Vasoconstrictive effect of bile acids on isolated human placental chorionic veins

Inadvertent intra-arterial injection of deoxycholic acid: A case report and proposed protocol for treatment

Deoxycholic acid (ATX-101) is a secondary bile acid that was approved as an injectable drug for the reduction of submental fat. Necrosis, an uncommon but serious adverse event, can occur due to inadvertent superficial injection or intra-arterial injection of the acid. The management of the intra-arterial injection of deoxycholic acid has not been well characterized. Here, we discuss methods to decrease the risk of such injections and draw on existing protocols for the inadvertent intra-arterial injection of sclerotherapy solutions and dermal fillers to propose a safe, practical approach to treatment. A case report is presented of a 42-year-old woman who received a deoxycholic acid injection for the correction of submental fullness, which was complicated by the inadvertent intra-arterial injection of the acid. The adaptation of published treatment protocols for the inadvertent injection of sclerosing solutions and dermal fillers allowed for a good outcome in this patient. The inadvertent intra-arterial injection of deoxycholic acid is a rare event. The risk of such injections can be reduced with attention to injection technique and can be managed successfully following the adaptation of protocols in the literature for similar events from vascular compromise due to dermal fillers and sclerosing solutions.

Intrahepatic Cholestasis of Pregnancy: A Case Study of the Rare Onset in the First Trimester

Intrahepatic cholestasis of pregnancy (ICP) is a gestation-specific liver disorder, defined most often as the onset of pruritus, usually from the third trimester of pregnancy, associated with abnormal liver test results and/or increased total serum bile acids and spontaneous relief after delivery. The 21-year-old patient was admitted to our ward in the 11th week of pregnancy due to raised liver enzymes. The first onset of pruritus and jaundice appeared a month before hospitalization. Immunology tests and Toxoplasma gondii were negative. We excluded viral etiology, while alpha-1-antitrypsin, serum and urine copper levels, and thyroid hormones were within the reference values. The patient denied she had taken any medicines and herbal preparations before and during pregnancy. Total bile acids in the serum were significantly elevated (242 μmol/L). The abdominal ultrasound revealed a regular finding. Liver biopsy suggested a cholestatic liver disorder. After a presentation of all risks, the patient decided to stop the pregnancy. After a month, the hepatogram was within the reference values. Very rarely an ICP can occur in early pregnancy (first trimester), which calls for close monitoring. The risk of serious adverse fetal outcomes and spontaneous preterm delivery is proportional with increased levels of maternal serum bile acid.

Perinatal outcomes of intrahepatic cholestasis of pregnancy in twin versus singleton pregnancies: is plurality associated with adverse outcomes?

PURPOSE

To determine the rate of obstetric and neonatal complications associated with intrahepatic cholestasis of pregnancy in twin versus singleton gestations.

METHODS

A retrospective cohort study including patients diagnosed with intrahepatic cholestasis of pregnancy at a single tertiary center between 2011 and 2016. Women were allocated into two groups: twin pregnancies (n = 56) and singleton pregnancies (n = 186). Obstetric and neonatal outcomes were compared between the two groups.

RESULTS

Intrahepatic cholestasis of pregnancy was diagnosed earlier in gestation in twin compared to singleton pregnancies (33.1 ± 2.8 vs. 35.1 ± 3.0 weeks, respectively; adjusted P < 0.001). Maternal serum levels of fasting total bile acids were significantly higher in twin pregnancies compared to singletons [27 (IQR 16-44) vs. 16 (IQR 10-26) µmol/L, respectively; P = 0.01]. None of the pregnancies in our cohort was complicated by fetal death. Apgar score at 5 min and umbilical artery and vein PH at delivery were comparable between the two groups.

CONCLUSIONS

Intrahepatic cholestasis of pregnancy in twin pregnancies appears to be more severe compared to singletons, as reflected by an earlier presentation and higher levels of maternal serum total bile acids. Large prospective studies are required to customize a management strategy specific for women with twin pregnancies and intrahepatic cholestasis of pregnancy.

Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy

BACKGROUND

Intrahepatic cholestasis of pregnancy is a pregnancy-specific liver disorder, possibly associated with an increased risk of severe fetal adverse events. Total serum bile acids (TSBA) concentration, alone or in combination with serum aminotransferases, have been the most often used biomarkers for the diagnosis of intrahepatic cholestasis of pregnancy in clinical practice. Serum bile acid profile, composed of primary or secondary, conjugated or non-conjugated bile acids, may provide more specific disease information.

OBJECTIVES

To assess and compare, independently or in combination, the diagnostic accuracy of total serum bile acids or serum bile acids profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women, presenting with pruritus. To define the optimal cut-off values for components of serum bile acid profile; to investigate possible sources of heterogeneity.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register, the Cochrane Library, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, BIOSIS, CINAHL, two Chinese databases (CKNI, VIP), Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Evidence Search: Health and Social Care by the National Institute for Health and Care Excellence (NICE), the World Health Organization (WHO) Reproductive Health Library (RHL), and the Turning Research into Practice database (TRIP). The most recent date of search was 6 May 2019. We identified additional references by handsearching the references of articles, meta-analyses, and evidence-based guidelines retrieved from the computerised databases, on-line trial registries, and grey literature through OpenSIGLE, National Technical Information Service (NTIS), ProQuest Dissertations & Thesis Database, and Index to Theses in Great Britain and Ireland.

SELECTION CRITERIA

Prospective or retrospective diagnostic case-control or cross-sectional studies, irrespective of publication date, format, and language, which evaluated the diagnostic accuracy of total serum bile acids (TSBA) or components of serum bile acid profile for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women of any age or ethnicity, in any clinical setting, symptomatic for pruritus.

DATA COLLECTION AND ANALYSIS

We selected studies by reading titles, abstracts, or full texts, and assessing their fulfilment of our inclusion criteria. We emailed primary authors to request missing data or individual participant data. Having extracted data from each included study, we built the two-by-two tables for each primary study and for all the index tests considered. We estimated sensitivity and specificity with their 95% confidence intervals (CI). We presented data in coupled forest plots, showing sensitivities and specificities of each study, and we plotted the studies in the Receiver Operating Characteristic (ROC) space. We performed meta-analyses adopting the hierarchical summary ROC model (HSROC) or the bivariate model to meta-analyse the data. We made indirect comparisons of the considered index tests by adding the index tests as covariates to the bivariate or HSROC models. We performed heterogeneity analysis and sensitivity analysis on studies assessing TSBA accuracy. We used Review Manager 5 (RevMan 5) and SAS statistical software, release 9.4 (SAS Institute Inc., Cary, NC, USA), to perform all statistical analyses. We used QUADAS-2 domains to assess the risk of bias of the included studies.

MAIN RESULTS

Our search yielded 5073 references, but at the end of our selection process, only 16 studies fulfilled the review inclusion criteria. Nine of these provided individual participant data. We analysed only data concerning TSBA, cholic acid (CA), glycocholic acid (GCA), chenodeoxycholic acid (CDCA), and CA/CDCA because the remaining planned index tests were assessed in few studies. Only one study had low risk of bias in all four QUADAS-2 domains. The most biased domains were the patient sampling and the reference standard domains. When considering all studies with a cut-off of 10 μmol/L, TSBA overall sensitivity ranged from 0.72 to 0.98 and specificity ranged from 0.81 to 0.97. After a sensitivity analysis excluding case-control studies, TSBA sensitivity ranged from 0.48 to 0.66 and specificity from 0.52 to 0.99. After a sensitivity analysis excluding studies in which TSBA was part of the reference standard, TSBA sensitivity ranged from 0.49 to 0.65 and specificity from 0.53 to 0.99. We found the estimates of the overall accuracy for some serum bile acid components (CA, GCA, CDCA, and CA/CDCA) to be imprecise, with the CI for sensitivity and specificity very wide or impossible to calculate. Indirect comparisons between serum bile acid profile components and TSBA were not statistically significant. None of the heterogeneity analysis performed was statistically significant, except for the timing of assessment of TSBA (onset of symptoms, peak value among multiple assessments, delivery) but without clinically relevant results. We could not analyse the diagnostic accuracy of combinations of index tests because none of the included studies carried them out, and because of the small number of included studies.

AUTHORS' CONCLUSIONS

The overall high risk of bias, the existing concern regarding applicability of the results in clinical practice, and the great heterogeneity of the results in the included studies prevents us from making recommendations and reaching definitive conclusions at the present time. Thus, we do not find any compelling evidence to recommend or refute the routine use of any of these tests in clinical practice. So far, the diagnostic accuracy of TSBA for intrahepatic cholestasis of pregnancy might have been overestimated. There were too few studies to permit a precise estimate of the accuracy of serum bile acid profile components. Further primary clinical research is mandatory. We need both further phase II and phase III diagnostic studies.

Ursodeoxycholic acid inhibits uptake and vasoconstrictor effects of taurocholate in human placenta

Intrahepatic cholestasis of pregnancy (ICP) causes increased transfer of maternal bile acids to the fetus and an increased incidence of sudden fetal death. Treatment includes ursodeoxycholic acid (UDCA), but it is not clear if UDCA protects the fetus. This study explores the placental transport of the bile acid taurocholate (TC) by the organic anion-transporting polypeptide, (OATP)4A1, its effects on the placental proteome and vascular function, and how these are modified by UDCA. Various methodological approaches including placental villous fragments and Xenopus laevis oocytes were used to investigate UDCA transport. Placental perfusions and myography investigated the effect of TC on vasculature. The effects of acute TC exposure on placental tissue were investigated using quantitative proteomics. UDCA inhibited OATP4A1 activity in placental villous fragments and oocytes. TC induced vasoconstriction in placental and rat vasculature, which was attenuated by UDCA. Quantitative proteomic analysis of villous fragments showed direct effects of TC on multiple placental pathways, including oxidative stress and autophagy. The effects of TC on the placental proteome and vasculature demonstrate how bile acids may cause fetal distress in ICP. UDCA inhibition of OATP4A1 suggests it will protect the mother and fetus against the vascular effects of TC by inhibiting its cellular uptake. UDCA may protect the fetus in ICP by inhibiting OATP4A1-mediated bile acid transfer and TC-induced placental vasoconstriction. Understanding the physiologic mechanisms of UDCA may allow better therapeutic interventions to be designed specifically for the fetus in the future.-Lofthouse, E. M., Torrens, C., Manousopoulou, A., Nahar, M., Cleal, J. K., O'Kelly, I. M., Sengers, B. G., Garbis, S. D., Lewis, R. M. Ursodeoxycholic acid inhibits uptake and vasoconstrictor effects of taurocholate in human placenta.

Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses

BACKGROUND

Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcomes, but the association with the concentration of specific biochemical markers is unclear. We aimed to quantify the adverse perinatal effects of intrahepatic cholestasis of pregnancy in women with increased serum bile acid concentrations and determine whether elevated bile acid concentrations were associated with the risk of stillbirth and preterm birth.

METHODS

We did a systematic review by searching PubMed, Web of Science, and Embase databases for studies published from database inception to June 1, 2018, reporting perinatal outcomes for women with intrahepatic cholestasis of pregnancy when serum bile acid concentrations were available. Inclusion criteria were studies defining intrahepatic cholestasis of pregnancy based upon pruritus and elevated serum bile acid concentrations, with or without raised liver aminotransferase concentrations. Eligible studies were case-control, cohort, and population-based studies, and randomised controlled trials, with at least 30 participants, and that reported bile acid concentrations and perinatal outcomes. Studies at potential higher risk of reporter bias were excluded, including case reports, studies not comprising cohorts, or successive cases seen in a unit; we also excluded studies with high risk of bias from groups selected (eg, a subgroup of babies with poor outcomes were explicitly excluded), conference abstracts, and Letters to the Editor without clear peer review. We also included unpublished data from two UK hospitals. We did a random effects meta-analysis to determine risk of adverse perinatal outcomes. Aggregate data for maternal and perinatal outcomes were extracted from case-control studies, and individual patient data (IPD) were requested from study authors for all types of study (as no control group was required for the IPD analysis) to assess associations between biochemical markers and adverse outcomes using logistic and stepwise logistic regression. This study is registered with PROSPERO, number CRD42017069134.

FINDINGS

We assessed 109 full-text articles, of which 23 studies were eligible for the aggregate data meta-analysis (5557 intrahepatic cholestasis of pregnancy cases and 165 136 controls), and 27 provided IPD (5269 intrahepatic cholestasis of pregnancy cases). Stillbirth occurred in 45 (0·83%) of 4936 intrahepatic cholestasis of pregnancy cases and 519 (0·32%) of 163 947 control pregnancies (odds ratio [OR] 1·46 [95% CI 0·73-2·89]; I2=59·8%). In singleton pregnancies, stillbirth was associated with maximum total bile acid concentration (area under the receiver operating characteristic curve [ROC AUC]) 0·83 [95% CI 0·74-0·92]), but not alanine aminotransferase (ROC AUC 0·46 [0·35-0·57]). For singleton pregnancies, the prevalence of stillbirth was three (0·13%; 95% CI 0·02-0·38) of 2310 intrahepatic cholestasis of pregnancy cases in women with serum total bile acids of less than 40 μmol/L versus four (0·28%; 0·08-0·72) of 1412 cases with total bile acids of 40-99 μmol/L (hazard ratio [HR] 2·35 [95% CI 0·52-10·50]; p=0·26), and versus 18 (3·44%; 2·05-5·37) of 524 cases for bile acids of 100 μmol/L or more (HR 30·50 [8·83-105·30]; p<0·0001).

INTERPRETATION

The risk of stillbirth is increased in women with intrahepatic cholestasis of pregnancy and singleton pregnancies when serum bile acids concentrations are of 100 μmol/L or more. Because most women with intrahepatic cholestasis of pregnancy have bile acids below this concentration, they can probably be reassured that the risk of stillbirth is similar to that of pregnant women in the general population, provided repeat bile acid testing is done until delivery.

FUNDING

Tommy's, ICP Support, UK National Institute of Health Research, Wellcome Trust, and Genesis Research Trust.

Lithocholic acid activates mTOR signaling inducing endoplasmic reticulum stress in placenta during intrahepatic cholestasis of pregnancy

AIMS

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific disorder, which increases risks of adverse fetal outcomes. However, the pathophysiology is not fully understood. Here, we explored the roles of mTOR signaling and ER stress in placenta during ICP.

MATERIALS AND METHODS

Placental tissues were collected from normal and ICP pregnancies. mTOR signaling and endoplasmic reticulum stress were detected by immunohistochemistry in the placenta. The human placenta trophoblast cell line HTR-8/SVneo was used in vitro experiment.

KEY FINDINGS

ICP placenta displayed histological abnormalities with fewer trophoblasts. Moreover, the expression of Bip and the phosphorylation of pS6(S235/236) or pAkt(S473) were higher comparing with normal placenta. In in vitro studies, the bile acids specifically to lithocholic acid rather than taurocholic acid or ursodeoxycholic acid, drastically increased the phosphorylation of pS6K1(T389), pS6(S235/236), or pAkt(S473), whereas the mTOR inhibitor can prohibit the upregulation. Similarly, the expressions of IRE1α and BiP increased sharply under lithocholic acid (20 μM) administration, while the same inhibitor can also decrease the expression. Additionally, transmission electron microscopy showed enlarged endoplasmic reticulum lumen under the lithocholic acid treatment. Furthermore, the cell viability reduced sharply under treatment with different dose of lithocholic acid. The mTOR inhibitor can reverse the decrease of cell viability to some extent.

SIGNIFICANCE

Bile acid can activate mTOR signaling which resulted in endoplasmic reticulum stress, leading to trophocyte viability decrease. mTOR pathway activation may be associated with the pathophysiology of ICP.

Intrahepatic Cholestasis of Pregnancy: A Review of Diagnosis and Management

Importance

Intrahepatic cholestasis of pregnancy (ICP) complicates approximately 0.2% to 2% of pregnancies and can lead to increased fetal risks in pregnancy.

Objective

This review aims to increase the knowledge of women's health care providers regarding the diagnosis, management, and fetal risks associated with ICP.

Results

The diagnosis of ICP is based on symptoms of pruritus that typically include the palms and soles, as well as elevated bile acid levels. Other liver function tests such as alanine aminotransferase and aspartate aminotransferase are also frequently elevated, and other causes of liver dysfunction should be ruled out. Fetal risks of ICP include increased risk of preterm birth, meconium-stained amniotic fluid, respiratory distress syndrome, or stillbirth. There is evidence that as bile acid levels increase, so does the risk of adverse neonatal outcomes. Ursodeoxycholic acid treatment has been shown to improve maternal pruritus symptoms, as well as biochemical tests, but no treatment has been shown to definitively improve fetal outcomes.

Conclusions and Relevance

Providers should be aware of the signs and symptoms of ICP and provide accurate diagnosis and management of affected women. Women with a diagnosis of ICP should be treated with ursodeoxycholic acid to improve maternal symptoms. Given the increased risk of stillbirth in the setting of ICP, delivery may be considered at 37 weeks' gestation.

In Vitro Action of Meconium on Bronochomotor Tonus of Newborns with Meconium Aspiration Syndrome

AIM

Here we studied the role of meconium in the respiratory system on live and exited newborns (weight 250-3000 g). Throughout this study is followed the response of tracheal rings in acetylcholine and histamine in different molar concentrations (10^-1, 10^-2, 10^-3, 10^-4 mol/dm³).

METHODS

To study the smooth tracheal musculature we used 23 tracheal preparations obtained from the newborns exited from meconium aspiration.

RESULTS

Based on the functional analysis of the tracheal specimen we have concluded that the meconium aspiration did not change the smooth musculature response on acetylcholine and histamine when compared to control group, exited from lung inflammatory processes (e.g., pneumonia, bronchopneumonia, atelectasis, cerebral hemorrhage), where tracheal smooth musculature response is significant (P for other causes is not significant (P > 0.01).

CONCLUSION

The conclusions suggest that meconium did not potentiate the constrictor action of acetylcholine and histamine in the tracheobronchial system and did not cause modulation of bronchomotor tonus in case of his aspiration. Meconium causes mild relaxation of smooth tracheal musculature with a mechanism which is not mediated by cyclooxygenase products, from tracheal epithelium or proteins. Also, direct activity in the smooth musculature of several tested acids seems to have no significant impact in increasing the tonus of respiratory airway of smooth tracheal musculature.

Role of ischemia-modified albumin in the evaluation of oxidative stress in intrahepatic cholestasis of pregnancy

Objective: The objective of this study is to investigate the ischemia-modified albumin (IMA) level, and the IMA/albumin ratio (IMAR) in healthy pregnant women, and pregnant women with intrahepatic cholestasis of pregnancy (ICP). Material and method: This cross-sectional study included 53 women with ICP and 52 healthy pregnant women. Their serum IMA and albumin levels were analyzed, and the women were followed up to delivery. Results: No significant intergroup differences were identified in maternal age, body mass index, and gestational age at the time that the blood samples were taken. The gestational age at delivery and the serum albumin level was significantly lower (p = .002 and p < .0001, respectively) in the ICP group than in the healthy pregnant women. Although no differences in IMA levels were shown between the groups, IMA/albumin levels were higher in the ICP group than in the healthy pregnant women (p = .004). Conclusion: Serum IMA levels did not differ between pregnant women with ICP and healthy pregnant women, while the IMAR was significantly higher in the ICP group versus the healthy pregnant women.

The role of vitamin B1-B2 and plasma lipid profile in intrahepatic cholestasis of pregnancy

AIM

The present study aimed to determine the levels of total cholesterol, triglycerides (TG), low-density lipoproteins (LDL), high-density lipoproteins (HDL), and vitamins B1 and B2 in intrahepatic cholestasis of pregnancy (ICP) patients, and to evaluate if these were involved in the pathophysiology of the disease.

METHODS

The prospective randomized study included 35 pregnant patients who were admitted to the Gynecology and Obstetrics Polyclinic, Faculty of Medicine at Dicle University and who were diagnosed with ICP (Group 1), and 40 healthy pregnant women who were admitted in the same period and who had no systemic diseases that might complicate the pregnancy during the pregnancy follow-up (Group 2). Serum lipid levels and vitamins B1 and B2 were determined and compared, and statistical comparisons of the groups were made.

RESULTS

There was no difference between the TG levels of the two groups (P=0.631). Total cholesterol, LDL, HDL, and vitamin B1 and B2 levels were higher in Group 1 than in Group 2 (P=0.001, P=0.001, P=0.001, P=0.001, and P=0.032, respectively).

CONCLUSIONS

Increased levels of vitamins B1 and B2 may indicate a need for increased energy metabolism at the fetus. So we believe that new studies are required, which will be supported by the placental analyses of the pyruvate and lactate levels in maternal blood at delivery and fetal cord blood in order to develop a better understanding on the fetal effects of energy metabolism.

Bile acids and gestation

There are numerous profound maternal physiological changes that occur from conception onwards and adapt throughout gestation in order to support a healthy pregnancy. By the time of late gestation, when circulating pregnancy hormones are at their highest concentrations, maternal adaptations include relative hyperlipidemia, hypercholanemia and insulin resistance. Bile acids have now been established as key regulators of metabolism, and their role in gestational changes in metabolism is becoming apparent. Bile acid homeostasis is tightly regulated by the nuclear receptor FXR, which has been shown to have reduced activity during pregnancy. This review focuses on the gestational alterations in bile acid homeostasis that occur in normal pregnancy, which in some women can become pathological, leading to the development of intrahepatic cholestasis of pregnancy. As well as their important role in maternal metabolic health, we will review bile acid metabolism in the feto-placental unit.

Intrahepatic Cholestasis of Pregnancy in Women With Twin Pregnancy

The aim of the present work was to determine maternal and fetal outcomes of intrahepatic cholestasis of pregnancy (ICP) in twin pregnancies. All twin pregnancies delivered above 28 gestational weeks in West China Second University Hospital from January 2013 to May 2015 were included. Data on maternal demographics and obstetric complications together with fetal outcomes were collected. The risk of adverse maternal and fetal outcomes were determined in relation to ICP by crude odds ratios (OR) and adjusted ORs (aOR) with 95% confidence intervals (CI). Subgroup analysis concentrated on the effect of assisted reproductive technology (ART), ICP severity, and onset time. A total of 1,472 twin pregnancies were included, of which 362 were cholestasis patients and 677 were conceived by ART. Higher rates of preeclampsia (aOR 1.96; 95% CI 1.35, 2.85), meconium-stained amniotic fluid (aOR 3.10; 95% CI 2.10, 4.61), and preterm deliveries (aOR 3.20; 95% CI 2.35, 4.37) were observed in ICP patients. Subgroup analysis revealed higher incidences of adverse outcomes in severe and early onset ICP groups. In conclusion, adverse maternal and fetal outcomes were strongly associated with ICP in twin patients. Active management and close antenatal monitoring are needed, especially in the early onset and severe groups.

Bile acids evoke placental inflammation by activating Gpbar1/NF-κB pathway in intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a cholestatic disorder with potentially deleterious consequences for fetuses. Although a clear correlation between the elevated levels of maternal serum bile acids and deficient fetal outcome has been established in clinical practice, the underlying mechanisms remain elusive. Herein, we report that bile acids induce NF-κB pathway activation via G protein-coupled bile acid receptor 1 (Gpbar1), with consequent upregulation of inflammatory genes in trophoblasts, leading to aberrant leukocyte infiltration and inflammation in placenta. Ursodeoxycholic acid (UDCA), a drug used clinically to treat ICP, competes with other bile acids for binding with Gpbar1 and thus inhibits bile acid-induced inflammatory response in trophoblasts and improves fetal survival in pregnant rats with obstructive cholestasis. Notably, inhibition of NF-κB by andrographolide is more effective than UDCA in benefiting placentas and fetuses. Thus, anti-inflammation therapy targeting Gpbar1/NF-κB pathway could be effective in suppressing bile acid-induced inflammation and alleviating ICP-associated fetal disorders.

Meconium-Associated Umbilical Vascular Myonecrosis: Correlations with Adverse Outcome and Placental Pathology

Intrauterine passage of meconium is common, occurring in approximately 10-15% of term births. Uncommonly, long-standing meconium exposure is associated with umbilical vascular myonecrosis, but few studies have evaluated specific clinical and pathologic features. This is a retrospective study of 481 term placentas: 139 with meconium-associated myonecrosis, 139 with meconium in fetal membranes, only 62 with meconium in the cord without myonecrosis, and 139 controls without meconium. We studied clinical factors, including clinical evidence of meconium discharge, fetal distress, APGAR scores, intrauterine growth restriction (IUGR), and intrauterine fetal demise (IUFD), and histologic factors, including acute chorioamnionitis, umbilical cord complications, uteroplacental malperfusion, fetal thrombosis, chorangiosis, and fetal nucleated red blood cells. Meconium myonecrosis was significantly associated with clinical meconium, fetal distress, IUGR, IUFD, acute chorioamnionitis, cord complications, fetal thrombosis, chorangiosis, and nucleated red blood cells when compared to controls (P < 0.05). Compared to cases with meconium in the membranes only, clinical meconium, fetal distress, IUGR, chorioamnionitis, thrombosis, chorangiosis, and nucleated red blood cells remained significant. Compared to cases with meconium in the cord without myonecrosis, only chorioamnionitis retained significance. In conclusion, myonecrosis was associated with adverse clinical outcome and placental lesions associated with hypoxia. Chorioamnionitis was significantly more common in all meconium groups compared to controls. As myonecrosis is an important lesion, a clinical history of meconium should trigger a meticulous search for meconium and specifically myonecrosis.

Management of intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease during pregnancy, characterized by otherwise unexplained pruritus in late second and third trimester of pregnancy and elevated bile acids and/or transaminases. ICP is associated with an increased risk of adverse perinatal outcomes for the fetus and the later development of hepatobiliary disease for the mother. Bile acids should be monitored throughout pregnancy since fetal risk is increased at serum bile acids >40 µmol/l. Management of ICP consists of treatment with ursodeoxycholic acid, which reduces pruritus. Early elective delivery is common practice but should be performed on an individualized basis as long as strong evidence supporting this practice is lacking. Mothers should be followed-up for normalization of liver function tests 6-12 weeks after delivery. Future research in large-scale studies is needed to address the impact of ursodeoxycholic acid and early elective delivery on fetal outcome.

The effect of 17α-ethynylestradiol induced intrahepatic cholestasis of pregnancy on placental P-glycoprotein in mice: Implications in the individualized transplacental digoxin treatment for fetal heart failure

INTRODUCTION

Placental P-glycoprotein (P-gp) plays a significant role in controlling transplacental digoxin transfer rate. Investigations on P-gp regulation in placenta of women with different pregnant pathological states are of great significance to individualized transplacental digoxin treatment for fetal heart failure (FHF). This study aimed to explore the effect of 17α-ethynylestradiol induced intrahepatic cholestasis of pregnancy (ICP) on placental P-gp in mice.

METHODS

ICP model in mice was induced by subcutaneous injection of 17α-ethynylestradiol dissolved in propylene glycol once daily from E12.5 to E16.5. Maternal plasma ALT, AST, TB, DBIL, γ-GT, LDH, ALP and TBA concentrations were measured. HE staining was applied for observation of maternal liver cells degeneration, necrosis and intrahepatic cholestasis. Placental Abcb1a/Abcb1b/HIF-1α mRNA and P-gp/HIF-1α protein expression were determined by real-time quantitative PCR and western-blot. Maternal plasma and fetal-unit digoxin concentrations were detected by a commercial kit assay.

RESULTS

The ICP group showed higher levels of maternal plasma ALT, AST, TB, DBIL, γ-GT, LDH, ALP and TBA concentrations, reduction in fetal survival rates, lower placental and fetal weights, and typical liver cells degeneration, necrosis and intrahepatic cholestasis. The placental Abcb1a mRNA and P-gp expression of ICP group were significantly elevated, while transplacental digoxin transfer rates were significantly decreased. Both placental HIF-1α mRNA and protein expression was significantly elevated in the ICP group, and there was a positive correlation between Abcb1a mRNA and HIF-1α mRNA.

CONCLUSIONS

17α-ethynylestradiol induced ICP could up-regulate placental P-gp expression and reduce transplacental digoxin transfer rate in mice, which might be partly associated with higher expression of HIF-1α.

The protective effect of ursodeoxycholic acid in an in vitro model of the human fetal heart occurs via targeting cardiac fibroblasts

Bile acids are elevated in the blood of women with intrahepatic cholestasis of pregnancy (ICP) and this may lead to fetal arrhythmia, fetal hypoxia and potentially fetal death in utero. The bile acid taurocholic acid (TC) causes abnormal calcium dynamics and contraction in neonatal rat cardiomyocytes. Ursodeoxycholic acid (UDCA), a drug clinically used to treat ICP, prevents adverse effects of TC. During development, the fetus is in a state of relative hypoxia. Although this is essential for the development of the heart and vasculature, resident fibroblasts can transiently differentiate into myofibroblasts and form gap junctions with cardiomyocytes in vitro, resulting in cardiomyocyte depolarization. We expanded on previously published work using an in vitro hypoxia model to investigate the differentiation of human fetal fibroblasts into myofibroblasts. Recent evidence shows that potassium channels are involved in maintaining the membrane potential of ventricular fibroblasts and that ATP-dependent potassium (KATP) channel subunits are expressed in cultured fibroblasts. KATP channels are a valuable target as they are thought to have a cardioprotective role during ischaemic and hypoxic conditions. We investigated whether UDCA could modulate fibroblast membrane potential. We established the isolation and culture of human fetal cardiomyocytes and fibroblasts to investigate the effect of hypoxia, TC and UDCA on human fetal cardiac cells. UDCA hyperpolarized myofibroblasts and prevented TC-induced depolarisation, possibly through the activation of KATP channels that are expressed in cultured fibroblasts. Also, similar to the rat model, UDCA can counteract TC-induced calcium abnormalities in human fetal cultures of cardiomyocytes and myofibroblasts. Under normoxic conditions, we found a higher number of myofibroblasts in cultures derived from human fetal hearts compared to cells isolated from neonatal rat hearts, indicating a possible increased number of myofibroblasts in human fetal hearts. Hypoxia further increased the number of human fetal and rat neonatal myofibroblasts. However, chronically administered UDCA reduced the number of myofibroblasts and prevented hypoxia-induced depolarisation. In conclusion, our results show that the protective effect of UDCA involves both the reduction of fibroblast differentiation into myofibroblasts, and hyperpolarisation of myofibroblasts, most likely through the stimulation of potassium channels, i.e. KATP channels. This could be important in validating UDCA as an antifibrotic and antiarrhythmic drug for treatment of failing hearts and fetal arrhythmia.

Pregnancy course in patients with intrahepatic cholestasis of pregnancy treated with very low doses of ursodeoxycholic acid

OBJECTIVE

Ursodeoxycholic acid (UDCA) has been proposed as the optimal pharmacological treatment for intrahepatic cholestasis of pregnancy (ICP). The lowest effective dosage of UDCA in women with ICP has not been established. The objective is to determine the risk of adverse pregnancy outcomes resulting from ICP and to measure changes in liver function parameters and pruritus severity in ICP patients treated with low doses of UDCA.

MATERIAL AND METHODS

ICP was diagnosed in 203 patients on the basis of pruritus and elevated liver biochemical parameters. Patients with total bile acids (TBA) ≥ 10 μmol/l (n = 157) received UDCA (300-450 mg/day; 4-6 mg/kg/day) until delivery. Maternal and fetal outcomes of women with ICP were compared with 100 patients without cholestasis. Patients with ICP were hospitalized for treatment and fetal surveillance.

RESULTS

There was no correlation between fetal and neonatal complication rates in ICP patients and biochemical markers of cholestasis. Significant declines in serum TBA (p = 0.003), bilirubin concentration (p = 0.026) and aminotransferase activity (p < 0.001) were observed during treatment with low doses of UDCA. Moreover, severity of pruritus was ameliorated during the 2 weeks of therapy (p = 0.037). A total of 17 patients (10.9%) did not respond to treatment.

CONCLUSIONS

UDCA at low doses improved biochemical markers and clinical symptoms in almost 90% of ICP patients.

Perinatal outcomes with intrahepatic cholestasis of pregnancy in twin pregnancies

OBJECTIVE

To describe perinatal outcomes of twin pregnancies complicated by intrahepatic cholestasis of pregnancy (ICP).

METHODS

We conducted a retrospective cohort study of women delivered at a large tertiary obstetric center in Shanghai, China from January 2006 to May 2014. Delivery data were abstracted from medical records of all twin gestations delivered at the hospital.

RESULTS

A total of 129/1922(6.7%) twin and 1190/92 273 singleton (1.3%) pregnancies were complicated by ICP. An increased risk of stillbirth among twin pregnancies was observed (3.9% and 0.8% in the ICP and non-ICP groups, respectively; aOR 5.75, 95% CI 2.00-16.6). Stillbirths with ICP and twins occurred between 33 and 35 weeks gestation compared to 36-38 weeks gestation among singletons. ICP in twins was also associated with an increased risk of preterm birth (<37 weeks) with an aOR of 4.17 (95% CI 2.47-7.04) and an aOR of 1.89 (95% CI 1.26-2.85) for delivery <35 weeks. Twin pregnancies complicated by ICP also had increased meconium staining of amniotic fluid and lower birth weight.

CONCLUSIONS

Twin pregnancies with ICP have significantly increased risks of adverse perinatal outcomes including stillbirth and preterm birth. Stillbirth occurs at an earlier gestational age in twin gestation compared to singletons, suggesting that earlier scheduled delivery should be considered in these women.

The impact of total bile acid levels on fetal cardiac function in intrahepatic cholestasis of pregnancy using fetal echocardiography: a tissue Doppler imaging study

AIM

The aim of this study was to assess total bile acid (TBA) levels and its impact on systolic and diastolic functions in fetuses of mothers with intrahepatic cholestasis of pregnancy (ICP) using tissue Doppler imaging (TDI), and to explore the correlation between TBA levels and fetal cardiac function.

SUBJECTS AND METHODS

The study employed 98 pregnant women with ICP who were divided into two groups according to their bile acid levels. Fifty pregnant women without ICP represented the control group.

RESULTS

Significant differences in the myocardial tissue velocities of both mitral and tricuspid valves were found between the fetuses of mothers with ICP and TBA levels of <40 mmol/L and the control group, versus fetuses of mothers with ICP and TBA levels >40 mmol/L. There was a significant increase in neonatal respiratory distress, meconium staining and neonatal TBAs in group II compared to the control group and group I. There was a correlation between maternal TBA levels and preterm delivery, APGAR scores and neonatal TBA levels at birth. There was also a positive correlation between maternal TBA and fetal myocardial tissue velocities of both mitral and tricuspid, and fetal diastolic myocardial tissue Doppler velocities.

CONCLUSION

ICP is a very serious condition especially when maternal TBA levels are >40 mmol/L. Fetal echocardiography with tissue Doppler is a useful tool for fetal assessment in patients with ICP. It could be an indication of induction of labor in cases of ICP and bile acid levels ≥40 mol/L. Neonatal echocardiography is mandatory for follow-up and management of these neonates.

A risk factor analysis on disease severity in 47 premature infants with bronchopulmonary dysplasia

Bronchopulmonary Dysplasia (BPD) is a rare chronic lung disease and one of the most difficult complications to treat in premature infants. With the progress at the medical treatment level, an increasing number of BPD premature infants are born, meanwhile, they would be at an increasing risk for numerous complications and rehospitalization because BPD affects many vital organ systems. The pathogenesis of BPD is clearly multifactorial. As the prognosis is closely connected with the severity of BPD, early diagnosis and treatment are of great help to control the development of BPD. This article focuses on risk factors that could influence the severity of BPD in order to provide a reliable basis for early diagnosis, treatment, and better patient assessment.

Role of postprandial bile acids in prediction of perinatal outcome in intrahepatic cholestasis of pregnancy

AIM

The aim of this study was to investigate the role of fasting and postprandial total bile acids (fTBA, ppTBA) in prediction of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy (ICP).

MATERIAL AND METHODS

A total of 111 patients, 57 with ICP and 54 controls, were evaluated for preterm birth (PTB), meconium-stained amnion (MSA), neonatal intensive-care unit admission and asphyxia. We further classified the ICP group as mild and severe. Logistic regression was performed to evaluate the associated biochemical and clinical parameters with adverse perinatal outcomes.

RESULTS

In the ICP group, PTB, asphyxia, admission to neonatal intensive-care unit, and MSA were more frequently observed (P = 0.001, P = 0.027, P = 0.006 and P = 0.030, respectively). In subgroup analysis, PTB was more frequent in severe ICP cases than in mild cases (P = 0.028). Fasting and ppTBA were positively correlated with serum aspartate aminotransferase and alanine aminotransferase levels. Postprandial TBA and difference between fasting and postprandial TBA levels were associated with asphyxia (P = 0.014 and P = 0.023, respectively). Gestational age at diagnosis and fTBA were associated with adverse perinatal outcomes (P = 0.001 and P = 0.025, respectively).

CONCLUSION

Postprandial TBA and difference of fasting and postprandial TBA are associated with asphyxia in ICP. The gestational age at diagnosis and fTBA are associated with adverse perinatal outcomes.

Drug resistant fetal arrhythmia in obstetric cholestasis

Obstetric cholestasis (OC) is a pregnancy specific liver disease characterized by increased levels of bile acid (BA) and pruritus. Raised maternal BA levels could be associated with intrauterine death, fetal distress, and preterm labor and also alter the rate and rhythm of cardiomyocyte contraction and may cause fetal arrhythmic events. We report a case of drug resistant fetal supraventricular tachycardia and concomitant OC. Conclusion. If there are maternal OC and concomitant fetal arrhythmia, possibility of the resistance to antiarrhythmic treatment should be kept in mind.

Fetal complications due to intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disorder of pregnancy. Diagnosis is based on the clinical picture, particularly the presence of pruritus with a deterioration of liver function tests, and typically elevated serum levels of total bile acids. ICP manifests in the second half of pregnancy, predominantly during the third trimester. Symptoms of the disease resolve spontaneously after delivery. Etiology is still not fully understood. Genetic defects in specific transport proteins, elevated levels of sex hormones, and various environmental factors are thought to play a role in the development of this disorder. Although practically benign for the pregnant woman, ICP represents a serious threat to the fetus. It increases the risk of preterm delivery, meconium excretion into the amniotic fluid, respiratory distress syndrome, and sudden intrauterine fetal death. Identifying fetuses at risk of ICP complications remains challenging. The ideal obstetrical management of ICP needs to be definitively determined. The aim of this review is to summarize the current knowledge on fetal complications of ICP and describe management options for their prevention.

Intrahepatic cholestasis of pregnancy: maternal and fetal outcomes associated with elevated bile acid levels

OBJECTIVE

The primary aim of this study was to investigate the correlation between pregnancy outcome and bile acid (BA) levels in pregnancies that were affected by intrahepatic cholestasis of pregnancy (ICP). In addition, correlations between maternal and fetal BA levels were explored.

STUDY DESIGN

We conducted a retrospective study that included women with pruritus and BA levels ≥10 μmol/L between January 2005 and August 2012 in 3 large hospitals in the Netherlands. The study group was divided in mild (10-39 μmol/L), moderate (40-99 μmol/L), and severe (≥100 μmol/L) ICP. Main outcome measures were spontaneous preterm birth, meconium-stained amniotic fluid, asphyxia, and perinatal death. Univariate and multivariate logistic regression analysis was used to study associations between BA levels and adverse outcome.

RESULTS

A total of 215 women were included. Gestational age at diagnosis and gestational age at delivery were significantly lower in the severe, as compared with the mild, ICP group (P < .001). Spontaneous preterm birth (19.0%), meconium-stained fluid (47.6%), and perinatal death (9.5%) occurred significantly more often in cases with severe ICP. Higher BA levels were associated significantly with spontaneous preterm birth (adjusted odds ratio [aOR], 1.15; 95% confidence interval [CI], 1.03-1.28), meconium-stained amniotic fluid (aOR, 1.15; 95% CI, 1.06-1.25), and perinatal death (aOR, 1.26; 95% CI, 1.01-1.57). Maternal BA levels at diagnosis and at delivery were correlated positively with umbilical cord blood BA levels (P = .006 and .012, respectively).

CONCLUSION

Severe ICP is associated with adverse pregnancy outcome. Levels of BA correlate between mother and fetus.

Intrahepatic cholestasis of pregnancy: a critical clinical review

Intrahepatic cholestasis of pregnancy is the most common liver disease of pregnancy. It is characterized by pruitus, elevated levels of maternal serum bile salts, and normal or mildly elevated liver enzymes occurring after 30 weeks of pregnancy. The primary risks associated with this condition include preterm delivery, meconium-stained amniotic fluid, and stillbirth. Management of intrahepatic cholestasis of pregnancy utilizes a 2-prong approach of oral medications and comfort measures along with active management close to term. The goal of active management has been to deliver women between 37 and 39 weeks of gestation in order to prevent the risk of stillbirth. Currently, expert opinions vary as to recommendations for fetal surveillance and induction of labor. Controversy exists as to whether there is an increased incidence of stillbirth between 37 and 39 weeks of gestation. This critical clinical review is a comprehensive overview of intrahepatic cholestasis of pregnancy, including background, controversies, and care of the pregnant woman with this condition and how to provide appropriate follow-up care later after delivery.

Pregnancy outcomes and prognostic factors in patients with intrahepatic cholestasis of pregnancy

The aim of this study was to describe maternal and fetal characteristics associated with intrahepatic cholestasis of pregnancy (ICP) and to determine clinical and biochemical predictors of fetal complications. A total of 89 singleton pregnancies with ICP were analysed, retrospectively. All data concerning laboratory results, symptom onset time, treatment response, delivery time and infant information were recorded in the study protocol. The mean gestational age at diagnosis was 32.6 ± 3.4 weeks; mean time of delivery was 36.8 ± 1.9 weeks. Binary logistic regression revealed that gestational age at diagnosis was predictive of preterm delivery (OR = 2.3, 95% CI: 1.5-3.3, p = 0.001). The incidence of respiratory distress syndrome (RDS), fetal growth restriction, fetal distress and preterm delivery were significantly higher in patients who were diagnosed before 30 weeks than after 34 weeks' gestation (p < 0.01). Gestational age at diagnosis is an important independent factor predicting adverse perinatal outcomes in patients with ICP.

Acidosis: A potential explanation for adverse fetal outcome in intrahepatic cholestasis of pregnancy. A case report

BACKGROUND

Intrahepatic cholestasis of pregnancy is a cholestatic disorder with an increased risk for adverse perinatal outcome. The mechanism underlying intrauterine demise is poorly understood.

CASE

A nulliparous woman with gestational age of 36 plus 6 weeks presented with suspected intrahepatic cholestasis. Continuous CTG monitoring evolved from a normal pattern towards a non-reassuring pattern. A male neonate was delivered by caesarean section. Apgar scores 0, 1 and 4 at 1, 5 and 10 min. Fetal cord gas analysis showed pH 6.98, base deficit -15 mmol/L. Blood results showed maternal serum bile acid concentration of 220 µmol/L.

CONCLUSION

Our case suggests gradual evolution towards hypoxia and acidosis. It is unknown whether certain components in the bile acid concentrations might contribute to a fetal metabolic component of the acidosis.

Intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy is the most common pregnancy-specific liver disease that typically presents in the third trimester. The clinical features are maternal pruritus in the absence of a rash and deranged liver function tests, including raised serum bile acids. Intrahepatic cholestasis of pregnancy is associated with an increased risk of adverse perinatal outcomes, including spontaneous preterm delivery, meconium staining of the amniotic fluid, and stillbirth. It is commonly treated with ursodeoxycholic acid. There is accumulating evidence to suggest that intrahepatic cholestasis of pregnancy has a lasting influence on both maternal and fetal health. We review the etiology, diagnosis, and management of this intriguing condition.

Reduced plasma corticotropin-releasing hormone levels during late gestation in patients with intrahepatic cholestasis of pregnancy

OBJECTIVE

Intrahepatic cholestasis of pregnancy (ICP) may lead to sudden onset of stillbirth, which most likely is related to uteroplacental insufficiency and dysregulation of the fetal blood supply. The relaxing effect of corticotropin-releasing hormone (CRH) on blood vessels was measured to examine the role of CRH in the pathogenesis of ICP.

METHODS

Eighty normal pregnant women and 80 ICP patients were divided into four groups of 20 cases, respectively, each based on gestational age from week 34 to 37. Radioimmunoassay was used to measure CRH in plasma samples collected from all of the subjects.

RESULTS

Plasma CRH increased markedly from week 34 to 37 in both ICP and healthy patients, but the increase was lower in the ICP group. Plasma CRH was 322 ± 61 pg/ml in mild ICP cases at 37 weeks' compared to 1,066 ± 173 pg/ml in controls (p < 0.05), but only 218 ± 128 pg/ml in severe ICP (p < 0.05). Plasma CRH was significantly lower at all other measured time points in patients with severe ICP. In ICP patients, there was a negative correlation between plasma CRH and total bile acid (TBA).

CONCLUSION

A limited increasing CRH level and negative correlation of CRH with TBA were unveiled in ICP patients.

Placental gene-expression profiles of intrahepatic cholestasis of pregnancy reveal involvement of multiple molecular pathways in blood vessel formation and inflammation

Background

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-associated liver disease with potentially deleterious consequences for the fetus, particularly when maternal serum bile-acid concentration >40 μM. However, the etiology and pathogenesis of ICP remain elusive. To reveal the underlying molecular mechanisms for the association of maternal serum bile-acid level and fetal outcome in ICP patients, DNA microarray was applied to characterize the whole-genome expression profiles of placentas from healthy women and women diagnosed with ICP.

Methods

Thirty pregnant women recruited in this study were categorized evenly into three groups: healthy group; mild ICP, with serum bile-acid concentration ranging from 10–40 μM; and severe ICP, with bile-acid concentration >40 μM. Gene Ontology analysis in combination with construction of gene-interaction and gene co-expression networks were applied to identify the core regulatory genes associated with ICP pathogenesis, which were further validated by quantitative real-time PCR and histological staining.

Results

The core regulatory genes were mainly involved in immune response, VEGF signaling pathway and G-protein-coupled receptor signaling, implying essential roles of immune response, vasculogenesis and angiogenesis in ICP pathogenesis. This implication was supported by the observed aggregated immune-cell infiltration and deficient blood vessel formation in ICP placentas.

Conclusions

Our study provides a system-level insight into the placental gene-expression profiles of women with mild or severe ICP, and reveals multiple molecular pathways in immune response and blood vessel formation that might contribute to ICP pathogenesis.

Immune mechanisms and the role of oxidative stress in intrahepatic cholestasis of pregnancy

INTRODUCTION

The purpose of this study was to investigate levels of inflammatory cytokines such as interleukin 6 (IL-6), tumor necrosis factor α (TNF-α) and neopterin and oxidative stress status in patients with intrahepatic cholestasis of pregnancy (ICP) as well as their potential role in the pathophysiology.

MATERIAL AND METHODS

Thirty patients with ICP (Group 1) and 30 healthy pregnant women (Group 2) were included in this prospective case-control study. Levels of IL-6, TNF-α and neopterin were determined in both of the groups. Total anti-oxidant status (TAS) and total oxidative stress (TOS) levels were determined by means of a fully automated Erel method. Oxidative stress index (OSI) was calculated as the ratio of TOS to TAS.

RESULTS

There was no significant difference between the groups in IL-6 and TNF-α levels (p = 0.105 and p = 0.722, respectively). The mean neopterin level was significantly higher in Group 1 compared to Group 2 (2.34 ±0.77 and 1.57 ±0.38, respectively, p = 0.001). In addition, TAS, TOS and OSI levels were significantly higher in Group 1 (p = 0.004, p = 0.001 and p = 0.001, respectively) compared to Group 2.

DISCUSSION

Intrahepatic cholestasis of pregnancy is an inflammatory disorder in which maternal immune reaction may play a role. Interleukin 6 and TNF-α, which are some of the markers of humoral reaction, act as an indicator of abnormal reaction rather than acute-phase reaction in ICP. Further clinical trials and supportive placental findings are needed on the role of cytokines in cellular and humoral immune reactions during the symptomatic period and delivery to better understand the role of immune mechanisms in the aetiology of ICP.

Bile acids in a multicenter, population-based case-control study of stillbirth

OBJECTIVE

We sought to compare bile acids in women with and without stillbirth in a population-based study.

STUDY DESIGN

The Stillbirth Collaborative Research Network conducted a multisite, population-based case-control study of stillbirth (fetal deaths ≥20 weeks). Maternal sera were obtained at the time of enrollment and frozen at -80°C until assay for bile acids.

RESULTS

Assays were performed in 581 women with stillbirth and 1546 women with live births. Bile acid levels were slightly higher in women with stillbirth (geometric mean [95% confidence interval {CI}] = 3.2 [3.0-3.5]) compared to live births (2.9 [2.7-3.1], P = .0327). However, the difference was not significant after adjustment for baseline risk factors for stillbirth. The proportion of women with elevated levels (≥10 or ≥40 μmol/L) was similar in stillbirths and live births. Results were similar when the analysis was limited to subsets of stillbirths and live births. In women with stillbirths not associated with fetal anomalies or obstetric complications bile acid levels were higher than in women with term live births (geometric mean [95% CI] = 3.4 [3.0-3.8] vs 2.9 [2.7-3.0], P = .0152, unadjusted; P = .06, adjusted). However, a similar proportion of women in both groups had levels ≥10 μmol/L (10.7 vs 7.2%; odds ratio [OR], 1.54; 95% CI, 0.97-2.44; adjusted OR, 1.29; 95% CI, 0.78-2.15) and ≥40 μmol/L (1.7 vs 0.7%; OR, 2.58; 95% CI, 0.85-7.84; adjusted OR, 2.28; 95% CI, 0.79-6.56).

CONCLUSION

Our data do not support testing for bile acids in cases of stillbirth in the absence of clinical evidence of intrahepatic cholestasis of pregnancy.

Lithocholic acid-induced placental tumor necrosis factor-α upregulation and syncytiotrophoblast cell apoptosis in intrahepatic cholestasis of pregnancy

AIM

To investigate tumor necrosis factor (TNF)-α expression and its relationship with serum bile acids in placental trophoblasts from patients with intrahepatic cholestasis of pregnancy (ICP).

METHODS

Human placenta, including normal pregnancies (n = 10) and patients with ICP (n = 10), were collected at term and subject to TNF-α measurements. Bile acid-induced TNF-α expression and cell apoptosis were evaluated in cultured syncytiotrophoblasts in vitro.

RESULTS

ICP placental trophoblasts displayed apoptotic histological abnormalities. TNF-α levels in ICP tissue were significantly greater than those of controls as measured by quantitative polymerase chain reaction and western blot. Levels of placental TNF-α mRNA were positively correlated with serum bile acid concentration in ICP patients. In vitro, lithocholic acid (LCA) significantly enhanced TNF-α mRNA at both doses, by 2.07-fold at 15 μm and by 3.41-fold at 30 μm, whereas deoxycholic acid mildly increased TNF-α mRNA by 1.41-fold at 100 μm only. LCA treatment produced significantly higher percentage of caspase-3 positive cells than vehicle treatment, rescuable by the addition of a TNF-α inhibitor, indicative of apoptosis induced by LCA-TNF-α pathway.

CONCLUSION

This study shows that the increase of TNF-α expression in placental trophoblasts is strongly associated with ICP pathology and is inducible by LCA in vitro, suggesting its potential value in the clinical prevention, diagnosis and treatment of ICP.

Uterine contractility in intrahepatic cholestasis of pregnancy

This study aims to compare uterine activity in intrahepatic cholestasis of pregnancy (ICP) patients vs normal pregnancies, and to determine the relevance of ICP and excessive uterine activity. A total of 59 patients with ICP and 89 with normal pregnancies were selected. Liver function, total bile acids and uterine activity were evaluated; uterine contraction parameters were compared at the specified range of gestational age. Uterine contraction frequency was significantly higher in the third trimester patients with ICP. Aspartate transaminase (AST) appeared to correlate with contraction frequency (r = 0.357, p = 0.006) and Montevideo units (MVUs) (r = 0.349, p = 0.007). For each 50 U/l increase in AST, the hazard ratio of excessive uterine activity was increased by 1.31-fold (95% CI = 1.034-1.663, p = 0.025). The present study demonstrates that third trimester uterine contractility increases in patients with ICP. These findings should be of note, given what is known about obstetric cholestasis, and should prompt further research.

Intra-hepatic Cholestasis of Pregnancy: A Comprehensive Review

Intra-hepatic cholestasis of pregnancy is a cholestatic disorder characterized by i) pruritus, with onset in the third trimester of pregnancy, without any primary skin lesions, ii) elevated fasting serum bile acids > 10 μmol/L (and elevated serum transaminases), iii) spontaneous relief of signs and symptoms within two to three weeks after delivery, and iv) absence of other disease that cause pruritus and jaundice. It is believed to be a multi-factorial disease with interplay between genetic, environmental and hormonal factors. Incidence is between 0.02% to 2.4% of all pregnancies; with wide geographical variations. Maternal prognosis is usually good but can result in adverse fetal outcomes like meconium staining of amniotic fluid, fetal bradycardia and even fetal loss. Response to anti-histaminic is poor. Of all the medical therapies that have been described for the treatment for IHCP, ursodeoxycholic acid has the best response in relieving pruritus in mother, and probably has a role in preventing even the perinatal complications. Timely diagnosis and treatment is urged in order to prevent fetal complications and an early delivery between 37 to 38 weeks should be contemplated in severe cases, especially once fetal lung maturity is attained.

Study on the regulation of cell adhesion molecule expression and function in placenta from women with intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a common complication of pregnancy manifested as skin pruritus of cholestasis. ICP occurs mainly in the second or third trimester of pregnancy and may cause fetal distress, unexpected intrauterine fetal death and does serious harm to maternal and fetal health. The pathogenesis of ICP is still unclear. In ICP placentas, placental syncytiotrophoblasts are the most direct contact between maternal high bile acid environment and fetus. Our previous study found that in ICP placental syncytiotrophoblasts, both mRNA expression level and protein expression level of vascular cell adhesion molecule-1 (VCAM-1), were significantly elevated. Since VCAM-1 is important in inflammatory injury of lymphocytes, we speculate that ICP pathogenesis may be associated with VCAM-1 up-regulation which may lead to inflammatory injury and cause intrauterine fetal distress, intrauterine fetal death and other adverse outcomes. Elucidation of this mechanism should help reveal the ICP pathogenesis and facilitate the clinical treatment of intrauterine fetal death.

High doses of ursodeoxycholic acid up-regulate the expression of placental breast cancer resistance protein in patients affected by intrahepatic cholestasis of pregnancy

BACKGROUND

Ursodeoxycholic acid (UDCA) administration in intrahepatic cholestasis of pregnancy (ICP) induces bile acids (BA) efflux from the foetal compartment, but the molecular basis of this transplacental transport is only partially defined.

AIM

To determine if placental breast cancer resistance protein (BCRP), able to transport BA, is regulated by UDCA in ICP.

METHODS

32 pregnant women with ICP (14 untreated, 34.9±5.17 years; 18 treated with UDCA--25 mg/Kg/day, 32.7±4.62 years,) and 12 healthy controls (33.4±3.32 years) agreed to participate in the study. Placentas were obtained at delivery and processed for membrane extraction. BCRP protein expression was evaluated by immunoblotting techniques and chemiluminescence quantified with a luminograph measuring emitted photons; mRNA expression with real time PCR. Statistical differences between groups were evaluated by ANOVA with Dunn's Multiple Comparison test.

RESULTS

BCRP was expressed only on the apical membrane of the syncytiotrophoblast. A significant difference was observed among the three groups both for mRNA (ANOVA, p = 0.0074) and protein (ANOVA, p<0.0001) expression. BCRP expression was similar in controls and in the untreated ICP group. UDCA induced a significant increase in placental BCRP mRNA and protein expression compared to controls (350.7±106.3 vs 100±18.68% of controls, p<0.05 and 397.8±56.02 vs 100±11.44% of controls, p<0.001, respectively) and untreated ICP (90.29±17.59% of controls, p<0.05 and 155.0±13.87%, p<0.01).

CONCLUSION

Our results confirm that BCRP is expressed only on the apical membrane of the syncytiotrophoblast and show that ICP treatment with high dose UDCA significantly upregulates placental BCRP expression favouring BA efflux from the foetal compartment.

Obstetric cholestasis: outcome with active management

AIM

To study the nature and clinical outcome of pregnancies with obstetric cholestasis on active management and to correlate perinatal outcome to gestational age at delivery.

MATERIAL AND METHODS

This prospective randomized study included 69 women with obstetric cholestasis. Fetal surveillance began at 34 weeks or later at diagnosis and included daily maternal record of fetal movements, and biophysical profile (i.e. non stress test, the four quadrant amniotic fluid index). Fetal monitoring was conducted weekly before 36 weeks and biweekly after that. Randomization into two groups was done where one group was planned for delivery at 37 weeks whereas in the other group, pregnancy was carried to 38 weeks under surveillance. The primary outcome variable was correlation of fetal and neonatal complication rates to gestational age at delivery.

RESULTS

There were no stillbirths in the study. No episode of fetal asphyxia or bradycardia was observed. The overall rate of meconium passage was 7.46% (5/67). However, there was no case of meconium aspiration syndrome. Women delivering at or after 38 weeks had a lower incidence of cesarean section (17.85% vs 25.8%), neonatal nursery admission (17.85% vs 22.5%), and neonatal jaundice (17.85% vs 19.35%) compared to those delivering at 37 weeks. The differences between the two groups were, however, not found to be statistically significant.

CONCLUSION

The current study demonstrates that with active intervention, pregnancies with obstetric cholestasis can be carried to a later gestation under surveillance.

Stereological assessment of placental morphology in intrahepatic cholestasis of pregnancy

OBJECTIVE

To apply stereology for the detection of possibly morphological abnormalities in placentas of women with intrahepatic cholestasis of pregnancy (ICP).

STUDY DESIGN

Prospective case-control study of placentas from untreated and UDCA-treated ICP, respectively, and normal pregnancies, examined for morphological differences by systematic random sampling generated by computerized stereology methodology.

MAIN OUTCOME MEASURES

Volume of placenta, surface area of terminal villi and capillaries, volume fraction of collagen, number of syncytial knots, and chorangiosis.

RESULTS

Surface area of terminal villi and capillaries, and number of syncytial knots were higher in placentas from all ICP, as compared to controls (p < 0.01). A reduction of collagen was found in placentas from UDCA-treated ICP, both in comparison to placentas from untreated ICP and controls (p < 0.05).

CONCLUSION

ICP affects the placenta morphologically as shown by increased terminal villous and capillary surface area, and number of syncytial knots.

Maternal and perinatal outcome in cases of fulminant viral hepatitis in late pregnancy

OBJECTIVE

To investigate maternal and perinatal outcomes in cases of fulminant viral hepatitis in late pregnancy (FVHILP).

METHODS

A multicenter retrospective study was conducted. The records of 40 patients with FVHILP were retrieved from 3 hospitals in China. To analyze the influence of mode of delivery on maternal and perinatal outcomes, women were allocated to the cesarean delivery group or the spontaneous vaginal delivery (SVD) group. To study the relationship between maternal outcome and perinatal outcome, patients were allocated to the maternal survival group or the non-survival group.

RESULTS

There were no significant differences between the cesarean group and the SVD group in clinical manifestations or laboratory indices before delivery, or in fatality rate (P>0.05 for all), whereas there were significant differences in newborn weight, 1-minute Apgar score, and incidence of severe perinatal asphyxia between the maternal survival group and the non-survival group (P<0.05 for all).

CONCLUSION

Maternal and perinatal outcomes in cases of FVHILP were not influenced by mode of delivery, whereas perinatal outcome significantly correlated with maternal outcome.