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We thank the authors of the 2 letters regarding our article investigating the risk of stillbirth in patients with intrahepatic cholestasis of pregnancy (ICP). In that study, we demonstrated both that ICP was associated with an increased risk of stillbirth and that gestational age at delivery that would minimize overall perinatal mortality was 36 weeks of gestation. For the latter, we utilized a relatively novel methodologic approach, which compares the risk of infant mortality at 1 gestational age to the risk of expectant management for 1 week including the risk of stillbirth plus the risk of infant mortality at the next week of gestation.


It appears that there were 2 primary concerns. The first is that we did not consider the baseline differences between women with ICP and the control women to whom they were compared. As we noted, we did indeed control for the various potential confounding factors listed in Table 1 in that article and there was still more than twice the risk for stillbirth in the ICP group. More importantly, our approach to identify the gestational age at which the lowest combined perinatal mortality rate can be identified is only within the specific at-risk cohort, in this case the women with ICP. In that population, we identified that delivery at 36 weeks’ gestation would minimize perinatal mortality.


The other apparent concern was the potential negative impact of intervention. We would certainly agree that there are morbidity tradeoffs with delivery at 36 or 37 weeks’ gestation such as increased risk of respiratory immaturity. Such tradeoffs between morbidity and mortality would need to be considered.


The other concern about intervention is the negative impact of induction of labor. While it is true that traditionally it was thought that induction of labor would increase the risk of cesarean delivery, there is increasing evidence to suggest that that may not be true. Even the HYPITAT trial that randomized a high-risk group, women with preeclampsia, to induction vs expectant management did not find a higher risk of cesarean delivery in those who were induced.


Unfortunately, ICP has been understudied and because it is a relatively rare complication of pregnancy, we have less information to make informed decisions about management. That being said, a recent decision analysis also found that 36 weeks was the optimal gestational age for delivery. We appreciate the interest in our study and hope that it provides additional information to clinicians and patients alike who are trying to manage the diagnosis of ICP to minimize the negative fetal and neonatal impacts.

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May 5, 2017 | Posted by in GYNECOLOGY | Comments Off on Reply

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