Maternal and neonatal outcomes of intrahepatic cholestasis of pregnancy in twin pregnancies: a systematic review and meta-analysis

BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) is linked with adverse perinatal outcomes; however, its impact in twin pregnancies remains unclear. This systematic review and meta-analysis aimed to evaluate maternal and neonatal outcomes in twin pregnancies complicated by ICP. METHODS: A comprehensive search of PubMed, Embase, Web of Science, and Scopus was conducted from inception to 14 February 2026. Cohort studies comparing twin pregnancies with and without ICP were included. Random-effects meta-analyses were performed to assess maternal and neonatal outcomes reported by at least three studies. RESULTS: Seven retrospective cohort studies were included. ICP in twin pregnancies was associated with increased risk of cesarean delivery, preeclampsia, and gestational diabetes mellitus. Preterm birth (PTB) <37 weeks was significantly increased with ICP in both crude and adjusted analysis. Mean gestational age was significantly reduced, and birthweight was lower in ICP. ICP was strongly associated with meconium-stained amniotic fluid and increased neonatal intensive care unit (NICU) admission. However, no significant association was noted between ICP and stillbirth, small-for-gestational age and postpartum hemorrhage. CONCLUSIONS: ICP in twin pregnancies is associated with PTB and increased maternal and neonatal morbidity. Current evidence is derived mostly from crude data and from a limited number of studies with high inter-study heterogeneity.