We read with great interest the article by Puljic et al. The authors demonstrated that intervention at 37 weeks reduced the risk of either neonatal or intrauterine fetal deaths. Unfortunately the authors did not distinguish between mild and severe intrahepatic cholestasis of pregnancy. Severe form (bile acids >40) has been shown to have an increased risk of adverse perinatal outcome, which is difficult to prevent with antenatal fetal surveillance. Meconium has been shown to be an independent risk factor for adverse fetal outcomes (odds ratio 7.3) in these patients. Several small series have shown improved outcomes when management of severe intrahepatic cholestasis of pregnancy included the following :

Transfer of prenatal care to tertiary center with neonatal intensive care unit capabilities;

Twice weekly antenatal fetal surveillance;

Amniocentesis at 34 weeks to assess amniotic fluid for the presence of meconium and fetal lung maturity;

In the presence of meconium or positive fetal lung maturity assessment, induction of labor or delivery was recommended;

If meconium was not present, then delivery was delayed until 36 weeks.

While we agree with the authors conclusions for the treatment of mild cholestasis, severe cholestasis needs more aggressive management to reduce the rate of neonatal mortality and morbidity.