Intrahepatic cholestasis of pregnancy : a

retrospective case-control study of perinatal outcome

in the University Hospital of Split

Nunhofer, Verena

Master's thesis / Diplomski rad

2018

Degree Grantor / Ustanova koja je dodijelila akademski / stručni stupanj: University of

Split, School of Medicine / Sveučilište u Splitu, Medicinski fakultet

Permanent link / Trajna poveznica: https://urn.nsk.hr/urn:nbn:hr:171:483003

Rights / Prava: In copyright / Zaštićeno autorskim pravom.

Download date / Datum preuzimanja: 2023-11-16

Repository / Repozitorij:

MEFST Repository
 UNIVERSITY OF SPLIT
SCHOOL OF MEDICINE

Verena Nunhofer

INTRAHEPATIC CHOLESTASIS OF PREGNANCY : A RETROSPECTIVE CASE-

CONTROL STUDY OF PERINATAL OUTCOME IN THE UNIVERSITY HOSPITAL
OF SPLIT

Diploma thesis

Academic year :
2017/2018

Mentor :
Assoc. Prof. Marko Vulić, MD, PhD

Split, September 2018

 UNIVERSITY OF SPLIT
SCHOOL OF MEDICINE

Verena Nunhofer

INTRAHEPATIC CHOLESTASIS OF PREGNANCY : A RETROSPECTIVE CASE-

CONTROL STUDY OF PERINATAL OUTCOME IN THE UNIVERSITY HOSPITAL
OF SPLIT

Diploma thesis

Academic year :
2017/2018

Mentor :
Assoc. Prof. Marko Vulić, MD, PhD

Split, September 2018

TABLE OF CONTENTS

1. INTRODUCTION .............................................................................................................. 1

1.1. Intrahepatic cholestasis of pregnancy .............................................................................. 2

1.2. Etiology and pathogenesis ............................................................................................... 3
1.3. Diagnosis ......................................................................................................................... 5
1.4. Pharmacological management ......................................................................................... 8
1.5. Non-pharmacological management ............................................................................... 10
1.6. After birth: follow-up and counseling ........................................................................... 12
2. HYPOTHESIS .................................................................................................................. 13

3. MATERIALS AND METHODS ...................................................................................... 14

4. RESULTS ......................................................................................................................... 16

5. DISCUSSION ................................................................................................................... 21

6. CONCLUSIONS............................................................................................................... 31

7. REFERENCES ................................................................................................................. 33

8. SUMMARY ...................................................................................................................... 38

9. CROATIAN SUMMARY ................................................................................................ 40

10. CURRICULUM VITAE ................................................................................................... 43

1. INTRODUCTION
1
1.1. Intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a unique hepatic disorder characterized

by mild to severe pruritus and disturbed liver function tests. After viral hepatitis, it is the
second most common cause of jaundice in pregnant women (1,2).

A wide variation of incidence in different regions globally has been observed, being
the highest among pregnancies in Chile, Bolivia, and Scandinavian countries; however, a
declining trend was noticed here, with more recent reports of prevalences between 1.4 and
4.0% in Chile and 0.1-1.5% in Scandinavia. Although there is no definitive explanation for
this drop, the aforementioned differences may suggest a geographical and seasonal
environmental influence (2,4). As outlined later, variations in the mother’s serum levels of
zinc, selenium, and copper, explainable with differences in dietary intake, seem to be
noteworthy in this context (1).

Obstetric cholestasis typically appears during the late second or the third trimester. It
is characterized by maternal signs and symptoms for which alternative causes could be ruled
out: pruritus of varying severity without skin rash is considered the cardinal symptom,
characteristically affecting the palms and the soles of the feet; patients may also suffer nausea,
vomiting and upper abdominal pain. The diagnosis is established with serologically proven
abnormal liver function tests and additionally or alternatively an increase in bile acid levels,
the latter being the laboratory parameter with the highest importance during workup (1,3,4,5).
The condition usually resolves within a short time after delivery, typically within a period of
48 hours (1,3).

Although the morbidity of mothers affected by ICP consists mainly of pruritus and an
increased risk of postpartum bleeding, their prognosis is good. Fetal morbidity and mortality,
however, appear to be markedly increased in pregnancies affected by ICP. A number of
complications can arise as a result of ICP, including preterm delivery (spontaneous or
iatrogenic), fetal distress, meconium staining of amniotic fluid and death in utero (1,3).

The aforementioned characteristics of ICP coupled with a remarkable prevelance

makes the condition discussed a matter of clinical importance and relevant for current day
research.

2
1.2. Etiology and pathogenesis

Even though the exact etiology for ICP is unknown, research sugests it to be
multifactoral. This includes factors such as hormonal inbalance, genetics, environment and
even inflammatory mechanisms appear to contribute to the pathogenesis of the condition
investigated (1,6).

1.2.1 Hormonal Influence:

Among steroid hormones, increased plasma estrogen and progesterone are proposed to
play a role in the development of ICP, which can be supported by multiple observations: The
condition appears during the third trimester, is more prevalent in pregnancies with multiples
and can feature complications similar to those in women using contraceptive medication with
high estrogen content. One can assume that, because of those higher estrogen values, a vicious
cycle of impaired sulfonation and transport of bile acids, resulting cholestasis and increased
oxidative stress on hepatocytes emerges. Furthermore, a disturbance in the elimination of
progesterone is discussed by some authors as an underlying pathophysiological mechanism.
Explanations include errors in metabolic and secretory mechanisms with a possible interplay
of overproduction of reduced hormone metabolites and malfunctioning or overloaded
transport systems (1,2,6,7).

1.2.2 Genetic Influence:

The possibility of genetic predisposition to intrahepatic cholestasis of pregnancy is
suggested by various factors, including clustering of that condition and other diseases of the
biliary system in families, differences in prevalence according to ethnicity and geographical
region and genetic mutations, even though it should be emphasized that the latter could be
proven only in a small proportion of cases (1,2). The theory is that genetically determined
changes in transport mechanisms of hepatocytes and cells of the biliary tract finally lead to
their malfunction. In this context most commonly mentioned is the canalicular phospolipid
export pump MDR3, coded in the gene ABCB4; due to mutations the pump seems to be
expressed in reduced number in the cellular membrane which causes a lower concentration of
phospholipids in bile (1,2,5,8). This phenomenon comes into the picture of several clinical
conditions: ICP, progressive familial intrahepatic cholestasis (PFIC) type 3, juvenile
cholelithiasis, neonatal and drug-induced cholestasis (8). Therapeutic relevance of this
circumstance lies within the aspect that that the abnormally low expression of the MDR3
pump can be stimulated and enhanced with drugs to a certain degree (9). Also on examination
3
of placentas of affected pregnancies, an insufficiency in the expression of bile acid
transporters was detected. Furthermore, based on placental genetic profiles of some cases of
ICP, it can be assumed that also the immune system and the regulation of angiogenesis are
relevant for the emergence of the pathology discussed here (1). Still, one should be aware of
the fact that genetic mutations such as the ones just explained above can be proven only in a
very low proportion of patients suffering obstetric cholestasis (2).

In addition, a significant incidence of ICP in hepatitis C – positive pregnant women

has been described. However, also here the correlation between these two diseases is yet to be
established (8).

1.2.3 Environmental Influence

Apart from the above mentioned and some other contributors, also factors from the
environment seem to play a key role in the development of intrahepatic cholestasis of
pregnancy, especially in women with hereditary predisposition. Studies have found that the
disease seems to appear more commonly during the winter months. This has been attributed to
the lower availability of selenium, a cofactor in metabolic processes in liver cells, in
seasonable diet, next to the diminished dietary intake of zinc during this period of the year. In
the same season-related context the connection of ICP with lower serum levels of 1,25-
dihydroxy vitamin D seems explainable. Levels of copper, on the other hand, were found to
be increased (1,10).

Not any less complex than the etiology of ICP are the pathophysiological
circumstances of this disease which bare a risk for the fetus in addition to the mother.

A combination of distinct factors seems to lead to hostile conditions for the fetus
alongside other complications. According to literature, increased flow of bile acids from the
maternal to the fetal compartment coupled with the limited capacity of the fetus to eliminate
those and functional changes in placental tissue coming down to the level of cell signaling
play a role (1,11). The consequently abundantly incurred bile acids result in multi-system
toxic effects: They are, on one hand, already in low concentrations hepatotoxic in the fetal
compartment and induce apoptosis in the fetal liver (1,10,11). On the other hand, these bile
acids have a cardiotoxic effect on the fetus and can therefore cause dysrhythmias and even
sudden intrauterine death (7). Apart from the fetal myocard, the increased flow of bile acids
through the placental vasculature exposes also this tissue to oxidative stress. Accordingly it
was observed that bile acids have a vasoconstrictive effect on chorionic veins in vitro as well

4
as umbilical cord vessels. Those two mechanisms affecting heart and placenta can provide an
explanation for acute fetal anoxia and consequently enhanced peristalsis, meconium staining,
the inhalation of the same and resulting neonatal death (1,7,11,12). Moreover, even though
the exact chain of events of preterm labor requires further exploration, also this pregnancy
complication might be explainable with results from in-vitro research: It has been shown that
elevated bile acid levels stimulate myometrial contractions and enhance the activity of
oxytocin, probably by inducing increased expression of oxytocin receptors in human
myometrium. Additionally, it is assumed that a modified and enhanced prostaglandin
synthesis and secretion is a contributing factor to premature labor (1,6,8,12).

Although in literature emphasis traditionally has been given to the risk on the fetus
while stating that there is no serious danger resulting from ICP for the mothers, the potential
maternal risk factors pre – and postpartum should not be neglected. One such example is the
risk of hemorrhagic complications such as postpartal bleeding resulting from a deficiency in
vitamin K, increasing fetal as well as maternal mortality (1,10). Furthermore to mention is the
fact that women affected by cholestasis of pregnancy have an increased risk for the
development of other diseases of the hepatobiliary system such as hepatocellular carcinoma.
Also a more frequent appearance of cardiovascular conditions has been described, as well as
of diseases mediated by the immune system such as Crohn’s disease and diabetes (10).

1.3. Diagnosis

The diagnostic workup of intrahepatic cholestasis of pregnancy is based on a suspect

clinical presentation and supported by various laboratory tests. According to diverse current
guidelines such as the Clinical Guideline used in South Australia or the Management
Guideline provided by NHS Worcestershire Acute Hospitals in England, the way to a
diagnosis generally includes the following:

In every pregnant woman presenting with pruritus, serum bile acid measurements and
liver function tests are undertaken. In case of abnormalities in these values, a differential
diagnostic evaluation for viral infections, autoantibodies including those against smooth
muscle or mitochondria, and coagulation studies need to be performed. Alongside these
laboratory tests abdominal ultrasound studies to examine the hepatobiliary system is

5
appropriate especially where abdominal complaints or unclear laboratory results are present.
The diagnosis is finally obtained on the basis of laboratory work (3,4,13).

To date there is not a single and independent diagnostic test for ICP (4). Therefore the
diagnosis has to be made on grounds of the synopsis of different laboratory parameters and
after exclusion of alternative causes for the clinical and laboratory abnormalities. It should be
pointed out that reference values specific for pregnancy need to be applied. However, also
here a consensus about aspects such as acceptable ranges of values and circumstances for
blood sampling are missing (4,14).

As already mentioned, the laboratory test of bile acids in the serum has a high
sensitivity and therefore the best diagnostic value, especially in patients with pruritus but still
normal transaminases (13). Their elevation can also markedly aid distinction from other
pregnancy-specific liver diseases, for example, hyperemisis gravidarum, HELLP
("hemolysis", "elevated liver enzymes", "low platelets") syndrome or fatty liver of pregnancy,
in which this parameter stays within normal limits. (5) Regarding bile acids, some studies
attribute high significance especially to an increased ratio of cholic acid and
chenodeoxycholic acid (CA/CDA), however, other papers negate a diagnostic advantage
(2,13,14). A variation of limit values is used and debated; this is accredited to a number of
factors such as fasting state during blood drawing, the technique used in the laboratory and
the gestational age at the time of diagnosis (4,10,12,15). Bile acid values from 10 to 15
μmol/L are considered diagnostic (2,3,10,12). Values of 40 or also 50 to 70 μmol/L are
associated with an increased fetal risk. Therefore serum bile acid values can be viewed as
diagnostic as well as prognostic (5,10,14).

Next to the above mentioned, transaminases can provide valuable clues in diagnostic
processes regarding ICP. Accordingly, the alanine aminotransferase (ALT) value is regarded
as very sensitive, and its elevation indicating cell damage in liver tissue should be alarming
and lead to further investigations (13). However, one needs to consider that this parameter is
within normal limits in a third of all cases (14). Consequently, in literature an increased value
is at times not considered diagnostic (4).

The same is true for alkaline phosphatase (ALP) which rises in case of pregnancy
cholestasis, but as well only with little diagnostic importance. The reason for this is that this
enzyme is also produced in placental and bone tissue; therefore, an increase in serum
concentration does not necessarily need to indicate a disease (13,14,15).

6
 Literature shows a great disagreement about whether an increase in γ-glutamyl
transferase (γ-GT) in ICP is characteristic for the condition at all. Unchanged values are being
reported, but also slight or severe elevation (2,5,14,16,17). Relevance lies in the fact that a
higher plasma value is suggestive for MDR3-mutations, which, however, is currently not
tested routinely (13).

Only in 15 – 20 % of all cases of ICP, bilirubin in serum is elevated. However, it can

become apparent in urine (13).

The missing consensus regarding reference values contributes to the fact that
intrahepatic cholestasis of pregnancy still is a diagnosis of exclusion (14).

Generally it must not be forgotten that the condition may not immediately become
evident in abnormal laboratory values as some pregnant women may suffer the characteristic
itching but still have normal liver function test results. In these cases a repeat measurement is
required after one or two weeks (4,15).

The differential diagnosis is broad-ranging and includes diagnoses that can be specific
for pregnancy or exist independently from it (8). Accordingly, by anamnesis one needs to
exclude causes like medicaments or alcohol abuse. Additionally, serological tests should be
performed to rule out hepatitis caused by agents such as hepatitis virus A, B and C or also as
consequence of infections with cytomegalovirus (CMV) or Epstein-Barr virus (EBV). Also
other, genetically caused hepatopathies can present with a similar clinical picture, suspicion in
those cases is raised by icterus and / or pruritus as adverse reaction to oral contraceptives or as
a problem in childhood. Also autoimmune conditions affecting the liver should be taken into
consideration, especially when the family history of the patient is positive. Other reasons for
pruritus can range from polymorphic eruption of pregnancy to dermatologically alternatively
explainable eczemas, atopies or pemphigoid (4,8,15). In early or otherwise atypical cases, pre-
eclampsia and fatty liver of pregnancy as reasons for diminished liver function should be
investigated, as mentioned earlier (15).

7
1.4. Pharmacological management

ICP is a condition that requires management. The aim is to alleviate maternal

symptoms and to reduce the risk to the fetus as much as possible, pharmacologically mainly
by means of the reduction of cholestasis and of bile acids in serum (1,18).

Currently considered the first line treatment option is ursodeoxycholic acid (UDCA), a
physiological component of human biliary secretions (18). There are several theories about
the mechanism of action of UDCA which, besides other aspects, concern the reparation or
correction of bile acid transport and consequently the enhancement of transplacental excretion
of bile acids, their reduction in maternal serum and amniotic fluid (1,18). After all, those
changes may be protective for hepatocytes, bile ducts and the fetal heart. Also, they can
contribute to an improved perinatal outcome, not only by their protective effect itself, but also
by a consequently longer maintenance of the pregnancy (1,18). However, there is no
consensus in current research about this improvement (19). A Cochrane review from 2013
stated that by usage of UDCA pruritus could be mildly diminished. However, in comparison
with a placebo group, no statistically significant difference regarding the benefit for fetal
distress could be observed (20). There are different dosage recommendations. Generally, 2 x
500 mg per day or 10, 15 or 20 mg/kg/d are prescribed, and an effect in low as well as in
higher standard doses is reported (1,18). This was noted on symptomatic as well as on
biochemical levels already after two weeks of therapy (21). In general, UDCA has a favorable
profile of side effects for mother and fetus, and the use in the third trimester of pregnancy is
safe (1). Only mild diarrhea was reported as a potential adverse drug reaction among mothers
treated with it (13). After follow-up checks on the children of mothers whose ICP was treated
with UDCA that lasted up to 12 years, no negative consequences on longer term regarding
growth and development or diseases could be observed (22). Despite all the mentioned
advantages and the medication’s popularity, it has to be noted though that its use in ICP is still
off-label: although its use has been approved for a number of cholestatic hepatopathies, this
approval has not been obtained yet with pregnancy cholestasis as an indication (13).

Cholestyramine belongs to the group of anion exchange resins and acts by binding bile
salts, diminishing their presence in the enterohepatic circulatory system (1,13,20). Acting in
this fashion, it would also bind UDCA and impair its action. Therefore, those drugs should be
administered separately from each other if one decides for the simultaneous usage of both
(13). Cholestyramine is shown to improve the mother’s morbidity, however, not the

8
biochemical test results or the fetal situation (1,18). According to the aforementioned
Cochrane review, sufficient evidence for its usefulness is missing (20). Furthermore, the relief
of the patient’s symptoms might be only of short duration and their recurrence after about a
week after treatment initiation has been reported (18). The use of this substance is considered
in very severe cases (17). Cholestyramine does not only bind and eliminate UDCA, it also
complexes with fat-soluble vitamins and lessens their enteral absorption (18,23). In this
context, especially the importance of vitamin K is emphasized in literature sources, but also
the other liposoluble vitamins A, D, and E and a sufficient maternal dietary intake or
supplementation of these should be considered (23,24). In case of a prolonged prothrombin
time, vitamin K should be administered in a daily oral dose of 10 mg (4). For the reason
explained previously, it is recommended to avoid the use of cholestyramine if possible (18).

S-Adenosyl-L-methionine (SAMe) is a substance changing the composition and

liquidity of cell membranes and enhancing the metabolism and elimination of hormone
metabolites (1). The benefit of its usage, however, is questionable, and there is not enough
evidence for its medicative effect: Not only were the results compared with placebo
conflicting, also an increased incidence of preterm delivery was reported after usage of SAMe
as a monotherapy which is the reason to advise against this way of application (18,20).

Phenobarbital is used in case of ICP to improve pruritus and is effective in it in 50% of

all cases (1). This improvement is suggested to be caused by the medication’s effect on the
central nervous system (18). However, no improvement could be seen in laboratory studies,
and also adverse effects such as malformations of the fetus, hypoventilation or diminished
intelligence must be pointed out (1,18).

For the treatment of itching, rifampin and antihistamines are in use as well. Because of
its sedating effect, the latter ones proved to be helpful especially against nocturnal pruritus
(1).

Also dexamethasone in high doses a 12 mg per day is thought to be helpful in the

management of ICP. However, solid evidence for this is lacking, and the drug seems to be not
very effective in lowering serum levels of bilirubin and bile acids and inefficient in the
therapy of pruritus (1,20). Not only the insignificant effect is a point to consider, but also that
dexamethasone has important side effects such as insulin resistance in the treated mother (20).
Even though this drug is known to lower the incidence of respiratory distress in neonates by

9
enhancing lung maturation in utero, on the other hand, it is still suggested by at least one
source to not use it, or at least not as a monotherapy (20).

In cases not responding to pharmacological treatment, the application of

plasmapheresis for the removal of bile acids from the serum or phototherapy with ultraviolet
B (UVB) radiation have been reported to be a beneficial treatment option (25,26).

1.5. Non-pharmacological management

Also non-pharmacological management in terms of surveillance and finally the timing

of delivery are aspects that are approached with several distinct concepts (13). Generally,
active and expectant management are distinguished, and both concepts have advantages and
disadvantages.

Regarding surveillance during the time of pregnancy it is worth mentioning that

different techniques are used, however, not in a provably effective way. A precise prediction
or even prevention of stillbirth seem not to be possible to date (15,27). Surveillance got
intensified since many practitioners seem to prefer expectant management, keeping in mind
though that an early onset or detection, respectively, seems to be associated with a higher risk
for the fetus (13,19).

There is disagreement about several aspects of care for pregnant women affected by
intrahepatic cholestasis, starting with the seemingly simple question of how often tests and
examinations should be performed. Trying to find an answer to this question, one should keep
in mind that death was not the result of a chronically developing problem but of a sudden
event (2). Weekly controls are suggested, next to the mother’s own continuous monitoring of
aspects that also lie within her own perception such as fetal movements, their decreasing
intensity or absence (1,4,13,15). This expectant management might take place in an outpatient
scenario, as suggested by the South Australian Perinatal Practice Guidelines, as long as serum
bile acids are below 40 μmol/l and ALT below 200 units per liter (4). In fact, as mentioned
earlier, bile acids are not only of importance for diagnosis but also during surveillance when it
is about to decide how to continue the management of the patient (2).

From the 30th week of gestation onwards, next to weekly non-stress tests, assessment
of amniotic fluid volume, Doppler sonography of the umbilical arteries and a growth scan are

10
suggested for surveillance (1). It is notable that the recommendation of the last mentioned
measure is in contradiction to the fact that fetal death happens as a sudden event, as explained
earlier (2). Other sources propose weekly cardiotocography, furthermore a weekly control of
laboratory values including coagulation studies such as prothrombin time (1,13). As a part of
active management, amniocentesis in the 36th gestational week for the control for meconium
and signs of fetal lung maturity are advised next to close and attentive monitoring, before
labor should be induced in week 37 (2). The just described active way of management is
supposed to make it possible to continue a pregnancy under close surveillance to the latest
possible point in time (29). However, some authors emphasize that there is no indication for
the endorsement of active management of pregnancies complicated by obstetric cholestasis
(30).

After all, birth is talked about as the only method that can prevent fetal mortality
definitely (27). When timing birth, for each patient the risk that early delivery carries needs to
be traded off individually against the dangers of continuing the pregnancy (1,2,13).

There are various opinions about the best point in time to induce labor. Some experts
suggest this for as early as week 36, or, in case ICP is diagnosed later, immediately at that
point, and justify this with the apparently then lowest risk of fetal, neonatal and infant
mortality; at the same time though they point to the morbidities of premature infants of this
gestational age (27).

Often, the 37th week of gestation is suggested as the most favorable moment for
delivery to prevent a stillbirth afterwards (15,31). However, this point in time might not be
optimal for twin pregnancies (7). Reference is made to biochemical tests as crucial for the
decision to induce birth: In case of bad or worsening laboratory values, or more specifically,
in case of bile acid values of 40 μmol/l or higher, induction of labor should be considered
(3,32). For the period of the 37th or also 38th week of pregnancy as optimal time window for
induction of labor in case of ICP solid evidence is lacking (1,10). Nevertheless, some
specialists prefer week 38 due to the aforementioned unpredictability of stillbirth after this
period (4,27). In case of favorable and stable laboratory results, also the planning of birth only
in week 39 is mentioned in literature (3).

Summarizing, one can note that also for timing of labor in case of obstetric cholestasis
there is no consensus and accordingly also no clear guideline (2).

11
1.6. After birth: follow-up and counseling

The circumstance that obstetric cholestasis is a diagnosis confirmed only after birth
makes following up the mother for a couple of weeks reasonable (3).

After one or two days, itching should disappear, jaundice after approximately one
week, and also bile acid and liver function test values should be within normal ranges within a
week to ten days postpartally (3,4). Normalization of liver values may take six to twelve
weeks though; if they are too high after this period of six weeks or longer, the patient should
be referred to a gastroenterologist (3). This is because such test results may indicate an
underlying liver disease (4). For this case, a screening for liver cancer and other diseases such
as autoimmune disorders is recommended (33).

Furthermore, counseling regarding a couple of points concerning the time after a

pregnancy complicated by ICP appears appropriate. For example, affected women should be
informed that, even though pruritus disappeared after pregnancy, it might return in future
pregnancies (34). Information about probability of this to happen varies from source to source
from 40 or 45 up to 60, 70 or even 90%, respectively (2,3,4.8). Also, skin itching might
appear cyclically around the time of ovulation (2). Regarding contraception, women should be
advised that oral combined contraceptives can be used as soon as liver test results normalized
after pregnancy, however, with the risk of pruritus and elevation of liver enzymes. (10)
Knowing of the risk of contraceptive-induced cholestasis, this medication should be
discontinued as soon as symptoms occur (8,13). There is no contraindication for breastfeeding
after suffering intrahepatic cholestasis during pregnancy (13).

Even though it is claimed that there are no serious long-term sequelae for the mother
nor the child (4), it was shown that changes in metabolism of children of affected mothers can
occur, becoming evident in the alternations in blood lipid profiles or increase in body mass
index (BMI) (33). Also an increased risk for cancer of the hepatobiliary system,
cardiovascular and autoimmune disorders in affected mothers was noticed, as well as a
connection to other, hereditary diseases of the liver and bile tract, next to a higher risk of the
development of obstetric cholestasis in female offspring of affected women (2,4,33).

12
2. HYPOTHESIS
13
 There is a significant difference in epidemiology and perinatal outcome between
pregnancies with cholestasis and healthy pregnancies. We assume a worse perinatal
outcome in the case group. In the case group we expect a higher age of mothers, higher
BMI of mothers, shorter pregnancy duration, more Cesarean sections, a lower Apgar
score, a lower umbilical cord blood pH and a lower weight, length and size for gestational
age of the fetus in comparison to healthy pregnancies.

14
3. MATERIALS AND METHODS

14
 We conducted a retrospective case-control study and used data collected on women
who gave birth between 1st of January and 31st of December 2016 in the University Hospital
of Split (KBC Split) and their newborns. The information about cases and controls were
obtained from handwritten birth protocols in the delivery room and patient files archived in
the Department of Gynecology and Obstetrics and transferred anonymized to an Excel table.

Identified as a case of ICP and therefore included into the case group was every
woman who presented with a clinical picture matching the diagnosis of ICP and whose serum
transaminases were elevated to double of normal. Exclusion criteria were aneuploidy,
malformations of the child and multiple pregnancy. Since such cases were not found within
the group of women with obstetric cholestasis, effectively none of the patients were excluded.

Included into the control group via a matching process was every birth consecutive to
a case of ICP with parity identical to that case. The data investigated included the mothers’
age in years, maternal BMI, parity, duration of pregnancy in completed weeks, fetal weight in
grams, fetal length in centimeters, Apgar score, umbilical cord blood pH, delivery mode and
size for gestational age.

Within the given period, we identified 28 cases of intrahepatic cholestasis of

pregnancy and obtained an equal number of controls. However, documentation was partly
incomplete in four patients of the control group and four patients in the case group so that in
analysis of some variables this number differed: In the case group, we obtained umbilical cord
blood pH values in only 23 cases and the mother’s BMI in 27 cases. In the control group, the
maternal BMI was documented 27 times, the pH value 26 times, and the newborn’s size for
gestational age 27 times.

For statistical testing we used the program Statistica 12 (StatSoft, USA). Student’s t-
test was used to test the difference between two numeric variables with normal distribution.
Normality was tested using Kolmogorov-Smirnov test.

Tests on categorical variables were χ2 test and, in case data sets did not meet the
prerequisites for it, Fisher’s exact test. To examine the difference in two proportions, two
proportion Z-test was used. P-values of less than 0.05 were considered statistically significant.

15
4. RESULTS

16
 Out of 4266 births that took place between the 1st of January 2016 and the 31st of
December 2016 in the University Hospital of Split, 56 were included in our study.

Parity was equally distributed in test and control groups of equal sizes (28 women
each) as we used this parameter for matching of the two. As shown in Figure 1, in both
groups, the documented birth was the first for 11 patients, for 12 patients each it was the
second, for 4 patients each it was the fourth, and for 1 patient each it was the fifth time giving
birth.

Further epidemiological and clinical characteristics observed in both groups are

given in Table 1. In the control group, the mean of the mother's age was 30.43 years with an
average deviation from the mean of 4.66 years. The mean BMI calculated in these mothers
was 23.53 with an average deviation of 4.99. In the case group, the mean of the mother's age
was 30.25 years with an average deviation from the mean of 4.07 years. The mean BMI found
in this group was 22.86 with a deviation of 2.58 on average. Values that were normally
distributed had an empirical p-value of more than 0.05 each. Evaluations of the difference in
values of case and control group gave a p-value of greater than 0.05 and therefore did not
indicate statistical significance.

Table 1. Epidemological and clinical characteristics of pregnant women with and without
intrahepatic cholestasis

ICPa Control group

P*
(N=28) (N=28)

Mothers' age
30.25±4.07 30.43±4.66 0.879
(years)

Maternal BMIb
22.86±2.58 23.53±4.99 0.535
(kg/m2)
*Student's t-test
a
Intrahepatic cholestasis of pregnancy
b
Body mass index

As aspects of perinatal outcome examined, in the case group, average fetal weight
was 3493.57 g with an average deviation from the mean of 551.75 grams. Average fetal
length was 50.39 cm with an average deviation from the mean of 1.97 cm. The average pH of
17
umbilical cord blood was 7.32 with an average deviation from the mean of 0.09. Values that
were normally distributed had an empirical p-value of more than 0.05 each. In the control
group average fetal weight was 3373.21 g with an average deviation from the mean of 517.02
grams. Average fetal length was 49.75 cm with an average deviation from the mean of 2.01
cm. The average pH of umbilical cord blood was 7.34 with an average deviation from the
mean of 0.07. Values that were normally distributed each had an empirical p-value of more
than 0.05. Since the p-value at the evaluation of differences was greater than 0.05, no
statistical significance could be observed here. The just described findings are shown in Table
2.

Table 2. Perinatal outcome of pregnancies with and without intrahepatic cholestasis

ICPa Control
P*
( N=28) (N=28)

Fetal weight
3493.57±551.75 3373.21±517.02 0.403
(g)

Fetal lenght
50.39±1.97 49.75±2.01 0.232
(cm)

pH 7.32±0.09 7.34±0.07 0.431

*Student's t-test
a
Intrahepatic cholestasis of pregnancy

It could be observed that in the case group fewer patients (25 = 89.29%) were pregnant
for 37 weeks or longer compared to the control group (27 = 96.43%). Two of the pregnancies
in the case group (7.14%) lasted between 34 and 36+6/7 weeks, compared to none in the
control group. One pregnancy on the case group (3.57%) and none in the control group was
between 32 and 33+6/7 weeks long. The control group contained one pregnancy that lasted
between 28 and 31+6/7 weeks (3.57%), in contrary to the control group which contained no
pregnancy of such duration. After creating, two groups regarding pregnancy duration, one
including pregnancies of 37 and more weeks, and the second one including those that lasted
shorter than 37 weeks and testing independence using Fisher exact test, we obtained an

18
empirical p-value of 0.118 from which we could conclude that differences in pregnancy
duration of cases and controls were not significant.
Examining Apgar scores in both groups, all 28 newborns (100%) in the control group
obtained one between 8 and 10. However, in the case group this was the case only in 26
(92.86%) of all deliveries, where two cases were observed with a score in the range between 4
and 7 (7.14 %). Independence was tested using Fisher exact test, and we obtained a p-value of
0,245 which led us to the conclusion that the difference in the prevalence of Apgar scores
among case and control patients was not of statistical significance.
22 pregnant women with cholestasis (78.57%) had a vaginal delivery in contrast to 18
(64.29%) in the control group. A Cesarean section was performed in 6 women in the case
group (21.43%) and 10 women in the control group (35.71%). We used χ2 test to examine
whether there is a correlation between the condition of intrahepatic cholestasis and mode of
delivery. Based on the obtained empirical χ2 value of 1.411 with degree of freedom of 1 and a
p-value of 0.235 we can conclude that the type of delivery is not significantly affected by the
presence or absence of ICP.
Children whose size was appropriate for gestational age (AGA) were given birth to by
23 women (85.2%) of the control group and 25 women (89.29%) with cholestasis. 2 children
(7.4%) each were considered small for gestational age (SGA) or large for gestational age
(LGA), respectively, in the control group. In the case group, 10.71% of born children were
LGA and none were SGA. Respective p-values over 0.05 indicated statistical insignificance
of the just mentioned differences in proportions.

19
Table 3. Perinatal outcome of pregnancies with and without intrahepatic cholestasis

ICP, n (%) Control, n (%) P

Pregnancy duration
(completed weeks) 0.118 *
<37 3 (10.71) 1 (3.57)
< 28 0 0
28-316/7 0 1 (3.57)
32-336/7 1 (3.57) 0
34-366/7 2 (7.14) 0
37 ≤ 25 (89.29) 27 (96.43)
Apgar score 0.118 *
4-7 2 (7.14) 0
8-10 26 (92.86) 28 (100.0)
Delivery mode 0.235 †
Vaginal 22 (78.57) 18 (64.29)
CSa 6 (21.43) 10 (35.71)
Size for gestational
age
SGAb 0 2 (7.4) 0.142 ‡
c
AGA 25 (89.29) 23 (85.2) 0.648 ‡
d
LGA 3 (10.71) 2 (7.4) 0.670 ‡
*Fisher's exact test
† χ2-test
‡ Two proportion Z-test
a
Cesarean section
b
Small for gestational age
c
Appropriate for gestational age
d
Large for gestational age

20
5. DISCUSSION
21
 While affected mothers traditionally are considered to have a good prognosis, fetal
morbidity and mortality appear to be considerably increased in pregnancies complicated by
intrahepatic cholestasis (1,3). This and the fact that medical research still has not come to
satisfactory understanding of the disease, make the condition discussed here a matter of
clinical and scientific interest. Various theories about the pathophysiology of ICP exist, as
outlined earlier. All these points may contribute to the circumstance that to date there are
several approaches to and no consensus among national and regional guidelines concerning
the management of pregnancies affected by cholestasis. Consequently, a review and
evaluation of pregnancy outcomes in the University Hospital of Split with the local current
practice seemed to be beneficial; identifying differences in cases of cholestasis compared to
unaffected control pregnancies could give important hints and could support or point to a need
of changing today’s approach and management of pregnant women with ICP.

For this study we identified all 28 documented cases in the birth registers of the
University Hospital of Split in 2016 (1.1. -31.12.) and compared next to epidemiological data
about the mothers (age, parity, BMI) information about the perinatal outcome (pregnancy
duration, delivery more, Apgar score of the first minute and umbilical cord blood pH, fetal
weight and length and size for gestational age) with those of a control group of equal size.
Doing so, we could not find any statistically significant differences in the parameters that
were analyzed and will be discussed separately below:

According to various sources such as the ACG Clinical Guideline referring to liver
disorders in pregnancy, higher age is counted as a risk factor for ICP, which made it important
to us to examine this parameter in our patient group (31). Doing so in our study, we found that
women in the case group were marginally younger than women of the healthy control group
(on average 30.25 vs. 30.43 years), however, this finding turned out to be of no statistical
significance (p>0.05). A similar but also insignificant observation was made by researchers in
Saudi Arabia who found women with ICP to be at the average age of 29.18 years compared to
the 29.86 years of unaffected mothers (35). These results differ from other studies which
suggest a link between the age of the mother and prevalence of ICP (8,10,31). In a study
focusing on twin pregnancies, for example, mothers with cholestasis turned out to be slightly
older (7). A different paper published by authors from Turkey which compared milder and
more severe cases of cholestasis according to their outcome even found a direct correlation of
higher age and greater severity of the disease (p<0.05) (36).

22
 Since age is listed as a risk factor for the development of obstetric cholestasis, as
explained above, and regardless of our results obtained from a rather small patient group, it
might be advisable to still take it into account and treat older mothers with increased vigilance
(10,28,31).

As we used parity as the characteristic to match controls to cases, we could not make
an observation about the difference in this variable between diseased and healthy pregnant
women, unfortunately. The Clinical Guideline for management of obstetric cholestasis
released by the Government of South Australia states that its distribution among women who
have not been pregnant before and multigravidae is generally equal (4). On average, women
with and without diagnosed ICP who gave birth in KBC Split had two children. In other
studies mothers with cholestasis were mostly primiparae (2,7,19). Otherwise cases of ICP
were found to have a lower parity compared to the control group; however, this was not a
significant observation (35).

Since a high body weight is commonly known to be a risk factor for many adverse
health events, among which metabolic diseases and cancers that can as well affect the liver
are listed, it was of interest to us to investigate also this parameter in the context of ICP (40).
In our study the body mass index before pregnancy of mothers suffering cholestasis turned
out to be insignificantly lower than the BMI of mothers that were not affected by this
condition. Contradicting this, the results of a different study published in 2017 showed that
more severe cases of obstetric cholestasis tended to have a higher BMI before pregnancy (12).
However, our findings are in concordance with the results of the study on twin pregnancies in
which women with ICP appeared to have a significantly lower pre-pregnancy BMI (22.9±2.9
compared to 23.6±3.2; p=0.017) (7). Likewise, the research conducted in Saudi Arabia
mentioned previously states state the observation of an insignificantly higher body mass index
in the control group (p=0.34). It is interesting to notice that in their study case as well as
control group were, according to World Health Organization (WHO) – definitions, with
average BMIs of 29.55 and 30.23 overweight or obese, respectively (35,40). Consequently
one might wonder how much of a role in the development of ICP a too high pre-pregnancy
BMI plays at all.

Still, dyslipidemia, a common finding in individuals with a too high BMI, i.e. a BMI
equal to or greater than 25, has been observed in the context of ICP (11,40). Furthermore, as
explained earlier, increased estrogen levels might play a role in the pathophysiology of the
disease (1,2). These two aspects support the idea that a high body mass index, which per
23
definition by the WHO corresponds to a great body fat percentage, in mothers might be a
factor favoring the development of obstetric cholestasis (40).

Shortened pregnancy duration is known to be linked to fetal risks and complications.

Consequently, the circumstance that preterm birth has been linked to ICP was our motivation
to conduct statistical analysis regarding this aspect among the patients of our groups. (1,3)
However, our results show no significant difference between women with and without the
diagnosis of ICP in the average duration of pregnancy or, more specifically, the incidence of
preterm birth which is defined as a delivery before the completion of the 37th week of
pregnancy (37). We could observe an insignificantly elevated rate of preterm birth in the case
group (p=0.118).

Still, the observation of a more common occurrence of preterm delivery was made in
many other studies: an article published in 1994 reports a significant (p<0.05) "2.8-fold
increase in the incidence of premature delivery (<37 weeks)" and also points out that this
observation includes a finding of three times as many spontaneous deliveries compared to the
healthy control group (38). Also other authors who compared cases of severe cholestasis with
healthy pregnancies found that affected women gave birth significantly earlier than women
without ICP (25% vs. 6.5%, p<0.001); however, in their study sample most preterm births
were iatrogenic (39). Iatrogenicity of preterm birth was not examined in our study. Matching
these findings, researchers from Istanbul conclude that the level of serum bile acids is in
correlation with premature birth (6). Also the figures of the study from 2017 that was referred
to earlier show that mothers affected by ICP gave birth earlier with increasing severity of their
disease according to their bile acid levels ( p = 0.002) (12).

These results are in direct contrast to the findings of other research papers such as of a
study conducted in Istanbul, Turkey, which could not correlate the degree of derangement of
laboratory values at diagnosis of ICP (serum TBA, AST, ALT, GGT and AP) with the
gestational age at delivery, however, with a p-value greater than 0.05 this finding was
statistically insignificant (19). As well opposing our results but also with a p-value indicating
insignificancy, the authors from Saudi Arabia reported a slightly higher incidence of preterm
birth in their case group (35).

Remarkable for the studies compared above are the varying and also contradicting
reports of the incidence of deliveries before week 37, especially iatrogenic ones. This
circumstance might reflect the missing consensus among professionals regarding active or

24
expectant management strategies and the recommendations in the many different guidelines
regarding timing of a possible induction of labor in case of cholestasis of pregnancy that was
discussed earlier.

Obstetric situations can quickly become acute and borderline and therefore require the
appropriate choice of delivery mode. C-section is often the method of choice in critical
situations and valued by many obstetricians because as surgical intervention it makes birth a
more controllable process (41). Given the risks that a pregnancy complicated with ICP carries,
a higher proportion of Cesarean sections would be expectable in the case group. However, an
insignificantly higher proportion of Cesarean sections as opposed to vaginal deliveries in the
control group compared to the case group could be observed in the control group in our study
(p=0.235). This distribution stands in contrast to the findings of other studies. In one the
authors report Cesarean section as mode of delivery in 25.9% of their ICP group and 16.9%
(p<0.05) and explain this higher proportion of C-sections in this group with an insignificantly
increased rate of elective procedures (37). Likewise, the incidence of Cesarean deliveries
elsewhere was reported to be higher in their case group (19.7%) compared to their control
group (14.5%), however with a higher percentage of emergency rather than elective
procedures in both groups (p=0.15) (35). Also figures published in 2014 showed
proportionally more Cesarean sections in the cholestasis group (25%) compared to healthy
pregnancies (23%), however, p-values higher than 0.05 indicate no statistical significance
(39).

Whether C-sections were elective, as it is not rarely the case in Western medical
practice, or necessary procedures in our study population was not subject to our evaluation
(41).

Apgar score has established itself as an important step in the standard protocol of the
first evaluation of the newborn and makes it possible to get an impression of the neonate’s
physical condition seconds after delivery which made it a valuable component of our analysis
of perinatal outcome (37). All newborns born to mothers of our control group had Apgar
scores of the 1st minute between 8 and 10, and in the case group this score was reached by 26
out of 28 neonates. According to the scoring concept proposed by Virginia Apgar in 1953,
children with this score are considered to be in "good condition" (42). The difference in this
subjectively obtained indicator of perinatal outcome measured in our study turned out to be
insignificant.

25
 Also, other sources do not mention a significant difference in Apgar scores between
neonates born to affected and unaffected mothers, respectively. However, a comparison
between our and their percentages might not be very sound. The reason for this is that their
definition of a satisfying score for the newborn seems to be a bit more permissive with a score
of only lower than 7 being used to describe a problematic perinatal outcome: One research
group reported a score < 7 in the first minute in 7.8% of their cases compared to 7.2% in their
control group (37). In the population studied with focus on twin pregnancies, after five
minutes, 2.4% of newborns of mothers suffering ICP had an Apgar score below 7, compared
to 2.0% in the healthy control group (p=0.565) (7). Other authors who studied a group of ICP
patients and put them into groups according to whether there were adverse perinatal outcomes
(Group I) or not (Group II) reported insignificantly better Apgar scores after one minute in
their second group (8.27±0.9 compared to 7.94±1.1 in Group I) (36). Overall, no significant
correlation between Apgar score and the presence or absence of cholestasis could be made.

As an objective numerical value, umbilical cord pH is a parameter that is

recommended to obtain during the assessment of newborns at least after high-risk births.
Since it is still not ideally reflecting the degree of asphyxia in the fetus, its appreciation in
combination with the Apgar score appears reasonable (43). Reference ranges among different
researchers and authors for the umbilical cord blood pH vary greatly, and the precise
definition of significant acidemia of the fetus remains debatable (44). Overall, professionals
seem to agree on a pH < 7.0 to be associated with severe consequences for the newborn if the
child does not appear "vigorous" (43,45).

In our study, with average pH values of 7.34 and 7.32 in the control and the case
group, respectively, we could not see a significant difference in this parameter. Generally and
according to teaching literature, those values > 7.30 can be considered "normal" (41).

In accordance with the suggestion to perform umbilical cord blood pH measurement in

births that seem to carry a risk, authors of an article mentioned earlier obtained the value in 21
newborns of the group with ICP and eight of the control group with the suspicion of distress
to the fetus during the delivery process, i.e. the indication was given more often in the case
group. They could detect asphyxia in a higher proportion of suspicious children of the case
group (12 out of 21 cases, or 57%) than in the control group (3 out of 8, or 37.5%) with
average values of 7.08 and 7.07, respectively (p-value was missing) that can be categorized as
advanced acidosis (35,41).

26
 Other studies rarely considered taking this variable into account to describe perinatal
outcome, it does not seem to be performed as a standard test. A reason for this can be that this
test, as all laboratory procedures, takes time and is an extra expense. Furthermore it has been
described that the umbilical cord pH value has a lot of confounding factors including the
timing of sampling and delivery mode (43). Besides, the Apgar score per se as a well-
approved routine measure seems to give a sufficiently solid estimation of the newborn’s
wellbeing.

Birth weight, especially set in relation to gestational age, can be an important indicator
concerning fetal risk, morbidity and mortality. Especially a low birth weight or small size for
gestational age, respectively, is often the consequence of placental malfunction (37). Since,
according to current research, also the placenta might be affected in ICP, it seemed reasonable
to include data on fetal growth (weight, length and size for gestational age) as descriptor of
perinatal outcome in our analysis (1). Doing so, we found an insignificantly higher birth
weight in children born to mothers with obstetric cholestasis compared to healthy mothers.
Furthermore, newborns of the case group were a bit longer; however, that difference had no
statistical significance either. Our results regarding fetal weight are contrasting those of other
research papers: authors of one article could observe the birth weight neonates of mothers
affected by ICP to be lower (on average 3049.5g) than in their control group (3357.5g) and
with a p-value < 0,001 their result was significant (39). Also in concordance with this, other
researchers measured significantly lower weights in their case group (2360±425g) compared
to patients of their control group (2459±446g) in their study on twin pregnancies (7).

Fetal length was not measured in other studies.

Newborns of the case group of our study were either of average size or in three cases
large for gestational age, compared to the control group who gave birth mostly to average
sized children, or, in two cases each, to children that were small or large for their gestational
age. This determination was based on population-adjusted diagrams visualizing percentiles as
body weight per weeks of gestation. However, the noted differences turned out as of no
statistical significance.

A similar trend becomes apparent in the results of researchers who compared the birth
weight centiles of their groups with and without cholestasis and detected significant
differences. In the mean the neonates of the case group were around the 47.6th centile of size
for gestational age and the ones of the control group were around the 40.8th (p<0,001). By

27
more detailed investigation of SGA (<10th centile) and LGA (>90th centile), they could
detect a significant higher proportion of SGA deliveries in healthy mothers (16% vs. 11% in
cases, p=0.007 after comparison adjusted for confounding factors). Also incidence of births to
LGA children was, like in our population, higher in the case group, however insignificantly as
a p-value of 0.44 showed (39).

Still, the above mentioned observations of mothers with ICP birthing slightly larger
neonates are unexpected, looking at the results of other studies.

In their study involving twin pregnancies, the authors report with 9.9% a significantly
higher incidence of newborns that were LGA in their healthy control group, compared to their
case group where they obtained this finding in 5.9% (p=0.049) so that they were even
referring to "a protective effect on the incidence of LGA". Their comparison of the incidence
of SGA was not significant (p=0.247) (7). A different paper as well reported a significant
correlation of the incidence of fetal growth restriction (p<0.01) with higher levels of total bile
acids and an earlier diagnosis of cholestasis of pregnancy (19). On the other hand, other
studies such as a recent one mentioned earlier could not observe such a pattern concerning
bile acids and SGA births (12).

The missing congruence of results regarding the association of intrahepatic cholestasis of

pregnancy and size for gestational age raises questions about placental involvement in
chronically evolving problems during ICP as opposed to acute events such as sudden
intrauterine death where placental involvement has been scientifically proposed. It may also
motivate to investigate further variables that can potentially affect fetal growth during ICP,
such as the mother’s stress level, diet or metabolic profile.

A rather small set of data was subjected to statistical testing. Since all cases that we
found have been integrated to come to one result per variable, it is not surprising that single
exceptional findings could not come to attention but might still deserve it.

Concerning the distribution of suboptimal findings in the different parameters

examined (specifically, a short pregnancy duration, low pH, and SGA / LGA), it is noticeable
that they did not appear combined in the healthy control group but only single.

This is different in the case group where they can indeed be observed in combination,
namely in younger primigravid women that were admitted mostly between September and

28
November 2016. This matches several epidemiological factors that have been linked to
cholestasis of pregnancy in studies and literature:

 One child was born after 365/7 weeks and showed an Apgar score of 6 with a pH of
7.211.
 One child was born after 365/7 weeks with an umbilical cord blood pH of 7.231.
 One child was born after 326/7 weeks with a weight of 1600g, still AGA, the pH value
was not recorded.
 Two children had acidotic pH values of 7.190 and 7.273, respectively, and were LGA.

Even though the overall statistical picture is satisfying since the outcome in pregnancies
complicated by ICP seems to be as good as the outcome of normal and healthy pregnancies in
the University Hospital of Split, these specific findings encourage to continue taking the
diagnosis of cholestasis in pregnancy especially serious and handle identified cases with care.

Strengths that can be attributed to our study are the following: The women in the case
and control groups were of very similar epidemiological background which gave the
observation of perinatal outcome itself a sort of neutral basis. Also, the umbilical cord pH that
was mostly missing as a parameter in comparable studies had been obtained for almost all
pregnancies.

Weaknesses of our study include a rather small sample size. This can be explained
with that we obtained our data observing a period of time that is rather short for a disease with
such a low incidence. Besides, during the referring time interval laboratory tests different
from the ones that are common today were used for diagnosis; therefore, one may assume that
with other tests and diagnostic criteria maybe more cases would have been identified.
Furthermore, medical documentation sometimes shows deficits so that not only data in the
birth protocols are missing occasionally but also patient histories seem to have some gaps.
This human error may possibly also be transferred to the process of data collection which was
conducted by a single person.

In the future it would be good to have a larger patient sample as well as to carry out
the search over a longer period of time. To be as efficient as possible, obtaining data from
other hospitals in Croatia would allow a larger sample size for the creation of a bigger
population-based picture regarding ICP.
29
 Also, by adapting laboratory diagnostic methods in the University Hospital of Split,
for example the introduction of measurement of serum bile acids indicated by a suspicious
clinical picture, more cases could be detected that might not come to attention with current
procedures used in this hospital.

To gain more insight into the effectiveness of the management strategies of ICP in
Split, future studies might follow patients regarding the treatment they received and other
related aspects. Generally, further clarification of the etiology and pathophysiology of
obstetric cholestasis is needed. With a deeper understanding, the treatment approach could be
shifted from an empiric and experience-based to a more standardized and objective one so
that a greater conformity and uniformity of guidelines for the management of ICP could be
achieved.

30
6. CONCLUSIONS
31
1. There is no significant difference in epidemiology and perinatal outcome between
pregnancies with and without ICP in our study population.

2. It is necessary to achieve more precise and more standardized diagnostic tools and
methods for obstetric cholestasis in clinical settings as an important step towards a
consensus regarding the management of patients with ICP.

32
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26. Sävervall C, Sand FL, Thomsen SF. Dermatological Diseases Associated with Pregnancy:
Pemphigoid Gestationis, Polymorphic Eruption of Pregnancy, Intrahepatic Cholestasis of
Pregnancy, and Atopic Eruption of Pregnancy. Dermatol Res Pract. 2015;2015:979635.

27. Puljic A, Kim E, Page J, Esakoff T, Shaffer B, LaCoursiere DY et al. The risk of infant
and fetal death by each additional week of expectant management in intrahepatic
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28. Kia L, Rinella ME. Interpretation and Management of Hepatic Abnormalities in

Pregnancy. Clin Gastroenterol Hepatol. 2013;11(11):1392-8.

29. Jain R, Suri V, Chopra S, Chawla YK, Kohli KK. Obstetric cholestasis: outcome with
active management. J Obstet Gynaecol Res. 2013;39(5):953-9.

30. Henderson CE, Shah RR, Gottimukkala S, Ferreira KK, Hamaoui A, Mercado R. Primum
non nocere: how active management became modus operandi for intrahepatic cholestasis
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31. Tran TT, Ahn J, Reau NS. ACC Clinical Guidline: Liver Disease and Pregnancy. Am J
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33. Erlinger S. Intrahepatic cholestasis of pregnancy: A risk factor for cancer, autoimmune
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34. Kamimura K, Abe H, Kawai H, Kamimura H, Kobayashi Y, Nomoto M et al. Advances in

understanding and treating liver diseases during pregnancy: A review. World J
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35. Al Shobaili HA, Hamed HO, Al Robaee A, Alzolibani AA, Amin AF, Ahmad SR.
Obstetrical and fetal outcomes of a new management strategy in patients with intrahepatic
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36. Ekiz A, Kaya B, Avci ME, Polat I, Dikmen S, Yildirim G. Alanine amonotransferase as a
predictor of adverse perinatal outcomes in women with intrahepatic cholestasis of
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8. SUMMARY

38
Objective: To determine whether there is a difference in the perinatal outcome in pregnancies
complicated by intrahepatic cholestasis compared to unaffected pregnancies.

Materials and methods: Out of 2466 births that took place in the University Hospital of Split
in 2016, 28 identified pregnancies affected by obstetric cholestasis were compared to an
equally sized control group regarding maternal epidemiology and perinatal outcome. Included
into the control group was every birth recorded consecutive to a case of with parity equal to
that case. Investigated parameters were the mothers’ age, maternal BMI, pregnancy duration,
fetal weight, fetal length, Apgar score, umbilical cord blood pH, delivery mode and size for
gestational age.

Results: There was no statistically significant difference in the observed variables in

pregnancies affected and not affected by intrahepatic cholestasis. The average maternal age of
the case group was 30.25±4.07 years, compared to 30.43±4.66 years in the control group
(p=0.879). Mothers with ICP had an average BMI of 22.86±2.58, those without had one of
23.53±4.99 (p=0.535). Pregnancy lasted 37 weeks or longer in 89.29% of cases of ICP,
shorter than that in 10.71%, compared to the control group where 96% of pregnancies lasted
at least 37 weeks and 3.57% lasted shorter (p=0.118). Average fetal weight in the case group
was 3493.57±551.75g and 3373.21±517.02g in the control group (p=0.403). Fetal length on
average was 50.39±1.97cm in the case group and 49.75±2.01cm in the control group
(p=0.232). 92.86% of babies of mothers with ICP had an Apgar score between 8 and 10 and
7.14% had one between 4 and 7, while after healthy pregnancies all neonates achieved a score
between 8 and 10 (p=0.118). The average umbilical cord blood pH in newborns of the ICP
group was 7.32±0.09 and 7.34±0.07 in the control group (p=0.431). 78.57% of women of the
case group had a vaginal delivery and 21.43% underwent a Cesarean section, while in the
control group 64.29% gave birth vaginally and 35.71% per C-section (0.235). No newborn of
the ICP group and 7.41% of the ones born to healthy group were SGA (p=0.142), 89.29% in
the case group and 85.19% in the control group were AGA (p=0.648), and 10.71% of
neonates in the group with cholestasis were LGA compared to 7.41% in the group without
cholestasis (p=0.670).

Conclusion: There is no difference in perinatal outcome between normal pregnancies and

pregnancies complicated by intrahepatic cholestasis in the University Hospital of Split.

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9. CROATIAN SUMMARY

40
Naslov: Intrahepatična kolestaza trudnoće: Retrospektivno istraživanje slučajeva i kontrola
perinatalnog ishoda u KBC-u Split

Cilj: Odrediti da li postoji razlika u perinatalnom ishodu u trudnoćama sa intrahepatičnom

kolestazom u usporedbi sa trudnoćama van utjecaja intrahepatične kolestaze.

Materijali i metode: Od 2466 porođaja koji su se dogodili u KBC-u Split u 2016. godini, 28
identificiranih trudnoća pod utjecajem intrahepatične kolestaze uspoređene su sa kontrolnom
skupinom iste veličine u vezi epidemioloških karakteristika majki i perinatalnog ishoda. U
kontrolnoj skupini je uključen svaki porod dokumentiran uzastopno slučaju intrahepatične
kolestaze sa paritetom jednakim tom slučaju. Istraženi parametri su bili dob majke, BMI
majke, trajanje trudnoće, porodna težina, porodna duljina, Apgar zbroj, pH krvi pupačne
vrpce, način rođenja i trofičnost djece.

Rezultati: Nije bilo značajnih razlika u istraženim varijablama u trudnoćama sa

intrahepatičnom kolestazom u usporedbi sa trudnoćama bez intrahepatične kolestaze.
Prosječna dob majka u ispitivanoj skupini je bio 30,25±4,07 godina, u usporedbi sa 30,43
±4,66 godina u kontrolnoj skupini (p=0,879). Majke sa kolestazom su imali prosječan BMI od
22,86±2,58, one bez kolestaze od 23,53±4,99 (p=0,535).Trudnoća je trajala 37 tjedana ili duže
u 89,29% slučaja kolestaze, kraće od toga u 10,71%, u usporedbi sa kontrolnom skupinom u
kojoj 96% trudnoća je trajalo barem 37 tjedana i 3,57% je trajalo kraće (p=0,118). Prosječna
porodna težina u ispitivanoj skupini je bila 3493,57±551,75g i 3373,21±517,02g je bila u
kontrolnoj skupini (p=0,403). Porodna duljina u prosjeku je bila 50,39±1,97cm u ispitivanoj
skupini i 49,75±2,01cm u kontrolnoj skupini (p=0,232). 92,86% novorođenčadi majki sa
intrahepatičnom kolestazom je imalo Apgar zbroj od 8 do 10 i 7,14% od 4 do 7, ali poslije
zdravih trudnoća sva novorođenčad je postigla zbroj između 8 i 10 (p=0,118). Prosječan pH
krvi pupačne vrpce u novorođenčadi od skupine sa kolestazom je bio 7,32±0,09, i 7,34±0,07
je bio u kontrolnoj skupini (p=0,431). 78,57% žena u ispitivanoj skupini su rodile vaginalno i
21,43% su se podvrgnule carskom rezu, dok u kontrolnoj skupini 64,29% su imale vaginalni
porod i 35,71% carski rez (p=0,235). Nijedno novorođenče iz skupine sa kolestazom i 7,41%
onih rođenih u zdravoj skupini nije bilo hipotrofično (p=0,142), 89,29% u ispitivanoj skupini i

41
85,19% u kontrolnoj skupini su bili eutrofični ( p=0,648), i 10,71% novorođenčadi u skupini
sa kolestazom su bili hipertrofični u usporedbi sa 7,41% u skupini bez kolestaze (p=0,670).

Zaključak: Ne postoji razlika perinatalnog ishoda između normalnih trudnoća i trudnoća

kompliciranih sa intrahepatičnom kolestazom u KBC-u Split.

42
10. CURRICULUM VITAE

43
Personal information :

Name and surname : Verena Nunhofer

Address : Spinčićeva 33a, 21000 Split

Telephone number : +385 95 7226779

E-mail address : verena_nunhofer@yahoo.de

Date and place of birth : 31st August 1992, Fürth, Germany

Nationality : German

Education :

2001 – 2010 : Melanchthon-Gymnasium Nürnberg

WS 2010/11 : Friedrich-Alexander-Universität Erlangen-Nürnberg,

BA studies in Latin and Ancient Greek

2012 : University of California Berkeley Extension,

distance course in Human Physiology

2012 – 2018 : University of Split School of Medicine,

Medical Studies in English

Clinical traineeships :

08.2015 : Klinikum Heidenheim, Heidenheim / Brenz ( DE ) : Cardiology

08.2016 : Klinikum Nürnberg Süd, Nürnberg ( DE ) : Neurology

08.2017 : Klinikum Nürnberg Süd, Nürnberg ( DE ) : Anesthesia

01.2018 : Klinikum am Europakanal, Erlangen ( DE ) : Psychiatry

Other activities :

2006 – 2008 : Workers' Welfare Association Nürnberg,

voluntary tutoring of pupils

2008 – 2012 : Private tutoring of pupils

2011 – 2012 : Internistische Fachklinik Dr. Steger, Nürnberg,

Federal Voluntary Service at the dialysis center

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