Impact of obstetric cholestasis on fetal outcome – An observational study

Background: Intrahepatic cholestasis of pregnancy (ICP) or obstetric cholestasis (OC), while classified as a pregnancy dermatosis, is in fact the most common liver disease of pregnancy associated with significant fetal mortality and morbidity, as well as lifelong health risks for the offspring. Older studies using biochemical abnormalities to diagnose OC have reported a perinatal mortality rate of 10%–15%. This has been reduced to 3.5% or less in more recent studies using policies of active management. ICP is relatively benign to women, but it has been reported to have important fetal implications with increased risk of respiratory distress, preterm delivery, low birth weight, meconium staining of amniotic fluid, fetal bradycardia, fetal distress, and fetal demise. Objective: The objective was to study the impact of OC on fetal outcome. Materials and Methods: The present study was a comparative study carried out on 55 pregnant patients who presented with OC of pregnancy between 30 weeks and 40 weeks of gestation. It was conducted in the Department of Obstetrics and Gynaecology, SKIMS, Soura, Srinagar, from June 2019 to November 2019. The study participants were classified into Group A: total bile acid level (TBA) 40 μmol/l. The fetal outcome was studied in terms of respiratory distress, low birth weight, stillbirth, and intrauterine fetal demise (IUFD). Results: Out of 55 patients diagnosed with ICP, 35 patients belonged to Group A with TBA 40 μmol/l. In Group A, only five (14.2%) cases of fetal complications were reported, among which three (60%) fetuses had respiratory distress and two (40%) had low birth weight. Most of the fetal complications occurred in Group B patients with TBA >40 μmol/l, among which ten (55.5%) fetuses had respiratory distress, five (27.7%) fetuses had low birth weight, and there was one (5.5%) stillbirth and two (11.1%) IUFDs. Conclusion: ICP is a relatively common condition that occurs in pregnancy as a consequence of the cholestatic effect of raised estrogen and progesterone in genetically susceptible women. Most of the fetal complications occur in those with higher bile acid pool. The agents that reduce maternal bile acids may reduce fetal complications, but if the mechanism of fetal death involves bile salt-induced fetal arrhythmias without any placental insufficiency, it may be that such monitoring will not be effective in preventing ICP-associated fetal loss.