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Foreign. One of the most troublesome symptoms of intrahepatic cholestasis of pregnancy is that darn itch. I mean, it's bothersome, it keeps patients up at night, and it just, it affects her quality of life. But if it itching was the worst of it. That's one thing. I mean, we can try a variety of either topical agents or oral medications, which we're gonna get into in this episode. But that's not the only factor. The bigger issue is that intrahepatic cholestasis of pregnancy. Remember, some authors call that ihcp, others simply call it icp. Whichever. Intrahepatic cholestasis of pregnancy is linked to a plethora of adverse obstetrical outcomes like preterm birth, meconium staining, growth restriction, preter term labor, and of course, the most dreaded is stillbirth. We know that we've covered intrahepatic cholestasis of pregnancy many times on this program, but in this episode we're gonna do things with a different flavor. And the reason we're covering this again is because in February of 2026 in the green Journal, there's new data out of New York out of a diverse patient population looking at recurrence rates or frequency of recurrence of intrahepatic cholestasis of pregnancy after a patient gets it the first time. Okay, now, nothing mind blowing there, even though we're gonna cover that very briefly. Everybody knows that once you get IHCP or ICP in one pregnancy, the patient is at extremely high risk to let it happen again, with some reports saying as high as 90%, others saying as low as 40%. So we'll see where this new publication coming out in February of 2026 lands in that spectrum. But nobody questions the Val of this thing recurring in a subsequent pregnancy. But here's where I want to go beyond that. Even though we are going to touch on this New York database, this retrospective study that looked at recurrence rates, we're going to talk about that. But the question that I wanted to also address in this episode, which is broader than recurrence rates, is the following. If a patient is known to have a higher risk of recurrence in a subsequent pregnancy, because that's not debated at all. Well, is there any way that we can prevent it from happening? In other words, does ursodiol or ursodeoxycholic acid as the first line oral medication for this condition? Is that known to be preventative in a follow up pregnancy and if it's not preventative and we give it, once it's established as a new occurrence in that follow up pregnancy, does it really decrease any sort of adverse perinatal outcome? Now, it's no question this makes the patient feel better. The itching tends to get better. That's not a question. My question has to do with does it actually affect, does it actually improve the outcomes here? Because that's really what we want to do. There's plenty of medications where we can help the patient feel less itchy. Corticosteroids, maybe antihistamines, oatmeal baths. I mean, there's a variety of things. But what we really want to do is decrease the rate of stillbirth or overall adverse neonatal outcomes. Does this medication do this? Now, here's another question. If a patient is known to be at higher risk of recurrence and they are well in the subsequent pregnancy, is there any role to empiric monitoring of serum bile acids before symptoms happen to catch it very early, or do we still await symptomatology so you see how much broader we're going to go? So when I saw this come out in ahead of print for the February 2026 Green Journal, I'm like, oh, recurrence rate. I read it, took a look at paper. All right, not bad, I get it. They landed at X percentage, which fits within the spectrum of a higher chance of getting it than not. But then I thought, well, if we're going to cover this, we got to go broader than this. Is there a preventative strategy so that this doesn't happen in the subsequent pregnancy? Is there a role of screening or surveillance serum bile acids in a subsequent pregnancy before the patient is symptomatic? And does ursodiol not a sponsor? Does the first line medication actually help reduce adverse perinatal outcomes? Now, acog, smfm, the American association for the Study of Liver Disease, that's the aasld, they all agree here. The European guidelines, just FYI, are a little bit more loosey goosey in their take on why to take ursodiol. And we'll get into that in a minute. But it is pretty clear that when we give this medication to a patient, 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. Thankfully, the itching Part which is super devastating in general, tends to get a little bit better. Yep, it does provide good assistance for that darn itch. But what else does it do? So that's where we're going in this episode. It's kind of broad, but we're going to use that February 2026 publication out of New York just as a door opener because the short of it is mind blowing. Yeah, it's a high risk of recurrence. Duh. But it was nice because this is in a diverse population. Other studies have looked at very stringent populations that tend to be either, for example, Asian ethnicity or just Caucasians. This a diverse population, so this is good. But, yeah, no brainer, guys. It does have a high risk of recurrence in a subsequent pregnancy, which was confirmed in this February 2026, soon to be release publication in the Green Journal. But then what can we do to prevent that? If there's anything at all? And then we're going to answer this question. If a patient is on ursodiol, does that affect subsequent serum bile acid results? The answer is both yes and no. So we're going to explain this in this episode. So I think I've set it up enough. We're going to answer, does your sodiol reduce adverse outcomes in icp? All right, I think we're done here. We'll be right back. This is Dr. Chapa's obgyn no spin podcast. You know, it's interesting that most professional societies, most national guidelines do agree one with each other, but sometimes they don't. So regarding cholestatic diseases of the liver, all right, ICP is just one of them. I mean, we have, of course, acog, smfm, specifically for women's health and pregnancy. We've got the cdc, we've got the European Society for the Study of Liver Disease, and we have the as aasld, that's the American association for the Study of Liver Disease, the AA sld. And in their guidance on cholestatic liver disease, they kind of give a little warning to us as women's healthcare providers, mainly obstetricians, who have diagnosed icp. Okay. And it is kind of a wake up call because, remember, that's what they do, that they're just liver specialists here. There are, after all, the American association for the Study of Liver Disease. But they do have this cautionary tale about the diagnosis of icp. Hey, they stick with the general guidance. Hey. Usually happens later. Part of pregnancy itching. We get that. Including the soles of the feet and the Palms of the hands. No other lesions are there. Nothing else can explain it. There's no rashes, and the serum bile acids are at least above 10. All right, so we all agree with that. However, they do give this word of caution, which says, hey, look, if a patient keeps deteriorating and the serum bile acids keep going up and up and liver function keeps getting worse and worse, you gotta keep looking for the diagnosis. Yes, it very well could be the multifactorial genetic and hormonal mistransport or mal. Transport of conjugated bile acids in the hepatocytes so that they back up into the bloodstream rather than going into the biliary tract, otherwise called intrahepatic cholestasis of pregnancy. However. However, you got to be really sure that you're not missing something else that could be potentially more chronic, like a primary biliary cholangitis. All right, so primary biliary cholangitis, or pbc, is their word of caution, which is in patients who keep deteriorating and who have increased liver function, and they just keep, you know, getting wor. Don't stop looking. So they bring this to note that, yes, ACOG and SMFM agree, along with aasld, that ultrasound is the first line in the evaluation of the liver and the biliary tract. We get that. However, in worsening cases, they make the reminder to us, guys, they give the statement, and again, this is in their guidance on cholestatic diseases of the liver, to not be appeased by, wow, it's just her ICP getting worse. And keep looking. Potentially getting a magnetic resonance image, an MRI of the biliary system without gadolinium, because that is second line for the evaluation of worsening intrahepatic cholestases of pregnancy. When an ultrasound has been done and already ruled out other things. Okay? So they just. It's a good reminder that ICP sometimes doesn't live by itself. It comes with extra friends. Okay? And extra friends could be worse, because if you miss primary biliary cholangitis, that's not going to go in pregnancy. It's gonna continue into the postpartum interval and can have lasting consequences. There's an autoimmune component to this, which is why, guys, here's a clinical pearl. And we're not even into the February 2026 publication yet, but that's gonna be easy because I'm just gonna tell you what they found very quickly. But that is why in anybody who has ICP in an index pregnancy, in a current pregnancy, you've got to make sure. That those serum bile acids and that the liver function resolve around six or eight weeks postpartum, because they should. Okay. If they do not, you gotta send them to your friendly neighborhood hepatologist, because potentially there's something else at play there. And of course, you got to rule out something like hepatitis C, because there's a direct correlation between hepatitis C, both occult infection and true infection, and interhepetocholestasis. So do a hepatitis C viral antibody screen or do a viral load or whatever to look for other things if you. If postpartum, they're not getting any better. Okay? So I like that. I respect that. I am not a hepatologist, but the AASLD has a very directed. Their words are like, hey, these obstetricians, man, they think everything is icp, high bile acid. They get all. Everybody gets urodiol. But it could be other things. And they're absolutely right. And not that they say it necessarily in a condescending way, but it's a little condescending. All right? All to say is that as that being their home liver disease, we as women's healthcare providers and obstetricians appreciate the reminder that sometimes zebras aren't zebras. Sometimes there's an occasional wild horse running through the pack. All right, so now that we've said that. Oh, another discrepancy. Just throwing this out there on when to deliver. If you remember ACOG's guidance on medically indicated late preterm and early term delivery, there's one little slip in the table for intrahepatic cholestasis, and ACOG uses when to deliver based only on serum bile acids. Remember that if it's under 100, then you can deliver starting at 36 weeks, all the way up until 39 weeks. Okay? However, if the total serum bile acids are greater than 100, then ACOG recommends delivery at 36 weeks. Right? So you got a little bit more loosey goosey if it's under 100. But at 100 or more total serum bowel acids, you should be out by 36 weeks or whenever you diagnose it after that. So ACOG uses its indication for delivery, the amount, the quantification of tracer and bowel glasses. But look at a mild discrepancy between that and smfm, because SMFM actually throws out something else. Okay, Now, SMFM in console series number 53 have this additional caveat of when you could get out. Because While ACOG uses 36 at its earliest, SMFM, again, console series number 53, that's the one on intrahepatic cholestasis of pregnancy. They say, hey, wait a minute, man, wait a minute. You can actually get out at 34 to 36 weeks if the following conditions are at play. All right, now, I haven't lost my mind. I know that we're going to talk about the February 2026 publication, but that's going to be relatively quick because spoiler. Yes, it recurs at a high frequency even in a diverse patient population. We knew that. Wow. I mean, so again, I'm not minimizing that. I'm always good for good research, but it validated. That's what we should do. Validate past information to see if it's. If it's correct. And it is. But the spread is anywhere from 40% up to 90% based on which population you look at and the age of the patient. And that's what this study showed because, yes, it's a high risk of recurrence at almost 50%. Okay, so we have to educate patients as get through this pregnancy that you've been diagnosed with icp, but in the future, this joker can come visit your pregnancy again. So they need to know that. They need to know that so they can plan accordingly. Now back to SMFM's Console Series 53 on induction. While ACOG uses total serum bowel acids alone at greater than 100 or less than 100, SMFM gives a specific caveat here. So let me read this directly. Okay. Because they say, wait a minute, you can actually do it between 34 and 36 weeks in this following situation. Let me read this directly. Console series number 53, quote, delivery between 34 and 36 weeks of gestation. See, there it is. Can be considered in women with ICP. Fine. With total bile acids of 100 millimole per liter. Okay. And with any of the following. So let's stop there. So for those who you're planning to get out between 34 and 36 weeks, they've got to have serum bowel acids. The first criteria is it's over 100. Because remember that risk of stillbirth we used to think it was, you know, elevated at a certain bowel acids of 40. We then push that up to 100 and that's pretty much where we're landing. But that's the risk of stillbirth. Having a zero bile acid of 40, 40 or above is still bad, guys. It still leads to other adverse issues like meconium staining, potentially growth restriction, preterm labor, pre labor rupture of membranes so just because you're under 100 doesn't mean you're out of the clear. 40 to 100 has its own set of issues, but the biggest issue is fetal death. That's horrifying. And that happens at 100 or more. All right, so I digress. Let me get back to SMFM's quote, because we got to keep moving. Quote. Delivery between 34 and 36 weeks can be considered in women with ICP, with total bile acids of 100 millimole per liter and with any of the following. So here we are. Number one, excruciating and unremitting maternal pruritus, not relieved with pharmacotherapy, end quote. So that's the first thing. If they are miserable, if they're not sleeping, if it's affecting their quality of life, damn, don't make them suffer. Get that kid delivered. I mean, you can get out. Okay, so excruciating and unremitting maternal pruritus, not relieved with pharmacotherapy. Next, remember, this is when you can get out early. If their serum bile acid is 100 or more and they have a history of stillbirth before 36 weeks due to ICP in a previous pregnancy, you can get out. The third condition is if they have 100 millimeter of per liter of trozone bowel acids and they've got worsening lab evidence of hepatic function. So if their LFTs are getting jacked and jacked and jacked, you don't want them to have fulminant hepatic failure. You can get out. All right, guys. So that's right out of console series number 53 from 2021. A little bit broader than ACOGs. Remember, ACOGs says, hey, based on medically indicated late preterm and early term delivery, just in that one guidance, this is considered 100. And remember, 36 over 100, you can get out at 36. Under 100, you can get out at36 or up to 39, and they leave it at that. However, SMFM is a lot more broad and says, no, no, no. If it's 100 and they have excruciating or unremitting pain, if they have a history of still, if they have a history of worsening liver function, if their LFTs are getting worse and worse and worse, you can get out between 34 and 36 weeks if the first criteria is met that their serum bile acid is 100, and then they have those other comorbidities. All right, so all that's just as an aside that sometimes professional societies agree, but to a lesser extent, disagree based on the nuances of the guidelines. All right, okay, so that's just a quick recap. Now I want to get back on track and focus. Two quick things, because I wasn't even supposed to talk about the others. The first has to do with this retrospective study out of Queens, New York. Hey, forget about it. Queens, New York. Which is that my New York accent. Is that what that is? Forget about it. Yeah. Queens, New York. Forget about it. Oh, my God. Hey, people make fun of Texas accents all the time, y'. All. All right? So if you can throw out a. If you're talking to a patient and you give a y', all, and you're only talking to one person, you might be a Texan, and that's all right. That's how we roll. So out of Queens, New York, it looked at recurrence rates. Guys. That's not a weird morning. Hello? Oh, my God. Hold on. Michael. Just hold on a minute. Hold on a minute. So it's. It's today. If it's. It's a holiday. When we're recording this. I don't know when this is gonna go out, but I'm recording this on a holiday. It's January 19th, but I still went in. We did this really cool case. We had a C section the team took. You know, child is out. Everything's good. We went through a vertical skin incision because she had, lo and behold, a 20 centimeter multi cystic complex at nex. So I just went in with the team and we just took that out. No rupture. Taken out in toto with a lso. It's phenomenal. Fun case. So anyway. Why am I saying that? Oh, I'm all, like, hyped up coming out of that surgery anyway. A minimum blood loss. She did great. We said that to pathology. I suspect it's a mucinous cyst adenoma. But all to say, this is why I'm all, like, distracted, because still, when you do a good case, doesn't make you feel good. I mean, man, this lady, we dropped her six and a half pounds or so from the child. And then this thing weighed four and a half pounds. Ish. So she just dropped ten pounds immediately just because of the loss of those two things. Phenomenal. I may post a picture. De identified and the patient gave permission as medical education of this 20 centimeter complex adnexal cyst, which was removed in toto at time of C section with no bleeding. I mean, we're across the IP Pedicle. Beautiful. Beautiful. Wow. I have totally. What, Michael? Where am I? Give me a minute. Oh, yeah. So. So let's cover the Queens. Thank you. The Queens, New York publication. First, let's do this very quickly because lo and behold, is exactly what we already knew. Yes, it recurs with high frequency. The title of this retrospective study is intrahepatic cholestasis of pregnancy Recurrence and a subsequent Pregnancy Surprise. All right, so, retrospective study out of Queens, New York. This followed pregnancies from 2015 to 2024. And in this diverse patient population, yes, no surprise. The rate of recurrence was 44% in a subsequent pregnancy. Now, there were some things that gave the patient higher risk of it happening. The higher the total serum bile acids, the higher the chance that they're gonna have a recurrence. And here they set that level at 40 and odd. I would never recommend this to a patient. A short interpregnancy interval was potentially protective of recurrence. Although short interpregnancy interval has its own set of problems like iron deficiency anemia, preterm birth, growth restriction, micronutrient depletion. So I don't recommend that. But it's just a quinky dink that they found that a short interpregnancy interval was potentially protective against recurrence. The short answer is, while some studies say it's about 40%, others say it's about 90. Recurrence in this New York population. Do you like that, Michael? New York. In this New York population, it was 44%. I got great friends at Monte Fiora. Got great friends in Queens. No problem. Guys, come on. You know I love you. You know I love you. Forget about it. So now that we've covered, It's a weird day, man. This is what I get from working on a national holiday. Should we take a break? No, not yet. Okay, hold on. So February 2026. Short answer is, yes, it recurs. Which leads us to our next issue. What do we do with that? Where do we go? What do we tell a patient when we have already prepped them, this can happen again. And they're going to say, well, Doctor, what can I do to prevent it? Here's the bummer. We're not going to take a break. We're going to keep going. Here's the bummer. The bummer is nada. Unfortunately, there is no data in the medical literature that says that preemptive strikes with ursodiol taken, it prophylactically prevents this thing from Happening. Although in true disclosure, nobody's really studied that. But it's not felt to be used empirically. In other words, prophylactically, that's not really a thing, but maybe one day it will be. Right now, there's no data, so maybe it does, but we do not have that data, and we don't know what that does, just taking it by itself. So as of right now, there is no data that using this medication, ursodiol, which is still considered a frontline medication, prevents a recurrence. So that was the first question we were going to answer. Right. Does this medication prevent recurrence? No. The second thing that we're going to look at now is, well, does this medication actually reduce adverse perinatal outcomes? Let me tell you what's not controversial. Ursodiol reduces itching. Yes. Ursodiol can improve liver function. Yes. And the reason it improves liver function is that it changes the composition. It is ursodeoxycholic acid. This is one of the bile acids that's actually measured in a total serum bile acid. So they're taking this because we're trying to swap out the bad accumulated bile salts with this benign bile salt. All right, so this is. Ursodiol is actually a bile salt. It's also approved as first line for pbc, okay, for primary cholangitis, primary biliary cholangitis, because it reduces the bad bile salt and changes the composition. It messes with the cholesterol composition of the bile so that you're replacing the bad one with a good one. So it improves liver function because the toxic bile salts are not accumulating to a higher degree anymore in the liver. Okay? So it causes that kind of periportal necrosis. This just kind of gets on top of that. So, yes, it reduces itching. Yes. It reduces LFTs. However, if you check bile acids after this, which you can do, and if they improve, phenomenal, but if they stay constant or maybe have a slight bump and they get worse, it's hard to read that. So you got to call the lab and say, what's causing the big bump here? Can you differentiate this? Because it is possible, especially if they're taking a very high dose of ursodiol, that the blood test is actually measuring the medication, because ursodeoxycholic acid is one of the bile salts that's measured in the test. All right? So I think it's fine we do that. Just as. As curiosity, you know, we do serial lab tests, even though SMFM says, I don't know if that's going to help you or not. So we. We do follow after we make a diagnosis because we want to see what's going on in the body. And if it goes up, we go. Well, I don't. If you're taking the medication and you really are taking it, then that could be the medication that you're taking. So I'm not that worried about it. And we also follow liver function tests because according to smfm, if they have worsening liver function and their bowel salts are greater than 100, we can get out before ACOG's guidance of 36. We can get out at 34. Everybody good? That was a lot of info. Okay, so what can ursodiol do? Well, it can reduce itching, it can improve LFTs. It can reduce total serum bile acids at the same time, ironically, and as an oxymoron, it can actually increase serum bile acids because if they're at a very high dose and the lab can't differentiate one from the other, it can be picking up the ursodeoxycholic acid in the body, okay? In the system. All right? So all to say is know what it can do and what it cannot do. And unfortunately, if you can't get where I'm going, guys, unfortunately, it cannot as of right now, even though that we had a little piece of data, which was a individual meta analysis, systematic review, meta analysis that said, maybe helps prevent a spontaneous preterm birth, maybe. But that was as a composite measure. 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. I'm gonna read you the quote directly, which is pretty much what I said. But you've gotta give patients the correct information. So I'm giving you this because I want you to stop itching. I'm giving this to you because I want your liver to behave itself. But I don't really know if it's going to protect all of the adverse issues, protect you from the adverse issues that can happen with this condition. Now, the reason that's the case is because some of the bile salts that go transplacentally to the child can set up this defect in the conduction system of the heart. And at any moment, those wirings can go haywire. And that's where you get the stillbirth potential from this cardiac toxicity of the bile salts. All Right. So even though you can improve the bile salts, the effect on the heart may be instant or somewhere down the road later on, even after the bowel salts have corrected themselves. Does that make sense? So it is debated, guys, and there are some, like the European guidance, the European Society for Liver Disease. Their guidance says, hey, maybe it can help reduce outcomes. If we now think about the logic, because they're correct. The European guidance say, since the risk of stillbirth is highest at 100, well, if you start this medication as early as possible, ideally between 10 and 40, so you make the diagnosis and catch it under 40. And if you start early enough, we can keep the serum bowel acid down so you don't get to 100. So in theory and biologically, it makes sense. So the European guidance says, yes, ursodiol can reduce itching, yes, it improves liver function and potentially has the ability to reduce adverse neonatal outcomes. But their statement is more in theory and in deduction rather than the true published evidence. All right, so they're a little bit more loosey goosey. So let me read you exactly what the AASLD, their 2021 guidance says, which is pretty similar to SMFM's guidance on this in console series 53, quote, urodeoxycholic acid is safe in pregnancy and reduces serum bile acid levels. Although. Here it is, guys, and we're almost done. Although data supporting a benefit in reducing fetal risks, including intrauterine fetal death, are lacking. End quote. They're lacking. Okay, now there's a lot of questions to remain. What if we get in early? What if we be very aggressive at a bile salt of 40 and prevent it from going to 100? So it is one possible. But as of right now, remember, it doesn't say that it doesn't do it. It says the data is lacking. Just something to be aware of. Now, it's pretty disappointing. That is true. And unfortunately, the PITCHES trial, like pitches, like pitchers of soda pitches. P I T C H E S. The pitches trial, which was one of the largest, it was multi sender, it was double blind, It's a large randomized placebo controlled trial. Michael put the reference of that in the list if we don't have it. The pitches trial was in 2019 and it looked at a variety of different outcomes and unfortunately they said, look, man, yes, the patients had less itching, but it didn't do anything to reduce adverse neonatal outcomes, including stillbirth. So we make the patient feel better. But unfortunately, the PITCHES trial did not find a reduction in true adverse Neonatal outcomes. The true title of this was ursodeoxycholic acid versus placebo in women with intrahepatic cold stasis of pregnancy. That's pitches a randomized control trial. Very quickly, the interpretation of this data as they give their little taggable, you know, tweetable statement, quote, treatment with ursodeoxycholic acid does not reduce adverse perinatal outcomes in women with enterhepatic cholestasis of pregnancy. Therefore, its routine use for this condition should be reconsidered. End quote. Now, that was out of the Lancet in 2019. While I agree that we don't have the data that it decreases adverse periodal outcomes, the idea that it should be reconsidered is wrong. Don't reconsider it. Use it. 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 because that is called throwing the baby out with the bath water. We want to use it for what it does do and give the patient education of what it does not do. Again, that was the Lancet 2019, the pitches trial. Now, don't send me a message. Don't send me a message because there is another meta analysis which I mentioned earlier. We're going to give you this one, then we're going to be done from 2021. I get that. That was also in the Lancet, but that was the Lancet Gastroenterology and hepatology from 2021. This was the independent systematic review and meta analysis using individual data points. I'm sorry, individual patient records. Now we get this in this publication, stillbirth alone was not decreased. However, they said with a number needed to treat a 15 guys, that's not a lot. So a number needed to treat you needed to treat 15 so that you would see benefit. They said if you start ursodeoxycholic acid, this is data from 2021 at a level of 40, you can potentially reduce the rate of preterm birth. Phenomenal. Again, I'm not saying that that's. We should minimize that. That's good, that's great. But again, it doesn't decrease overall rate of stillbirth. So I get that. While we have been. The pitches trial in 2019, 2021, a meta analysis looking at maternal serum bile acids concentrations and ursodeoxycholic acid, while it did not improve stillbirth, it did have the ability to reduce preterm birth rates. So Again, little controversial, but know what it can do and it cannot do. And right now, it does not prevent overall stillbirth with maybe the possibility of preventing preterm birth. And the last thing that we're going to say is that is why the European guidelines, the easl, okay, the European association for the Study of Liver Disease, the EASL says, hey, why not? Maybe it might could help with preterm birth. Maybe if we keep the bowel acids less than 100, prevent stillbirth. That's in theory. Even though we don't have the concrete data, you're going to feel better because you're not itching as much as before. So that is the European guidance, a little bit more loosey goosey, a little bit more inclusive, if you will, of the theory. Whereas the AASLD is like, nope, we don't have data, doesn't prevent stillbirth. So short answer as we wrap this up, recurrence rates happen. Number two, nothing that we can do to prevent it. And there is no data that doing serum bile acid checks before the patient is symptomatic is a thing. So as of right now, the entire management of ICP is based on symptomatology. So if your thought is, hey, as soon as she turns in the third trimester or 28 weeks, I'm doing weekly monitoring of Serum Bile AC. There's no evidence of that. You can do that, but there's no evidence that you're going to catch it any sooner than her symptoms, because her symptoms are going to pop up before your labs are abnormal. Remember that itching usually precedes lab abnormalities from anywhere from one week up to two weeks before the rise is detectable. All right? So as of right now, 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 bowel acids and. Or start empiric therapy with ursodiol. But you should check liver function test to make sure that the patient is not decompensating to some kind of fulminant hepatic failure. All right, so podcast family, we've covered a lot, right? I thought we're going to take a break, and I didn't. But so we. We've covered the February 2026 publication, we've covered the data from AASLD from the European Society for Liver Disease. We've talked about SMFM, ACOG's guidance, a lot of stuff, talking about what ursodiol can do and what it cannot do. So, short answer, I'm all for it. 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. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, Michael, come on, let's take it home. This has been Dr. Chapa Zobechyn, no Spin Podcast podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast.