Pruritus may be troublesome and is thought to result from elevated serum bile salt concentrations. Antihistamines and topical emollients may provide some relie. Although cholestyramine is reported to be efective, this compound also lowers absorption of fat-soluble vitamins, which may lead to vitamin K deficiency. Fetal coagulopathy with subsequent intracranial hemorrhage and stillbirth have been reported (Matos, 1997; Sadler, 1995).
A recent metaanalysis suggests that ursodeoxycholic acid relieves pruritus, lowers bile acid and serum enzyme levels, and may reduce certain neonatal complications. hese include preterm birth, fetal distress, respiratory distress syndrome, and neonatal intensive care unit (NICU) admission (Bacq, 2012). Kondrackiene and associates (2005) randomly assigned 84 symptomatic women to receive either ursodeoxycholic acid ($ to 10 mg/kg/d) or cholestyramine. hey reported superior relief with ursodeoxycholic acid-67 versus 19 percent, respectively. Similarly, Glantz and coworkers (2005) found superior beneits to women randomly assigned to ursodeoxycholic acid versus dexamethasone. he American College of Obstetricians and Gynecologists (2015) has concluded that ursodeoxycholic acid relieves pruritus and improves fetal outcomes, although evidence for the latter is not compelling.
Earlier reports describe excessive adverse pregnancy outcomes in women with cholestatic jaundice. That said, data accrued during the past two decades are ambiguous concerning increased perinatal mortality rates and whether close fetal surveillance is preventative. Several studies also illustrate this. In one evaluation of 693 Swedish women, perinatal mortality rates were slightly increased, but only in mothers with severe disease (Glantz, 2004). Sheiner and coworkers (2006) described no diferences in perinatal outcomes in 376 afected pregnancies compared with their overall obstetrical population. However, rates of labor induction and cesarean delivery in afected women signiicantly rose. Lee and associates (2009) described two cases of sudden fetal death not predicted by nonstress testing. In another study of 101 afected women, no term fetuses died, but 87 percent of women underwent labor induction, ostensibly to avoid adverse outcomes (Rook, 2012). Nonetheless, neonatal complications developed in a third of the pregnancies, particularly respiratory distress, fetal distress, and meconium-stained amnionic luid. These problems were noted more frequently in those with higher total bile acid levels. Herrera and coworkers (2017) reported similar results. Finally, Wikstrom Shemer and colleagues (2013) reported outcomes in 5477 women with cholestasis from a database of 1,213,668 births. They described novel associations of cholestasis with preeclampsia and gestational diabetes. Although neonates were more likely to have a low 5-minute Apgar score and to be large for gestational age, the stillbirth rate was not increased. This was thought to reflect higher induction and preterm birth rates. Thus, by this time, many had now recommended early labor induction to avoid stillbirth. Relecting this, at Parkland Hospital, some maternal-fetal specialists ofer induction at 38 weeks, whereas others suggest 39 weeks.