New Review Reveals Best Intervention for Obstetric Cholestasis

Of the available treatments for obstetric cholestasis, ursodeoxycholic acid (UDCA) is associated with the greatest improvements in the symptom of pruritus, according to findings of the first update of an intervention review conducted by the Cochrane Pregnancy and Childbirth Group.¹
   
Obstetric cholestasis is a condition in which pregnancy hormones adversely affect gallbladder function that ultimately results in a build up of bile acids in the liver that overflow into the blood stream. The primary and often only symptom of this condition is severe pruritus, which occurs most often in the third trimester. The treatment goal is to relieve itching, but which treatment is most effective is unknown. This condition may put the fetus at increased risk for fetal distress, preterm birth, or stillbirth.
   
In this review, the researchers evaluated 21 trials involving 1197 women to determine the safety and effectiveness of interventions for obstetric cholestasis. Most of the trials involved moderate to high risk of bias.
   
UDCA was associated with greater improvements in pruritus than was placebo. In addition, use of UDCA, compared with placebo, resulted in significantly fewer total preterm births. However, no significant differences were found between UDCA and placebo for rates of fetal distress or spontaneous preterm births.
   
Trials involving the comparison of S-adenosylmethionine (SAMe) with placebo had mixed results. Some trials reported that SAMe was associated with greater improvements in pruritus symptoms, while others found no significant differences between treatment groups.
   
Compared with SAMe or cholestyramine alone, UDCA more effectively improved pruritus. UDCA plus SAMe was more effective than SAMe alone, but UDCA plus SAMe was no more effective than UDCA alone for improvement in pruritus. When UDCA and dexamethasone were compared, UDCA was associated with a significant improvement in pruritus only in women with severe obstetric cholestasis.
   
Overall, fewer cases of fetal distress or asphyxia were reported in patients who received UDCA than in those who received placebo, but the difference was insignificant. Large trials of UDCA are needed to determine more definitively whether it is associated with fetal benefits or risks.

Pertinent Points:
- The available evidence suggests that ursodeoxycholic acid (UDCA) significantly improves pruritus associated with obstetric cholestasis, although the benefit is modest.
- Fewer cases of fetal distress and asphyxial events were reported in the UDCA groups when compared with placebo, but the difference did not reach significance.
 

References:

1. Gurung V, Middleton P, Milan SJ, et al. Interventions for treating cholestasis in pregnancy. Cochrane Database Syst Rev. 2013;6.DOI: 10.1002/14651858.CD000493.pub2.