Our study is the first to uncover the relationship between peak TBA levels in ICP and outcomes of twin pregnancies, based on data from 1156 patients. This large-scale, single-center cohort study aims to elucidate the association between peak TBA levels in ICP and adverse pregnancy outcomes, including preterm birth, stillbirth, and fetal distress.
Over the past decades, the rate of multiple pregnancies has markedly increased due to the rise in assisted reproductive technologies (20). However, recent studies indicate a decrease in twin pregnancy rates since 2014 (21, 22). Twin pregnancies not only result in higher rates of cerebral palsy, stillbirth, and neonatal morbidity and mortality (23–25), but also elevate the risk of maternal complications such as hypertension (26). Moreover, the risk of stillbirth is greater and occurs earlier in multiple pregnancies(27, 28). In our study, the stillbirth rate was 1.82%, which is higher than the previously reported 0.28% for severe ICP pregnancies (19). The incidence of intrauterine death for singletons in our study was 1.64%, which is consistent with the 0.5–6.8% range reported in earlier studies (29). Additionally, our analysis of stillbirth rates at different gestational ages indicates a relatively stable rate between 32 and 36 weeks of gestation for overall ICP. Among the three groups, the incidence increased in the mild group, whereas it decreased in the moderate-low and moderate-high groups. This indicates that when managing patients with twin pregnancies complicated by ICP, enhanced fetal monitoring should be considered in late pregnancy, particularly for single chorionic twin pregnancies(30).
Severe ICP is a common cause of fetal complications. When TBA > 40, each 1 µmol/L increase in TBA increases the risk of fetal complications by 1–2% (31, 32), and the fetal myocardium is also more prone to damage (33). Fetal complications include spontaneous preterm birth, fetal distress, arrhythmias, pulmonary insufficiency, meconium-stained amniotic fluid, and intrauterine death (34, 35). The relationship between ICP severity and meconium-stained amniotic fluid may indicate underlying fetal distress. The pathophysiological mechanisms of stillbirth due to ICP remain unclear (36), with some studies suggesting that bile acids may cause fetal arrhythmias and placental vascular spasms, leading to acute fetal hypoxia (37, 38).
PTB is conventionally defined as being born before 37 weeks of pregnancy. It is classified further into extreme preterm (before 28 weeks), very preterm (from 28 to 32 weeks), and moderate to late preterm (from 32 to 36 weeks) (12). It is estimated that 15 million infants are born preterm each year, representing one-tenth of the total number of newborns, while approximately 1 million children die from complications related to prematurity each year (39, 40). Preterm birth is the leading cause of perinatal death and morbidity in multiple pregnancies, and the underlying mechanisms of preterm birth are complex and multifactorial (41–43), and our understanding of these mechanisms is still insufficient. Therefore, the available interventions for preventing preterm birth show inconsistent benefits (44, 45). Research on pregnant women with ICP has acknowledged the association between elevated bile acids and the increased risk of preterm birth (19, 34). A meta-analysis shows a significant correlation between increased TBA levels and a higher risk of spontaneous preterm birth; a clear dose-response relationship can be observed above the threshold of 20 µmol/L (46). Our study cohort also displayed the same trend, where the proportion of full-term births declined significantly as bile acid levels increased. Given the differing stillbirth risks associated with various chorionic types and the influence of complications, it is essential to further discuss recommendations for the timing of pregnancy termination in twin pregnancies associated with ICP, to reduce the impacts of preterm birth on newborns (47, 48).
At present, ICP is primarily linked to adverse pregnancy outcomes, and its major symptoms usually alleviate within 48 hours post-treatment or after delivery; hence, current studies on ICP mainly concentrate on perinatal management and fetal outcomes (49). Nevertheless, as a pregnancy-specific complication, there is a relative scarcity of research on maternal and neonatal outcomes following the incidence of ICP; recent cohort studies show that patients with ICP face an increased risk of liver diseases, such as cholangiocarcinoma, liver cancer, gallstones, cirrhosis, autoimmune disorders, and cardiovascular diseases (50–52). Therefore, in addition to enhancing prenatal monitoring, postpartum follow-up for mothers and assessment of liver disease risk are also important measures to improve long-term outcomes (53).
Our research provides additional evidence on the relationship between the severity of ICP and the occurrence of preterm birth in twin pregnancies, as well as an analysis of the variations in stillbirth rates among different groups at different anticipated delivery weeks. Further research with larger cohort studies is necessary to investigate the relationship between bile acid levels and the prognosis of twin pregnancies, which will assist clinicians in making more informed decisions.