[Clinical analysis of fetal death cases in intrahepatic cholestasis of pregnancy].

OBJECTIVE: To investigate the clinical features, critical laboratory parameters, and fetal monitoring methods in intrahepatic cholestasis of pregnancy (ICP).

METHODS: A retrospective analysis of 21 cases of ICP suffered with fetal death in Women's hospital, School of Medicine, Zhejiang University from January 1999 to December 2010 were discussed.

RESULTS: (1) The average age of ICP patients suffered with fetal death were (30.2 ± 4.6) years old. Among them, 4 cases were older than 35 years, six cases were multipara, one of them suffered stillbirth 2 year before. Twenty cases were singleton pregnancies and 1 case was twin pregnancy. (2) All 21 cases of fetal death occurred in the third trimester, 12 cases occurred before 37 weeks, 9 cases after 37 weeks.Nine cases were diagnosed by ultrasound in outpatient clinics, fetal heart beat disappeared in 9 patients after admission because of ICP, two disappeared after labor, one during anesthesia before emergent surgery. Perinatal mortality rate of ICP was 0.148% (21/14 184), and fetal death occurred from 29 to 41 weeks with an average gestational age of (33.8 ± 4.2) weeks. (3) Puritus occurred in all 21 cases while 11 of them had pruritus all over the body. Ten pregnant women felt the fetal movement decreased or disappeared before diagnosis of fetal death. The glycocholic acid levels increased in all of the 21 cases. Among them, glycocholic acid levels in 11 cases were (21.49 - 64.48) µmol/L, while in 10 cases were ≥ 64.48 µmol/L. Serum bile acid levels elevated in 16 cases which had been analyzed (the other 5 cases had not been checked), and the highest level reached 270 µmol/L. Serum alanine aminotransferase and aspartate aminotransferase were increased in 14 cases. Seven cases had their total bilirubin > 21 µmol/L, and 12 cases had their direct bilirubin levels significantly elevated. Among the 21 cases of ICP, 15 cases were in severe status, while the other 6 cases were mild. (4) Nine patients had no antepartum surveillance since fetal death were diagnosed before admission. The results of antepartum surveillance were as follows: 2 cases had nonreassuring nonstress test (NST), one had mild "V" type deceleration. Absence of diastolic flow in umbilical artery were found in 3 cases, and low fetal biophysical score was got in one case. (5) All 21 patients had vaginal delivery. Six of them delivered after natural contraction, and the remaining 14 cases delivered after oral intake of mifepristone and amniotic injection of ethacridine, or oxytocin induced labor within 48 hours, only one case delivered after additional dinoprostone suppositories. The appearance of fetus, placentas and membranes were normal, the lengths of umbilical cord were average. Four cases were found with cords binding the necks or the bodies. Eighteen cases had grade III amniotic fluid with meconium-stained, and 2 cases complicated by oligohydramnios. Ten cases had their fetuses and placentas examined by pathologist. Among them, one case had multiple malformations, no more obvious pathological abnormalities were found in other fetuses. Pathologic examination showed that fibrin deposited around chorion and deciduas basalis, large vessels accompanied by calcification, degeneration, hemorrhagic infarction, and increased focal syncytial nodules could be seen in all of the ten placentas.

CONCLUSIONS: Fetal death in pregnant women with ICP often occurs after the contractions, Severe ICP may be a key factor that involved in the occurrence of fetal death. Up to now, there is no valid indicators in fetal monitoring, which can predict fetal death. Extensive assessment of the severity and careful antepartum surveillance should be achieved before timely termination of pregnancy.