Outcome after implementation of a modern management strategy for intrahepatic cholestasis of pregnancy.

OBJECTIVE: The aim of this study was to determine whether the institution of a modern management strategy affected pregnancy outcomes for intrahepatic cholestasis of pregnancy (ICP). METHODS: We performed a retrospective cohort study of women diagnosed with ICP at one hospital from 2005 to 2013. A new management protocol for ICP was instituted in 2009 for women with total bile acids >40 µmol/L at <36 weeks. This strategy included inpatient admission, continuous fetal heart rate monitoring, with delivery between 36 and 37 weeks. We compared maternal and neonatal outcomes prior and subsequent to the institution of this protocol. RESULTS: We identified 186 singleton gestations with bile acids >40 µmol/L and diagnosis <36 weeks. Patient demographics were similar between the groups, with the exception of greater maternal age and gestational diabetes in the newer cohort. The newer cohort demonstrated a significant reduction in the incidence of stillbirth 0% versus 3.4%, p= 0.035). There was no difference in the age at delivery, cesarean delivery rates or NICU admissions. CONCLUSION: Application of our management strategy for ICP reduced the stillbirth rate without adversely affecting other maternal and neonatal outcomes.

Predictive value of combined serum biomarkers for adverse pregnancy outcomes.

OBJECTIVE: To determine if a combination of first and second trimester serum biomarkers (pregnancy-associated plasma protein A (PAPP-A), free ßhCG, and maternal serum alpha-fetoprotein (msAFP)) may be utilized to develop a predictive model for adverse pregnancy outcomes. STUDY DESIGN: We conducted a retrospective analysis including all women who delivered at our institution between 2007 and 2010. We estimated the area under the ROC curve (AUC) to compare predictive abilities of PAPP-A, free ßhCG, and msAFP singularly, and in combination for adverse pregnancy outcomes. We sought to predict the risks of preeclampsia, preterm delivery (PTD, <37 weeks gestational age) and low birth weight (LBW, <2500g). Using logistic regression analysis, we created models that controlled for maternal age, race, parity, body mass index, and histories of chronic hypertension and tobacco use. RESULTS: The final sample included 2199 women. Determining the AUC and optimal cutoff probability values for each of the biomarkers, we found that for PTD and LBW, the combination of all three biomarkers was most predictive, while for preeclampsia the combination of msAFP and PAPP-A was most predictive. The AUC of the three biomarker combination to detect adverse pregnancy outcomes are as follows: LBW 67%, PTD 72%, and preeclampsia 77%. We created race-specific logistic regression models to predict the risk probabilities. To illustrate, the predictive probability for a 33-year-old African American, nullipara with a BMI of 50, chronic hypertension, tobacco use, PAPP-A 0.3, msAFP 2.0 and free ßhCG 0.98 MOMs are: PTD 59%, LBW 61% and Preeclampsia 91%. CONCLUSION: The combination of biomarkers currently utilized in Down syndrome screening may also be used to predict additional adverse pregnancy outcomes. Further studies are needed to determine optimal maternal and fetal surveillance, if and when increased risks are identified.

Increased recurrence of preterm delivery with early cessation of 17-alpha-hydroxyprogesterone caproate.

OBJECTIVE: The purpose of this study was to identify the effect of early cessation of 17-alpha-hydroxyprogesterone caproate (17P) on the incidence of spontaneous recurrent preterm delivery (PTD). STUDY DESIGN: Retrospective analysis of data from women who were enrolled for outpatient 17P administration between January 2004 and May 2006 included women with previous PTD and current singleton pregnancy who were beginning weekly 17P injections (250 mg intramuscularly) at 16-20.9 weeks. The study group was comprised of patients who were electively terminating 17P at <32.0 weeks and who delivered >10 days from the last injection. The control group consisted of patients who received weekly 17P injections until PTD or 36.9 weeks of gestation. The primary study outcome was the rate of recurrent spontaneous PTD. RESULTS: Study group patients were significantly more likely to have spontaneous recurrent PTD at <37 weeks of gestation (48.1% vs 33.3%; P = .011), at <35 weeks of gestation (30.9% vs 14.0%; P < .001), and at <32 weeks of gestation (16.0% vs 7.0%; P = .020). CONCLUSION: Early cessation of 17P treatment is associated with an increased risk for spontaneous recurrent PTD.