Podcast Summary

Podcast: Dr. Chapa’s OBGYN Clinical Pearls
Episode: Does Ursodiol Reduce Adverse Outcomes in ICP?
Date: January 21, 2026
Host: Dr. Chapa

Episode Overview

This episode delves into the effectiveness of ursodiol (ursodeoxycholic acid) in managing intrahepatic cholestasis of pregnancy (ICP), with a focus on its impact on adverse obstetric and neonatal outcomes. Dr. Chapa uses a newly published February 2026 study from New York as a springboard to explore recurrence rates, evidence for prophylactic or preventive use of ursodiol, guideline differences, and whether ursodiol can meaningfully reduce risks such as stillbirth.

Key Discussion Points & Insights

1. ICP Overview, Recurrence, and Morbidity

• ICP Symptoms and Risks:
  • "One of the most troublesome symptoms of intrahepatic cholestasis of pregnancy is that darn itch... But that's not the only factor. The bigger issue is that intrahepatic cholestasis of pregnancy... is linked to a plethora of adverse obstetrical outcomes like preterm birth, meconium staining, growth restriction, preterm labor, and of course, the most dreaded is stillbirth." (00:00)
• Recurrence of ICP:
  • Recurrence after one affected pregnancy is high: studies show rates from 40% up to 90%; the new 2026 NY data found a 44% recurrence rate in a diverse population. (16:04)
  • "So, retrospective study out of Queens, New York... yes, no surprise. The rate of recurrence was 44% in a subsequent pregnancy." (16:40)
  • Factors: Higher initial bile acids increase recurrence risk. Short interpregnancy interval (potentially protective) noted but not recommended due to its own risks.

2. Ursodiol: What Does the Evidence Show?

A) Does Ursodiol Prevent Recurrence?

• "Does this medication prevent recurrence? No." (19:58)
  • There is no evidence that starting ursodiol prophylactically in subsequent pregnancies prevents ICP from recurring.

B) Does Ursodiol Reduce Adverse Perinatal Outcomes (e.g., stillbirth, preterm birth)?

• "Ursodiol reduces itching. Yes. Ursodiol can improve liver function. Yes." (20:30)
• On Stillbirth:
  • "Most of the publications [AASLD and SMFM] state that while some data is promising with its reduction in stillbirth, as of now, and because questions remain, the medication does not overall decrease adverse perinatal outcomes or stillbirth. I know, it sucks." (23:00)
• On Preterm Birth:
  • "2021 ... meta analysis ... said if you start ursodeoxycholic acid at a level of 40, you can potentially reduce the rate of preterm birth ... But again, it doesn't decrease overall rate of stillbirth." (26:14)
• Notable RCT:
  • The PITCHES Trial (Lancet, 2019): "Treatment with ursodeoxycholic acid does not reduce adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy. Therefore, its routine use for this condition should be reconsidered." (25:13)
  • Dr. Chapa’s response: "Use it because it protects the patient from itching, it helps liver function, and just because it doesn't decrease perinatal outcomes, we're not just going to scrap it all together." (25:43)

C) Ursodiol and Laboratory Monitoring

• Ursodiol changes bile acid composition and can sometimes artificially elevate measured serum bile acids due to lab limitations.
• Serial bile acid checks can be misleading if patient is on medication. (21:13)
• "If they have worsening liver function and their bile salts are greater than 100, we can get out [deliver] before ACOG's guidance of 36 [weeks]." (21:50)

3. Guideline Nuances: When to Deliver?

• ACOG vs. SMFM Differences:
  • ACOG: Delivery at ≥36 weeks if bile acids >100; otherwise, 36-39 weeks.
  • SMFM (Consult Series #53): Delivery at 34-36 weeks may be considered for bile acids >100 plus:
    • Excruciating maternal pruritus unrelieved by therapy,
    • Prior stillbirth attributed to ICP,
    • Worsening hepatic function (elevating LFTs).
  • "SMFM is a lot more broad and says ... if it's 100 and they have excruciating or unremitting pain, if they have a history of worsening liver function ... you can get out between 34 and 36 weeks." (13:38)

4. Differential Diagnosis & Postpartum Follow-Up

• Persistent or worsening liver function postpartum should raise suspicion for primary biliary cholangitis or chronic liver disease.
  • "Anybody who has ICP in an index pregnancy ... you've got to make sure that those serum bile acids and that the liver function resolve around six or eight weeks postpartum ... If they do not, you gotta send them to your friendly neighborhood hepatologist." (07:38)
• Rule out hepatitis C due to its strong association. (08:27)

5. Should We Screen Asymptomatic High-Risk Patients?

• No evidence supports routine surveillance of bile acids before symptom onset in at-risk women.
• "Itching usually precedes lab abnormalities from anywhere from one week up to two weeks before the rise is detectable." (29:32)
• "No, you do not monitor serum bile acids prophylactically to try to get ahead of it. You wait for symptomatology to occur and then you get your serum bile acids..." (29:07)

Notable Quotes & Memorable Moments

• On Patient Communication:

  • "We need to let them know what it can do and what it just cannot do. Because we don't want to put any false hope on a patient that, well, I'm taking my medication, it's fine, everything's great. Because there's things that it can do and things that it cannot do." (05:18)

• Personal Touch:

  • Dr. Chapa shares a story from the OR about a large ovarian cyst removed during a C-section, adding a human and humorous touch: "Why am I saying that? Oh, I'm all, like, hyped up coming out of that surgery anyway." (15:30)

• Summary of Guideline Differences:

  • "Sometimes professional societies agree, but to a lesser extent, disagree based on the nuances of the guidelines." (15:03)

• On the PITCHES Trial:

  • "The true title of this was Ursodeoxycholic Acid versus Placebo in Women with Intrahepatic Cholestasis of Pregnancy. That's PITCHES, a randomized control trial... patients had less itching, but it didn't do anything to reduce adverse neonatal outcomes, including stillbirth." (25:13)

Timestamps for Major Segments

| Timestamp | Segment | |-----------|----------------------------------------| | 00:00 | Introduction & key questions | | 05:00 | International guidelines & possible pitfalls in diagnosis | | 10:22 | Differences between ACOG & SMFM delivery recommendations | | 16:04 | Recap of new 2026 Queens, NY recurrence data | | 19:58 | Evidence on ursodiol preventing recurrence | | 20:30 | Ursodiol’s concrete benefits & limitations | | 23:00 | Major guidelines: Stillbirth and neonatal outcomes | | 25:13 | PITCHES trial and implications | | 26:14 | Meta-analysis on preterm birth reduction | | 29:07 | Surveillance in high-risk women: Why it’s not supported | | 29:32 | Symptom-based diagnosis, patient counseling, wrap-up |

Key Takeaways

• Recurrence of ICP is high; patient counseling regarding future pregnancies is essential.
• Ursodiol:
  • Does improve maternal symptoms and LFTs.
  • Does not have proven benefit in reducing stillbirth or most adverse neonatal outcomes, according to strongest available evidence (PITCHES trial, meta-analyses).
  • May help reduce preterm birth if started early at lower bile acid levels (unproven, but some suggestive data).
• Professional guidelines differ slightly in timing of delivery and qualifying features.
• Routine pre-symptomatic surveillance of bile acids is not evidence-based.
• Always rule out other causes in persistent or severe disease; refer postpartum non-resolvers to hepatology.

Final Word from Dr. Chapa

"If we understand its limitations, it's gonna make them feel better. It's gonna protect the liver to some degree. But is it really going to help prevent overall adverse perinatal outcomes? As of now, data is lacking." (31:17)

For more on guidelines, recent literature, and nuanced perinatal counseling around ICP, listen to the full episode or access cited articles (PITCHES trial, 2021 meta-analysis) for deeper review.