We read with interest the retrospective review of intrahepatic cholestasis of pregnancy (ICP) by Brouwers et al. During the study period, to avoid unexplained term stillbirth, the standard of care for ICP-affected pregnancies included active management to deliver infants as early as 37 weeks of gestational age (GA). However, despite routine implementation of active management, 2 fetal deaths occurred in the group affected by severe ICP. Regrettably, the reader is not provided with any information to consider confounders that may have contributed to the perinatal mortality such as fetal gestational age, maternal cardiovascular disease, or prior cases of intrauterine death or growth restriction.

We are chagrined that in the absence of supportive evidence, because active management did not prevent the 2 fetal deaths, the authors suggest future investigation is warranted to evaluate earlier delivery of ICP-affected pregnancies between 35 and 37 weeks’ GA. Given that active management to deliver late preterm infants at 37 weeks’ GA is associated with documented maternal and perinatal harm without substantiated evidence of perinatal benefit, we oppose the consideration of earlier delivery of ICP-affected pregnancies.

Brouwers et al reported that 30% of gravidas in the severe ICP group had either spontaneous or iatrogenic preterm births. The author cites evidence that elevated bile acids increase the sensitivity and expression of oxytocin receptors in human myometrium. However, in this retrospective report, the severity of ICP was not directly related to the incidence of spontaneous preterm labor. Indeed, the mildly affected group had the highest rate of spontaneous preterm labor. The mild, moderate, and severe ICP study groups had spontaneous preterm labor rates of 28 of 108 (25.9%), 10 of 86 (11.68%) and 4 of 21 (19.0%), respectively. Whereas this lack of direct correlation between preterm labor and ICP severity likely is due to inadequate power for this subgroup analysis, these findings do not suggest bile acids have a direct effect on oxytocin receptors in the myometrium.