1. Twin pregnancies with intrahepatic cholestasis of pregnancy (ICP) are associated with an increased risk of adverse perinatal outcomes than singletons
2. Twin pregnancies with ICP had increased total bile acid levels in maternal serum, which can be transported through the placenta
Evidence Rating Level: 2 (Good)
Intrahepatic cholestasis of pregnancy (ICP) typically presents in the late second or third trimester and has a prevalence rate ranging from 0.2-25%, with a prevalence up to five times higher in multiple pregnancies. ICP is associated with an increased risk of many adverse perinatal outcomes such as preterm birth, meconium-stained amniotic fluid, fetal distress, fetal hypoxia, sudden intrauterine fetal death, respiratory distress syndrome, neonatal asphyxia, and neonatal intensive care unit admission. Increased serum total bile acid (TBA) levels are present in twin pregnancies than in singletons, however management guidelines of ICP in twin pregnancies are unclear. This retrospective cohort study included 633 twin pregnancies and 1267 singleton pregnancies with ICP. TBA levels in maternal serum and umbilical cord blood were analyzed from 33 twin pregnancies. Regular antenatal care was performed every 2 weeks before 28 weeks and then weekly after 28 weeks, including nonstress test, ultrasound scanning and biochemical surveillance. Twin pregnancies with ICP had a higher risk of cesarean section (96.4% vs 76.1%), preterm birth (82.6% vs 19.7%), fetal distress (2.0% vs 1.3%), and neonatal intensive care unit admission (23.6% vs 5.1%) and were significantly associated with increasing TBA levels (P<0.05). Managing stillbirth is the main concern of ICP and can often lead to iatrogenic preterm birth and may play a role in the high rates of preterm birth seen in this study. This study also found a link between maternal serum TBA levels and umbilical cord blood TBA levels, indicating that TBA can be transported across the placenta, and is perhaps the mechanism leading to some of these adverse outcomes. Further studies involving larger centers are needed to further help facilitate management plans for ICP in pregnancy, especially those with multiple gestations.
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