Severe Neonatal and Obstetric Outcomes in Recurrent Early Intrahepatic Cholestasis of Pregnancy in a Patient with Pre-Existing Myasthenia Gravis: A Case Report of Two Consecutive Pregnancies

Intrauterine fetal demise (IUFD) is a recognized risk in intrahepatic cholestasis of pregnancy (ICP), particularly when bile acids exceed 40 µmol/l. Therefore, many obstetric societies recommend considering induction of labor at or before term, depending on bile acid levels. The Danish guidelines recommend induction of labor after gestational week 34+0 if bile acids exceed 100 µmol/l. This report details a case of a woman experiencing recurrent early ICP, characterized by initially elevated bile acid levels, leading to IUFD at 33+6 weeks of gestation in her first pregnancy and a preterm subacute delivery at 32+1 weeks of gestation in her second pregnancy. Comprehensive medical evaluations during and after the first pregnancy identified no underlying hepatic disorders. Despite an initial decline in bile acid levels following treatment in both pregnancies, pruritic symptoms intensified and bile acid levels began to rise again at beginning of the third trimester. This case suggests that an early onset of ICP, characterized by increasing bile acids despite treatment and reduced fetal movements, may warrant consideration for preterm delivery even before 34 weeks of gestation; however, the decision to deliver is complex. Abbreviations IUFD - Intrauterine fetal demise ICP – Intrahepatic cholestasis of pregnancy ALT - alanine-aminotransferase MRCP - magnetic resonance cholangiopancreatography CT - scan - computed tomography scan MRI - magnetic resonance scan