Departments of Obstetrics and Gynecology.
Departments of Obstetrics and Gynecology.
Am J Obstet Gynecol. 2023 Oct;229(4):453.e1-453.e8. doi: 10.1016/j.ajog.2023.06.036. Epub 2023 Jun 20.
Intrahepatic cholestasis of pregnancy is associated with a 4- to 10-fold increase in the risk of stillbirth in the absence of intervention, leading to recommendations for antenatal assessment, ursodiol use, and often preterm or early term delivery.
This study aimed to determine whether current management strategies for intrahepatic cholestasis of pregnancy mitigate the elevated risk of stillbirth at a population level.
This was a retrospective cohort study using the 2015-2020 National Readmissions Database, an administrative database developed by the United States Agency for Healthcare Research and Quality. Our study identified delivery hospitalizations, gestational age at delivery, occurrence of intrahepatic cholestasis of pregnancy and stillbirth, and comorbid conditions using the International Classification of Diseases diagnosis and procedure codes. Moreover, this study compared the timing of delivery and stillbirth rates of pregnant patients with intrahepatic cholestasis of pregnancy vs those without intrahepatic cholestasis of pregnancy at the time of delivery hospitalization.
This study identified a cohort of 9,987,705 delivery hospitalizations in the National Readmissions Database, corresponding to a weighted national estimate of 18,609,207 births. Of these births, 152,040 (0.8%) were noted to have an intrahepatic cholestasis of pregnancy diagnosis. Patients with an intrahepatic cholestasis of pregnancy diagnosis were older, with small differences in comorbidities, such as a higher rate of gestational diabetes mellitus, than patients without an intrahepatic cholestasis of pregnancy diagnosis at delivery hospitalization. The overall rates of stillbirth were lower among those with intrahepatic cholestasis of pregnancy than among those without intrahepatic cholestasis of pregnancy (252 vs 386 per 100,000 deliveries; risk difference, 133 fewer per 100,000 deliveries; 95% confidence interval, 98-170), a finding that persisted after adjustment for insurance status, socioeconomic factors, and comorbid conditions (risk difference, 160 fewer stillbirths per 100,000 deliveries; 95% confidence interval, 127-194). Furthermore, although patients with intrahepatic cholestasis of pregnancy were more likely to deliver before term than those without intrahepatic cholestasis of pregnancy (30.1% vs 9.3%; P<.001), increased rates of stillbirth were not noted at any point after stratification of the cohort by gestational age at delivery.
Patients with intrahepatic cholestasis of pregnancy diagnosis codes delivered earlier than those without intrahepatic cholestasis of pregnancy diagnosis codes, but the percentage of births affected by stillbirth was lower, even when stratifying for gestational age at birth. These results may provide reassurance to patients receiving an intrahepatic cholestasis of pregnancy diagnosis that current management does mitigate stillbirth risk in intrahepatic cholestasis of pregnancy.
妊娠肝内胆汁淤积症（Intrahepatic Cholestasis of Pregnancy，ICP）如果不进行干预，其导致死胎的风险会增加 4 至 10 倍，因此建议进行产前评估、熊去氧胆酸（Ursodiol）治疗，并常采取早产或早期分娩。
本研究旨在确定当前妊娠肝内胆汁淤积症的管理策略是否能降低人群水平的死胎风险。
这是一项使用 2015-2020 年全国再入院数据库（National Readmissions Database）的回顾性队列研究，该数据库是由美国医疗保健研究与质量局开发的行政数据库。我们的研究使用国际疾病分类（International Classification of Diseases）诊断和手术代码确定分娩住院、分娩时的孕龄、妊娠肝内胆汁淤积症和死胎的发生情况以及合并症。此外，本研究比较了有和无妊娠肝内胆汁淤积症孕妇在分娩住院时的分娩时机和死胎率。
本研究在全国再入院数据库中确定了一个 9987705 例分娩住院的队列，相当于全国估计的 18609207 例分娩。在这些分娩中，有 152040 例（0.8%）被诊断为妊娠肝内胆汁淤积症。与没有妊娠肝内胆汁淤积症的孕妇相比，有妊娠肝内胆汁淤积症诊断的孕妇年龄更大，合并症的差异较小，如妊娠期糖尿病的发生率更高。有妊娠肝内胆汁淤积症诊断的孕妇的死胎率总体上低于没有妊娠肝内胆汁淤积症诊断的孕妇（每 10 万例分娩中有 252 例 vs 386 例；风险差异为每 10 万例分娩减少 133 例；95%置信区间为 98-170），这一发现在调整了保险状况、社会经济因素和合并症后仍然存在（风险差异为每 10 万例分娩减少 160 例死胎；95%置信区间为 127-194）。此外，尽管有妊娠肝内胆汁淤积症的孕妇比没有妊娠肝内胆汁淤积症的孕妇更有可能早产（30.1% vs 9.3%；P<.001），但在按分娩时孕龄分层后，在任何时间点都没有观察到死胎率增加。
有妊娠肝内胆汁淤积症诊断代码的孕妇比没有妊娠肝内胆汁淤积症诊断代码的孕妇分娩更早，但即使考虑到出生时的孕龄，受死胎影响的分娩比例也较低。这些结果可能会让接受妊娠肝内胆汁淤积症诊断的患者感到安心，即当前的管理确实降低了妊娠肝内胆汁淤积症的死胎风险。
