholar
  • 16 Williamson C, Miragoli M, Sheikh Abdul Kadir S. et al. Bile acid signaling in fetal tissues: implications for intrahepatic cholestasis of pregnancy. Dig Dis 2011; 29 (01) 58-61
    CrossrefPubMedSuche in Google Scholar
  • 17 Di Mascio D, Quist-Nelson J, Riegel M. et al. Perinatal death by bile acid levels in intrahepatic cholestasis of pregnancy: a systematic review. J Matern Fetal Neonatal Med 2021; 34 (21) 3614-3622
    CrossrefPubMedSuche in Google Scholar
  • 18 Puljic A, Kim E, Page J. et al. 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; 212 (05) 667.e1-667.e5
    CrossrefPubMedSuche in Google Scholar
  • 19 Lo JO, Shaffer BL, Allen AJ, Little SE, Cheng YW, Caughey AB. Intrahepatic cholestasis of pregnancy and timing of delivery. J Matern Fetal Neonatal Med 2015; 28 (18) 2254-2258
    CrossrefPubMedSuche in Google Scholar
  • 20 Committee on Obstetric Practice. Indications for outpatient antenatal fetal surveillance: ACOG Committee Opinion, Number 828. Obstet Gynecol 2021; 137 (06) e177-e197
    CrossrefPubMedSuche in Google Scholar
  • 21 Maldonado M, Alhousseini A, Awadalla M. et al. Intrahepatic cholestasis of pregnancy leading to severe vitamin k deficiency and coagulopathy. Case Rep Obstet Gynecol 2017; 2017: 5646247
    CrossrefPubMedSuche in Google Scholar
  • 22 Mahle AC, Morris BD, Frazer Z, Novak C. Severe vitamin deficiencies in pregnancy complicated by progressive familial intrahepatic cholestasis. BMJ Case Rep 2021; 14 (03) 240248
    CrossrefPubMedSuche in Google Scholar
  • 23 Sarker MR, Warren L, Getrajdman C, Ferrara L. Severe cholestasis-associated coagulopathy diagnosed by routine screening: a case report. AJOG Glob Rep 2023; 3 (03) 100235
    CrossrefPubMedSuche in Google Scholar
  • 24 Sarker M, Getrajdman C, Warren L, Ferrara L. Severe fat-soluble vitamin deficiency suspected secondary to intrahepatic cholestasis of pregnancy: a case report. Case Rep Womens Health 2022; 35: e00430
    CrossrefPubMedSuche in Google Scholar
  • 25 Sarker M, Canfield D, Ferrara L, Ramos GA, DeBolt CA. Adverse outcomes associated with progressive intrahepatic cholestasis of pregnancy. Am J Perinatol 2024; (e-pub ahead of print)
    Thieme ConnectPubMedSuche in Google Scholar