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Evaluating the 2023 European Association for the Study of the Liver Guidelines for Intrahepatic Cholestasis of
Nina Rodriguez1, Cecilia Katzenstein1, Lauren Alpert2
1Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Introduction:
Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease of pregnancy, varying in incidence based on population and associated with adverse outcomes. We assessed the prevalence and outcomes of ICP categories defined by the 2023 European Association for the Study of the Liver guidelines in a diverse US population.
Methods:
We conducted a retrospective cohort study (January 2009-April 2024) at our ethnically diverse health system. Suspected ICP patients were identified by pregnancy records with total serum bile acids (TSBA) ordered and categorized into Group A (normal TSBA, alanine aminotransferase [ALT]/aspartate aminotransferase [AST]), B (elevated ALT/AST, normal TSBA), or C (TSBA >19, normal or elevated ALT/AST).
Results:
Among 165,503 pregnancies, we identified 4,386 (3.6%) suspected ICP cases. The cohort was classified as A (65%), B (24%), or C (11%). On multivariable analysis, a pre-existing history of autoimmune disease, metabolic dysfunction-associated steatotic liver disease, and gestational hypertension were significantly associated with Group B compared with A. Group C was more strongly associated with Hispanic ethnicity, history of hepatitis C, and immune-mediated liver diseases. Preeclampsia was 3 times as common in Groups B and C compared with A. Group C had the highest odds of spontaneous preterm birth, meconium-stained amniotic fluid, and neonatal respiratory distress. Group B and C had higher rates of incident postpartum hepatobiliary diseases.
Discussion:
Our systematic evaluation of the 2023 European Association for the Study of the Liver guidelines for suspected ICP demonstrated that this novel group-based classification offers clinically meaningful risk stratification. Our findings support that both elevated TSBA (Group C) and elevated ALT/AST alone (Group B) warrant antepartum surveillance for adverse pregnancy outcomes. Group C's association with Hispanic ethnicity and pre-existing liver disease highlights the need for individualized monitoring during pregnancy. Group-specific increased incidence of postpregnancy hepatobiliary disease emphasizes the importance of targeted postpartum follow-up.
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