1. Ruth McCuaig, Fergus Gardiner, Thomas Cairns, Chris Arthur
Retrospective cohort study into incidence and birth outcomes of Intrahepatic Obstetric Cholestasis of pregnancy at a tertiary teaching hospital
Ruth McCuaig, Fergus Gardiner, Thomas Cairns, Chris Arthur

2. Background
Intrahepatic cholestasis of pregnancy (ICP) increases pregnancy risk, and although uncommon the increased risk of stillbirth can cause maternal anxiety and depression.
The incidence varies depending on population
Stillbirth in ICP is likely due to acute anoxia
Diagnostic criteria for and management of ICP are not well defined in Australia
We aimed to determine the prevalence and pregnancy outcomes of ICP at The Canberra Hospital (TCH)
ICP is characterised by pruritus in the absence of a skin rash as well as with abnormal LFTs, with neither an alternative cause and both resolving after delivery
Classically itchy palms and soles
Incidence from 0.7% up to 5% in selected populations
English multiethnic population 0.7%
Indian-Asian or Pakastani-Asian origin %
Chilian 2.4%
Araucanian-Indian 5%
Given demise is not related to placental insufficiency Ultrasound and CTG are of little benefit but may help relieve maternal anxiety
Limitations are concerning as ICP is associated with increased fetal risks including preterm birth, iatrogenic preterm birth and fetal death
Furthermore the mental well being of the mother is associated with maternal morbidity relating to severe pruritis, sleep deprivation and stress and anxiety associated with linkages to preterm stillbirths in patients with ICP.
RCOG guidelines state a discussion should take place with women regarding IOL from 37wks, with a stronger case in patients with severely deranged pathology (IE BA >40)
We hypothesised that the prevalence of ICP would be low and ICO pregnancy outcomes would be statistically non-inferior to those without ICP

3. Methods – data collected during patient note audit
Description
Data collected
Demographic information
Age, ethnicity, BMI, family history, previous contraception, assisted conception, and previous pregnancy outcomes.
Pathology result and ordering information
LFT pathology, including Bilirubin, Aspartate aminotransferase, and Alanine aminotransferase.
Bile acid pathology (µmol/1).
Diagnosed pruritus
Clinical itch with non-pregnancy causes excluded
Direct mention of the following in the electronic note:
Obstetric cholestasis
Intrahepatic cholestasis of pregnancy
Liver disease of pregnancy
Management and monitoring
Medication use
Pathology, CTG and ultrasound
Pregnancy outcomes
Gestational age of diagnosis, stillbirth, gestational age at delivery, birthweight, PPH, caesarean section rate, assisted delivery rate, IOL rate, NICU admission, follow-up
Retrospective cohort study between 1st January 2014 to 31st December 2016 (36 months)
Raw data gained through Birth Outcomes System, a record of all pregnancies at TCH and the medical records reviewed for all ICP pregnancies
Exclusion criteria – women with pruritus but no elevation in serum bile acids or LFTs and/or pregnancies ending prior to 24 weeks gestation

4. Results – demographics comparing all pregnancies and ICP group
Description
Non-ICP
(n=10364)
ICP
(n=66)
P-value
Maternal age 30
29.6
>0.05
Booking BMI >35
903 (8.7%)
8 (12.1%)
Gestational age at delivery
39.3 37
<0.001
IOL
2841 (27.4%)
44 (66.7%)
Mean birth weight
3.283
3.02
Caesarean section
2943 (28.4%)
25 (37.9%)
Assisted – Forceps
707 (6.8%)
8.0 (12.2%)
Assisted – Vacuum
711 (6.9%)
0 (0%)
N/A
Disbetes (GDM, T2DM, T1DM)
1760 (16.9%)
27 (40.9%)
Admission to NICU ( )
365 (3.5%)
1 (1.5%)
Stillbirths
121 (1.2%)
Twin birth rate
252 (2.4%)
9 (13.6%)
<0.01
There were births during the study period including 66 ICP pregnancies (0.64% incidence)
The statistics
The majority of women were Caucasian (68.2%) followed by sub-continental at 22.7%
The primary clinical outcomes of ICP include a median gestational age at delivery of 37 compared to 39+3 weeks and despite an earlier gestational birth age and ;pwer birth weight there was no increase in NICU admission
Perinatal mortality did not differ significantly

5. Results 99% of women presented with pruritic Management of ICP
100% pathology performed
87.9% had deranged LFTs
83.3% had elevated bile acids
35.7% induction booked at diagnosis
34.8% were monitored with CTG
63.6% were monitored with pathology
68.1% had an obstetric ultrasound
16.7% had a upper abdominal ultrasound and liver panel performed
Treatment for ICP
65.2% ursodeoxyxholic acid prescribed
43.9% antihistamines
18.2% emolients
The majority of patients had pruritis (99%), deranged LFTs (87.9%) and elevated bile acids (83.3%)
It was also observed that the majority of patients were managed with ursodeoxycholic acid and symptoms treated with antihistamines and emolients

6. Conclusion
ICP pregnancies had higher induction rates at earlier gestations
This did not result in statistically significant lighter babies or more NICU admissions
There was no difference in caesarean section rate, instrumental deliveries or stillbirths between ICP and all pregnancies
The treatment methodology for ICP pregnancies results in similar outcomes to other pregnancies
Larger multicentre observational studies are required to determine stillbirth rate and reduction with early IOL

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