We thank the authors regarding our paper investigating the risk of stillbirth in patients with intrahepatic cholestasis of pregnancy (ICP). To summarize that study, we found that: (1) ICP was associated with an increased risk of stillbirth as compared to pregnancies without ICP, and (2) when comparing immediate delivery vs expectant management, delivery at 36 weeks of gestation would minimize overall perinatal mortality. The authors questioned whether we had any information regarding severity of cholestasis and suggested that timing of delivery management might be changed with a more severe case of ICP.

It is certainly true that there have been attempts to stratify ICP by such features as symptoms (eg, levels of pruritus) or degree of laboratory abnormalities (eg, bile acids above/below a particular value). However, we are not aware of definitive information that would suggest that the risks of fetal compromise are statistically or clinically different by these features. However, it does seem that management of cholestasis with improved diagnosis and fetal monitoring may impact the rate of stillbirth, thus it may be that the optimal gestational age at delivery could be different from what we estimated. However, in that scenario it would be later than the 36 weeks we suggested, not earlier.

The authors suggest amniocentesis at 34 weeks’ gestation and delivery if mature. That seems significantly earlier than we demonstrated in our analyses. It is also earlier than a previous study that utilized decision analysis to identify the optimal gestational age, which also found that 36 weeks’ gestation minimized the combined morbidity and mortality. Other than the fetal/neonatal outcomes in the setting of absent/reversed diastolic flow in the setting of intrauterine growth restriction, a fetal indication for delivery at 34 weeks’ gestation is rare, so we would caution practitioners to be very careful about such management and consider whether expectant management could be employed at such an early gestational age.

Meanwhile, what is critically underscored by the authors’ letter is the importance of the management of ICP and the need for larger studies to examine the impact of medical management and predictors of outcomes. It is only through ongoing research that we will be able to improve the care for these women and their children.