We read with great anticipation the report by Puljic et al. The authors presented data in support of a positive correlation between advancing gestational age in intrahepatic cholestasis of pregnancy (ICP)-affected pregnancies and risk of fetal demise. The authors controlled for the large number of disparities and confounding maternal variables, such as older age, member of ethnic minority, and the presence of cardiovascular disease, between the 2 study groups. However, we suggest the higher stillbirth rates identified in the study group are directly related to the prevalence of the confounders known to be risks for fetal demise. The authors should have provided characteristics of women in the study who experienced a stillbirth, along with a data plot permitting review of the correlation and adjustments used for their analysis. Puljic et al provided a citation indicating that active management of ICP-affected pregnancies is not associated with increased rates of cesarean deliveries. This cited randomized delivery trial enrolled 30 and 32 women in the active and expectant management group, respectively. While 100% (30/30) of women assigned to early term delivery were actively managed and delivered early, only 37% (12/32) of women assigned to receive expectant management had no intervention before the onset of spontaneous labor. Therefore, we suggest the small sample size and intent-to-treat analysis of this randomized trial would call into question its use as evidence that active management of ICP-affected pregnancies is not a risk for a cesarean delivery. The early impetus for evaluating the association between ICP and adverse perinatal outcome was that ICP was a cause of unexplained stillbirth. In their analysis, Puljic et al have inappropriately treated accepted independent explanations for stillbirths as irrelevant confounding information.