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Gurung V, Stokes M, Middleton P, Milan SJ, Hague W, Thornton JG. Interventions for treating cholestasis in pregnancy. Cochrane Database Syst Rev 2013; 2013:CD000493. [PMID: 23794285 PMCID: PMC7043272 DOI: 10.1002/14651858.cd000493.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Obstetric cholestasis has been linked to adverse maternal and fetal/neonatal outcomes. As the pathophysiology is poorly understood, therapies have been empiric. The first version of this review, published in 2001, and including nine randomised controlled trials involving 227 women, concluded that there was insufficient evidence to recommend any of the interventions alone or in combination. This is the first update. OBJECTIVES To evaluate the effectiveness and safety of therapeutic and delivery interventions in women with cholestasis of pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 February 2013) and reference lists of identified studies. SELECTION CRITERIA Randomised controlled trials that compared two intervention strategies for women with a clinical diagnosis of obstetric cholestasis. DATA COLLECTION AND ANALYSIS The review authors independently assessed trials for eligibility and risk of bias. We independently extracted data and checked these for accuracy. MAIN RESULTS We included 21 trials with a total of 1197 women. They were mostly at moderate to high risk of bias. They assessed 11 different interventions resulting in 15 different comparisons.Compared with placebo, ursodeoxycholic acid (UDCA) showed improvement in pruritus in five (228 women) out of seven trials. There were no significant differences in instances of fetal distress in the UDCA groups compared with placebo (average risk ratio (RR) 0.67; 95% confidence interval (CI) 0.22 to 2.02; five trials, 304 women; random-effects analysis: T² = 0.74; I² = 48%). There were significantly fewer total preterm births with UDCA (RR 0.46; 95% CI 0.28 to 0.73; two trials, 179 women). The difference for spontaneous preterm births was not significant (RR 0.99; 95% CI 0.41 to 2.36, two trials, 109 women).Two trials (48 women) reported lower (better) pruritus scores for S-adenosylmethionine (SAMe) compared with placebo, while two other trials of 34 women reported no significant differences between groups.UDCA was more effective in improving pruritus than either SAMe (four trials; 133 women) or cholestyramine (one trial; 84 women), as was combined UDCA+SAMe when compared with placebo (one trial; 16 women) and SAMe alone (two trials; 68 women). However, combined UDCA+SAMe was no more effective than UDCA alone in regard to pruritus improvement (one trial; 53 women) and two trials (80 women) reported data were insufficient to draw any conclusions from. In one trial comparing UDCA and dexamethasone (83 women), a significant improvement with UDCA was seen only in a subgroup of women with severe obstetric cholestasis (23 women).Danxiaoling significantly improved pruritus in comparison to Yiganling. No significant differences were seen in pruritus improvement with other interventions.Eight trials reported fetal or neonatal deaths, with two deaths reported overall (both in the placebo groups).Women receiving UDCA and cholestyramine experienced nausea, vomiting and diarrhoea. Guar gum caused mild abdominal distress, diarrhoea and flatulence during the first days of treatment. Women found charcoal suspension unpleasant to swallow. Dexamethasone caused nausea, dizziness and stomach pain in one woman.One trial (62 women) looked at the timing of delivery intervention. There were no stillbirths or neonatal deaths in 'early delivery' or the 'await spontaneous labour' group. There were no significant differences in the rates of caesarean section, meconium passage or admission to neonatal intensive care unit between the two groups. AUTHORS' CONCLUSIONS Different approaches to assessing and reporting pruritus precluded pooling of trials comparing the effects of UDCA versus placebo on pruritus, but examination of individual trials suggests that UDCA significantly improves pruritus, albeit by a small amount. Fewer instances of fetal distress/asphyxial events were seen in the UDCA groups when compared with placebo but the difference was not statistically significant. Large trials of UDCA to determine fetal benefits or risks are needed.A single trial was too small to rule in or out a clinically important effect of early term delivery on caesarean section.There is insufficient evidence to indicate that SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, Salvia, Yinchenghao decoction (YCHD), Danxioling and Yiganling, or Yiganling alone or in combination are effective in treating women with cholestasis of pregnancy.
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Affiliation(s)
- Vinita Gurung
- University of NottinghamDepartment of Obstetrics and GynaecologyNottingham City Hospital NHS TrustHucknall RoadNottinghamNottinghamshireUKNG5 1PB
| | - Michael Stokes
- The University of AdelaideDiscipline of Obstetrics and Gynaecology1st Floor, Queen Victoria Building, Women's and Children's Hospital72 King William RoadNorth AdelaideSAAustralia5006
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | | | - William Hague
- Women's and Children's HospitalKing William RoadAdelaideSouth AustraliaAustraliaSA 5006
| | - Jim G Thornton
- University of NottinghamDivision of Child Health, Obstetrics and Gynaecology, School of MedicineNottingham City Hospital NHS TrustHucknall RoadNottinghamNottinghamshireUKNG5 1PB
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Intrahepatic cholestasis of pregnancy: Biochemical predictors of adverse perinatal outcomes. ACTA ACUST UNITED AC 2013; 33:412-417. [DOI: 10.1007/s11596-013-1133-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Indexed: 12/12/2022]
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Zhangxue H, Min G, Jinning Z, Yuan S, li W, Huapei S, Rui L, Chunyu Z. Glycochenodeoxycholate induces rat alveolar epithelial type II cell death and inhibits surfactant secretion in vitro. Free Radic Biol Med 2012; 53:122-8. [PMID: 22569305 DOI: 10.1016/j.freeradbiomed.2012.04.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 04/01/2012] [Accepted: 04/09/2012] [Indexed: 12/14/2022]
Abstract
Bile acid-induced lung injury has become an important topic for neonatologists after the discovery of a high incidence of infant respiratory distress syndrome complicated from maternal intrahepatic cholestasis. To explore the molecular pathway of bile acid-induced lung injury, we investigated the cytotoxicity of the glycochenodeoxycholate (GCDC) to alveolar epithelial type II cells (AECII), as the main component of bile acid. The results demonstrated that glycochenodeoxycholate induced oxidative stress, mitochondrial damage, and increased caspase activity in the primary cultured AECII. Moreover, ROS scavengers and caspase inhibitors could rescue cell death induced by GCDC in rat AECII. Our results also indicated that GCDC inhibited AECII surfactant secretion. In conclusion, this study suggested that cell death prevention and cell therapy should be considered as therapeutic strategies for infant respiratory distress syndrome complicated from maternal intrahepatic cholestasis.
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Affiliation(s)
- Hu Zhangxue
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing 400042, China.
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Chappell LC, Gurung V, Seed PT, Chambers J, Williamson C, Thornton JG. Ursodeoxycholic acid versus placebo, and early term delivery versus expectant management, in women with intrahepatic cholestasis of pregnancy: semifactorial randomised clinical trial. BMJ 2012; 344:e3799. [PMID: 22695903 PMCID: PMC3420230 DOI: 10.1136/bmj.e3799] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To test whether ursodeoxycholic acid reduces pruritus in women with intrahepatic cholestasis of pregnancy, whether early term delivery does not increase the incidence of caesarean section, and the feasibility of recruiting women with intrahepatic cholestasis of pregnancy to trials of these interventions. DESIGN First phase of a semifactorial randomised controlled trial. SETTING Nine consultant led maternity units, United Kingdom. PARTICIPANTS 125 women with intrahepatic cholestasis of pregnancy (pruritus and raised levels of serum bile acids) or pruritus and raised alanine transaminase levels (>100 IU/L) recruited after 24 weeks' gestation and followed until delivery. 56 women were randomised to ursodeoxycholic acid, 55 to placebo, 30 to early term delivery, and 32 to expectant management. INTERVENTIONS Ursodeoxycholic acid 500 mg twice daily or placebo increased as necessary for symptomatic or biochemical improvement until delivery; early term delivery (induction or delivery started between 37+0 and 37+6) or expectant management (spontaneous labour awaited until 40 weeks' gestation or caesarean section undertaken by normal obstetric guidelines, usually after 39 weeks' gestation). MAIN OUTCOME MEASURES The primary outcome for ursodeoxycholic acid was maternal itch (arithmetic mean of measures (100 mm visual analogue scale) of worst itch in past 24 hours) and for the timing of delivery was caesarean section. Secondary outcomes were other maternal and perinatal outcomes and recruitment rates. RESULTS Ursodeoxycholic acid reduced itching by -16 mm (95% confidence interval -27 mm to -6 mm), less than the 30 mm difference prespecified by clinicians and women as clinically meaningful. 32% (14/44) of women randomised to ursodeoxycholic acid experienced a reduction in worst itching by at least 30 mm compared with 16% (6/37) randomised to placebo. The difference of 16% (95% confidence interval -3 to 34); this would represent a number needed to treat of 6, but it failed to reach significance. Early term delivery did not increase caesarean sections (7/30 (23%) in the early term delivery group versus 11/32 (33%) in the expectant management group (relative risk 0.70, 95% confidence interval 0.31 to 1.57). No serious harms were noted in either trial. 22% (73/325) of eligible women participated in the drug trial and 19% (39/209) in the timing of delivery trial; both groups had a similar spectrum of disease severity to non-participants. CONCLUSIONS Ursodeoxycholic acid significantly reduces pruritus, but the size of the benefit may be too small for most doctors to recommend it, or for most women to want to take it. Women are, however, likely to differ in whether they consider the benefit to be worthwhile. Planned early term delivery seems not to increase incidence of caesarean section, although a small increase cannot be excluded. A trial to test whether ursodeoxycholic acid reduces adverse perinatal outcomes would have to be large, but is feasible. A trial to test the effect of early term delivery on adverse fetal outcomes would have to be significantly larger and may not be feasible. TRIAL REGISTRATION Current Controlled Trials ISRCTN37730443.
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De Luca D, Minucci A, Trias J, Tripodi D, Conti G, Zuppi C, Capoluongo E. Varespladib Inhibits Secretory Phospholipase A2 in Bronchoalveolar Lavage of Different Types of Neonatal Lung Injury. J Clin Pharmacol 2012; 52:729-737. [DOI: 10.1177/0091270011405498] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Arlicot C, Le Louarn A, Bacq Y, Potin J, Denis C, Perrotin F. Prise en charge de la cholestase intrahépatique gravidique en France : enquête nationale des pratiques auprès des gynécologues-obstétriciens. ACTA ACUST UNITED AC 2012; 41:182-93. [DOI: 10.1016/j.jgyn.2011.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 09/07/2011] [Accepted: 09/15/2011] [Indexed: 12/27/2022]
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Rook M, Vargas J, Caughey A, Bacchetti P, Rosenthal P, Bull L. Fetal outcomes in pregnancies complicated by intrahepatic cholestasis of pregnancy in a Northern California cohort. PLoS One 2012; 7:e28343. [PMID: 22403605 PMCID: PMC3293870 DOI: 10.1371/journal.pone.0028343] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 11/06/2011] [Indexed: 12/27/2022] Open
Abstract
Background Intrahepatic cholestasis of pregnancy (ICP) has important fetal implications. There is increased risk for poor fetal outcomes, including preterm delivery, meconium staining of amniotic fluid, respiratory distress, fetal distress and demise. Methods One hundred and one women diagnosed with ICP between January 2005 and March 2009 at San Francisco General Hospital were included in this study. Single predictor logistic regression models were used to assess the associations of maternal clinical and biochemical predictors with fetal complications. Clinical predictors analyzed included age, race/ethnicity, gravidity, parity, history of liver or biliary disease, history of ICP in previous pregnancies, and induction. Biochemical predictors analyzed included serum aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total bilirubin, direct bilirubin, albumin, total protein, and total bile acids (TBA). Results The prevalence of ICP was 1.9%. Most were Latina (90%). Labor was induced in the majority (87%) and most were delivered by normal spontaneous vaginal delivery (84%). Fetal complications occurred in 33% of the deliveries, with respiratory distress accounting for the majority of complications. There were no statistically significant clinical or biochemical predictors associated with an increased risk of fetal complications. Elevated TBA had little association with fetal complications until reaching greater than 100 µmoL/L, with 3 out of 5 having reported complications. ICP in previous pregnancies was associated with decreased risk of fetal complications (OR 0.21, p = 0.046). There were no cases of late term fetal demise. Conclusions Maternal clinical and laboratory features, including elevated TBA, did not appear to be substantial predictors of fetal complications in ICP.
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Affiliation(s)
- Michelle Rook
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California San Francisco, San Francisco, California, United States of America
| | - Juan Vargas
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
- Department of Radiology, University of California San Francisco, San Francisco, California, United States of America
| | - Aaron Caughey
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Philip Rosenthal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California San Francisco, San Francisco, California, United States of America
- Department of Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Laura Bull
- Liver Center Laboratory and Institute for Human Genetics, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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De Luca D, Capoluongo E, Rigo V. Secretory phospholipase A2 pathway in various types of lung injury in neonates and infants: a multicentre translational study. BMC Pediatr 2011; 11:101. [PMID: 22067747 PMCID: PMC3247178 DOI: 10.1186/1471-2431-11-101] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 11/08/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Secretory phospholipase A2 (sPLA2) is a group of enzymes involved in lung tissue inflammation and surfactant catabolism. sPLA2 plays a role in adults affected by acute lung injury and seems a promising therapeutic target. Preliminary data allow foreseeing the importance of such enzyme in some critical respiratory diseases in neonates and infants, as well. Our study aim is to clarify the role of sPLA2 and its modulators in the pathogenesis and clinical severity of hyaline membrane disease, infection related respiratory failure, meconium aspiration syndrome and acute respiratory distress syndrome. sPLA2 genes will also be sequenced and possible genetic involvement will be analysed. METHODS/DESIGN Multicentre, international, translational study, including several paediatric and neonatal intensive care units and one coordinating laboratory. Babies affected by the above mentioned conditions will be enrolled: broncho-alveolar lavage fluid, serum and whole blood will be obtained at definite time-points during the disease course. Several clinical, respiratory and outcome data will be recorded. Laboratory researchers who perform the bench part of the study will be blinded to the clinical data. DISCUSSION This study, thanks to its multicenter design, will clarify the role(s) of sPLA2 and its pathway in these diseases: sPLA2 might be the crossroad between inflammation and surfactant dysfunction. This may represent a crucial target for new anti-inflammatory therapies but also a novel approach to protect surfactant or spare it, improving alveolar stability, lung mechanics and gas exchange.
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Affiliation(s)
- Daniele De Luca
- Pediatric Intensive Care Unit, Dept of Emergency and Intensive Care, University Hospital "A.Gemelli", Catholic University of the Sacred Heart - Rome, Italy
- Laboratory of Clinical Molecular Biology, Dept of Molecular Medicine, University Hospital "A.Gemelli", Catholic University of the Sacred Heart - Rome, Italy
| | - Ettore Capoluongo
- Pediatric Intensive Care Unit, Dept of Emergency and Intensive Care, University Hospital "A.Gemelli", Catholic University of the Sacred Heart - Rome, Italy
| | - Vincent Rigo
- Neonatal Intensive Care Unit, University of Liège, CHU de Liège (CHR Citadelle), Belgium
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Abstract
Research over the last decade has uncovered roles for bile acids (BAs) that extend beyond their traditional functions in regulating lipid digestion and cholesterol metabolism. BAs are now recognized as signaling molecules that interact with both plasma membrane and nuclear receptors. Emerging evidence indicates that by interacting with these receptors, BAs regulate their own synthesis, glucose and energy homeostasis, and other important physiological events. Herein, we provide a comprehensive review of the actions of BAs on cardiovascular function. In the heart and the systemic circulation, BAs interact with plasma membrane G-protein-coupled receptors, for example, TGR5 and muscarinic receptors, and nuclear receptors, for example, the farnesoid (FXR) and pregnane (PXR) xenobiotic receptors. BA receptors are expressed in cardiovascular tissue, however, the mechanisms underlying BA-mediated regulation of cardiovascular function remain poorly understood. BAs reduce heart rate by regulating channel conductance and calcium dynamics in sino-atrial and ventricular cardiomyocytes and regulate vascular tone via both endothelium-dependent and -independent mechanisms. End-stage liver disease, obstructive jaundice, and intrahepatic cholestasis of pregnancy are prominent conditions in which elevated serum BAs alter vascular dynamics. This review focuses on BAs as newly recognized signaling molecules that modulate cardiovascular function.
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Affiliation(s)
- Sandeep Khurana
- Division of Gastroenterology and Hepatology, VA Maryland Health Care System and University of Maryland School of Medicine, Baltimore, MD, USA.
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Abstract
Premature delivery of an infant is occasionally performed because of complications of pregnancy. This article reviews common medical indications for preterm delivery and the available evidence supporting delivery before 37 weeks of gestation. In many conditions, few data exist to guide optimal timing of delivery and management is guided by expert opinion. Ultimately, an individual assessment must be made in each case to weigh the risks that pregnancy continuation poses to the mother and/or fetus with the risks of prematurity and its associated morbidities.
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Affiliation(s)
- Amy E Wong
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
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Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disorder characterized by maternal pruritus in the third trimester, raised serum bile acids and increased rates of adverse fetal outcomes. The etiology of ICP is complex and not fully understood, but it is likely to result from the cholestatic effects of reproductive hormones and their metabolites in genetically susceptible women. Equally unclear are the mechanisms by which the fetal complications occur. This article reviews the epidemiology, clinical features, diagnosis, etiology and management of ICP.
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Oztekin D, Aydal I, Oztekin O, Okcu S, Borekci R, Tinar S. Predicting fetal asphyxia in intrahepatic cholestasis of pregnancy. Arch Gynecol Obstet 2009; 280:975-9. [PMID: 19322574 DOI: 10.1007/s00404-009-1052-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 03/10/2009] [Indexed: 12/18/2022]
Abstract
PURPOSE Intrahepatic cholestasis of pregnancy (ICP) is a disease associated with high-perinatal morbidity and mortality rates. It is important to have parameters that aid in predicting fetal outcomes. Certain parameters affecting asphyxia in newborns to mothers with ICP are evaluated in this study. METHODS One hundred eighty-seven cholestatic pregnancies were analyzed, retrospectively. Fetal asphyxia was defined as an APGAR score of less than 7 at 5 min postpartum. Predictors of asphyxia in ICP were analyzed by binary multivariate logistic regression analysis. RESULTS Thirty-six of the cholestatic pregnancies ended up having an asphyctic newborn at the time of delivery (19.2%). There was a statistically significance difference in the levels of total bile acids (TBA) (42.4 +/- 15.2 vs. 33.8 +/- 12.9 micromol/L, P < 0.01), HDL cholesterol (54.2 +/- 15.9 vs. 61.3 +/- 12.2, P = 0.01), total cholesterol (279.0 +/- 51.4 vs. 257.7 +/- 51.6, P = 0.02), and triacylglycerol (299.4 +/- 94.6 vs. 260.4 +/- 118.7) between the asphytic and nonasphytic group. Binary multivariate logistic regression analysis demonstrated that TBA levels (OR 1.04, 95% CI 1.01-1.08, P = 0.03) and exposure time (OR 1.11, 95% CI 1.05-1.17, P < 0.01) were the most important independent variables predicting fetal asphyxia in ICP. CONCLUSIONS In this study, it has been demonstrated that for the evaluation of fetal status, increased TBA levels in the mother and increased exposure time for the fetus to these increased values of TBA within the maternal circulation system help to predict increased risk of asphyxia in newborns to ICP mothers.
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Affiliation(s)
- Deniz Oztekin
- Department of Obstetrics and Gynecology, Agean Obstetrics and Gynecology Training and Research Hospital, Izmir, Turkey.
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Hepburn IS, Schade RR. Pregnancy-associated liver disorders. Dig Dis Sci 2008; 53:2334-58. [PMID: 18256934 DOI: 10.1007/s10620-007-0167-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 11/26/2007] [Indexed: 12/14/2022]
Abstract
Liver disorders associated with pregnancy include hyperemesis gravidarum (HG), intrahepatic cholestasis of pregnancy (ICP), preeclampsia, syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP), and acute fatty liver of pregnancy (AFLP). These conditions are relatively common and unique to pregnancy and are more likely to occur at certain terms of gestation specific to each condition. They can be associated with significant maternal and fetal morbidity and mortality. Although managing such patients may be very challenging, spontaneous resolution of the disease occurs shortly after termination of the pregnancy, usually without hepatic sequellae. Early diagnosis and timely treatment is a key to therapeutic success. This article explores the clinical features, pathophysiology, and management of these disorders.
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Affiliation(s)
- Iryna S Hepburn
- Department of Medicine, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912, USA.
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Zecca E, De Luca D, Barbato G, Marras M, Tiberi E, Romagnoli C. Predicting respiratory distress syndrome in neonates from mothers with intrahepatic cholestasis of pregnancy. Early Hum Dev 2008; 84:337-41. [PMID: 17928172 DOI: 10.1016/j.earlhumdev.2007.09.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Revised: 04/21/2007] [Accepted: 09/10/2007] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Intrahepatic cholestasis of pregnancy (ICP) has been associated with prematurity and fetal mortality. Recently, ICP has also been recognised as a risk factor for neonatal respiratory distress syndrome (RDS) in term or near-term neonates. Since fetal mortality is more frequent in pregnancies with an early ICP onset, we speculated that the time of exposure (ET) to maternal bile acids at the delivery (BAdeliv) could be involved in neonatal lung damage too. Study aim was to develop a scoring system to predict the RDS occurrence. DESIGN We conducted a retrospective analysis of 77 pregnancies complicated by ICP (years 2000-2004) looking for factors associated to the neonatal RDS. We developed a risk score as follows: RDS risk score=BAdeliv x ET/gestational age and we prospectively applied it to 30 neonates from ICP pregnancies (years 2005-2006). RESULTS ROC analysis indicated 9 as the score with the highest sensitivity (83.3%) and specificity (87.5%). Considering a RDS incidence of about 25% in babies coming from ICP pregnancies, the post-test probability showed a risk increased to 66.7% with a score>9 and reduced to 4.8% with a score<or=9. CONCLUSION Our score is easy to apply and is based on the three most important variables involved in the RDS genesis. Score reliability is high enough to use it in clinical practice and to verify it in wider populations.
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Affiliation(s)
- Enrico Zecca
- Division of Neonatology, Institute of Pediatrics, Catholic University of the Sacred Heart, Rome, Italy
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Sentilhes L, Bacq Y. La cholestase intrahépatique gravidique. ACTA ACUST UNITED AC 2008; 37:118-26. [DOI: 10.1016/j.jgyn.2006.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 09/08/2006] [Accepted: 09/18/2006] [Indexed: 12/27/2022]
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Zecca E, De Luca D, Baroni S, Vento G, Tiberi E, Romagnoli C. Bile acid-induced lung injury in newborn infants: a bronchoalveolar lavage fluid study. Pediatrics 2008; 121:e146-9. [PMID: 18166532 DOI: 10.1542/peds.2007-1220] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Neonatal respiratory distress syndrome is associated with intrahepatic cholestasis of pregnancy, and bile acids may play a major role in neonatal bile acid pneumonia. Our aim was to demonstrate the bile acid presence in the bronchoalveolar lavage fluid of neonates affected by respiratory distress syndrome who were born from intrahepatic cholestasis of pregnancy and to investigate bile acid mechanisms of action in acute lung injury. METHODS In this prospective study, we enrolled 10 neonates delivered from intrahepatic cholestasis of pregnancy, affected by respiratory distress syndrome requiring mechanical ventilation (intrahepatic cholestasis of pregnancy group) and 2 control groups. The first group consisted of 20 infants with respiratory distress syndrome delivered from pregnancies without any sign of intrahepatic cholestasis of pregnancy (respiratory-distress-syndrome group), and the second group included 20 neonates with no lung disease who were ventilated for extrapulmonary reasons (no-lung-disease group). We measured bile acid and pH in the bronchoalveolar lavage fluid and serum bile acid levels in the first 24 hours of life. RESULTS Bile acids were measurable in the bronchoalveolar lavage fluid of all of the infants in the intrahepatic cholestasis of pregnancy group but were absent in the 2 control groups. Bronchoalveolar lavage fluid pH was not different among the 3 groups. Infants in the intrahepatic-cholestasis-of-pregnancy group had significantly higher serum bile acid levels compared with those in both of the control groups. CONCLUSIONS Bile acids are detectable in the bronchoalveolar lavage fluid of newborns from intrahepatic cholestasis of pregnancy affected by respiratory distress syndrome. Elevated serum bile acid levels in these infants allow us to hypothesize that bile acid reaches the lung after an uptake from the circulation. These findings strongly support a role for bile acid in causing bile acid pneumonia.
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Affiliation(s)
- Enrico Zecca
- Division of Neonatology, Department of Pediatrics, University Hospital A. Gemelli, Catholic University of the Sacred Heart, Rome, Italy.
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Gilson SD, Stone EA. Sinus mucocele secondary to craniofacial trauma in a dog. J Am Vet Med Assoc 1991; 35:321-6. [PMID: 1885313 DOI: 10.1007/s00134-008-1321-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 09/21/2008] [Indexed: 12/16/2022]
Abstract
A sinsus mucocele formed in the frontal sinus of a dog secondary to obstruction of the nasofrontal opening. The dog was successfully treated by surgical enlargement of the nasofrontal opening, curettage of the sinus epithelium, and placement of a fat graft and drain in the sinus. Although mucocele formation is uncommon in animals, it should be considered as a differential diagnosis for masses of the sinonasal area. Characteristic radiographic and cytologic findings should alert the clinician to this diagnosis, and along with aggressive treatment, should shorten the diagnostic and treatment delay experienced by the dog in this report.
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Affiliation(s)
- S D Gilson
- Department of Companion Animals and Special Species Medicine, College of Veterinary Medicine, North Carolina State University, Raleigh 27606
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