We thank Dr Lee et al for a thoughtful critique. Our systematic review was prompted by the same limitations in intrahepatic cholestasis of pregnancy literature that Lee et al noted: retrospective studies, underpowered study size, and lack of biochemical testing. Nevertheless, these papers continue to be cited as supportive evidence for active management in the absence of more robust studies. It is unfortunate that our literature review was complete and our manuscript was already in the publication pipeline by the time the article by Geenes et al, the largest prospective national cohort study of severe intrahepatic cholestasis of pregnancy, was first published online. Inclusion of the article by Geenes et al would have added support to our findings.

However, we disagree with many of the other suppositions of Lee et al. When evaluating unexplained term stillbirth, it is appropriate to exclude cases with comorbid conditions known to be independent risks for fetal demise. The control group in the article by Geenes et al excluded complicated pregnancies, while their study group included complicated pregnancies. When only stillbirths occurring in uncomplicated pregnancies are considered, study groups of Geenes et al have similar stillbirth rates: 3/713 and 11/2205, respectively, P = .79.

We also disagree with the suggestion of Lee et al that an appropriate background stillbirth rate during our study period should be 1-2/1000. While we relied on public surveillance data for our background stillbirth rates, epidemiologic evidence cited by Lee et al indicates that during our study period stillbirth rates after 28 weeks of gestation varied between 2.97 and 4.95/1000.