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Gunaydin B, Tuna AT. Anesthetic considerations for liver diseases unique to pregnancy. World J Anesthesiol 2016; 5:54-61. [DOI: 10.5313/wja.v5.i3.54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/01/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Liver diseases that are most unique to pregnancy consist of hyperemesis gravidarum, acute fatty liver of pregnancy, intrahepatic cholestasis of pregnancy, and hemolysis, elevated liver enzymes and low platelets syndrome. In this review, risk factors, etiology, symptoms, diagnosis, prognosis and treatment of each entity followed by principles of anesthetic management based on the case reports or retrospective records will be addressed.
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Romito I, Gulino FA, Laganà AS, Vitale SG, Tuscano A, Leanza G, Musmeci G, Leanza V, Rapisarda AMC, Palumbo MA. Renal and Hepatic Functions after A Week of Controlled Ovarian Hyperstimulation during In Vitro Fertilization Cycles. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2016; 11:15-19. [PMID: 28367300 PMCID: PMC5215706 DOI: 10.22074/ijfs.2016.4689] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/24/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND One the main aspects of in vitro fertilization (IVF) cycle is to avoid any possible systemic damage on women undergoing a controlled ovarian hyperstimulation (COH). The aim of this work is to evaluate renal and hepatic function blood tests in patients undergoing controlled ovarian hyperstimulation during IVF cycles. MATERIALS AND METHODS We performed a prospective cohort analysis. All patients re- ceived a long stimulation protocol with gonadotropin-releasing hormone (GnRH) analogues by daily administration, since the twenty-first day of the previous ovarian cycle followed by COH with recombinant follicle-stimulating hormone (FSH). The daily dose of exogenous gonadotropins for every single patient was modified according to her follicular growth. The oocytes were retrieved during the oocyte pick up and fertilized by standard procedures of intracytoplasmic sperm injection (ICSI). The blood samples to evaluate renal and hepatic functions were taken at the 7th day of ovarian stimulation. RESULTS We enrolled 426 women aged between 19 and 44 years, with a mean body mass index (BMI) of 24.68 Kg/m2. The mean value of blood urea nitrogen was 14 ± 3.16 mg/ dl, creatinine: 1 ± 0.45 mg/dl, uric acid: 4 ± 1.95 mg/dl, total proteins: 7 ± 3.93 mg/dl, aspartate aminotransferase: 18 ± 6.29 mU/ml, alanine aminotransferase: 19 ± 10.41 mU/ ml, alkaline phosphatase: 81 ± 45.25 mU/ml, total bilirubin 1 ± 0.35 mg/dL. All of the results were considered as a normal range following the Medical Council of Canada. CONCLUSION Our data suggest that, unlike ovarian hyperstimulation syndrome (OHSS), COH patients did not show any alteration to renal and hepatic functions.
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Affiliation(s)
- Ilaria Romito
- 1. Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Ferdinando Antonio Gulino
- 1. Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Antonio Simone Laganà
- 2. Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Salvatore Giovanni Vitale
- 2. Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Attilio Tuscano
- 1. Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Gianluca Leanza
- 1. Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Giulia Musmeci
- 3. Department of Experimental and Clinical Pharmacology, University of Catania, Catania, Italy
| | - Vito Leanza
- 1. Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | | | - Marco Antonio Palumbo
- 1. Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
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Cetin O, Karaman E, Arslan H, Kolusarı A, Yıldızhan R, Ozgokce M, Batur A, Akbudak I. Evaluation of maternal liver elasticity by acoustic radiation force impulse elastosonography in hypertensive disorders of pregnancy: a preliminary descriptive study. J Matern Fetal Neonatal Med 2016; 30:2281-2286. [DOI: 10.1080/14767058.2016.1246526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Orkun Cetin
- Department of Obstetrics and Gynecology, Yuzuncu Yil University, Van, Turkey and
| | - Erbil Karaman
- Department of Obstetrics and Gynecology, Yuzuncu Yil University, Van, Turkey and
| | - Harun Arslan
- Department of Radiology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Ali Kolusarı
- Department of Obstetrics and Gynecology, Yuzuncu Yil University, Van, Turkey and
| | - Recep Yıldızhan
- Department of Obstetrics and Gynecology, Yuzuncu Yil University, Van, Turkey and
| | - Mesut Ozgokce
- Department of Radiology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Abdussamet Batur
- Department of Radiology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Ibrahim Akbudak
- Department of Radiology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
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104
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Huang GQ, Wang XD. New insights into diagnosis and treatment of intrahepatic cholestasis of pregnancy. Shijie Huaren Xiaohua Zazhi 2016; 24:3749-3756. [DOI: 10.11569/wcjd.v24.i26.3749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific disease, characterized by maternal pruritus and abnormal serum biochemistries in the late second and third trimester of pregnancy. The symptoms and abnormal biochemistries resolve rapidly after fetal delivery. As a diagnosis of exclusion, the diagnosis of ICP is based on unexplained pruritus with other causes and impaired liver function presenting with elevated serum liver transaminases and/or bile acids. It is considered as severe ICP when bile acid ≥ 40 μmol/L during pregnancy. The pathogenesis of ICP is still unclear. Adverse perinatal outcomes associated with ICP are focused on increased risk of preterm, meconium-stained amniotic fluid, and perinatal mortality. Unpredictable fetal hypoxia may result in intrauterine fetal death, fetal distress during birth and even stillbirth, and lead to an increase of iatrogenic preterm and cesarean section. The etiology and pathogenesis of fetal stress in ICP are not yet clarified, which may be associated with impaired infrastructure and decreased stress-compensatory in human utero-placental-fetal unit, and related with vascular constriction of chorionic veins and umbilical cord due to elevated bile acids in fetal serum and amniotic fluid. The essential measures of standard treatment of ICP include: (1) monitoring and evaluation of disease, uterine contraction and fetus; (2) prevention and treatment of uterine contraction; (3) treatment with ursodeoxycholic acid (500-1500 mg/d) alone or in combination with S-adenosylmehionine (800-1000 mg/d) or rifampicin (300-1200 mg/d) to promote drainage of bile acids; (4) promotion of fetal growth and lung development; (5) treatment with vitamin K1 before delivery to prevent maternal and fetal hemorrhage; (6) and timely termination of pregnancy. Gestational weeks, fetal condition and severity of disease need to be taken into account when obstetricians decide the time of termination. Elective early delivery is still an effective measure to avoid stillbirth during prolongation of gestational weeks.
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105
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Cheong JN, Wlodek ME, Moritz KM, Cuffe JSM. Programming of maternal and offspring disease: impact of growth restriction, fetal sex and transmission across generations. J Physiol 2016; 594:4727-40. [PMID: 26970222 PMCID: PMC5009791 DOI: 10.1113/jp271745] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/16/2016] [Indexed: 12/16/2022] Open
Abstract
Babies born small are at an increased risk of developing myriad adult diseases. While growth restriction increases disease risk in all individuals, often a second hit is required to unmask 'programmed' impairments in physiology. Programmed disease outcomes are demonstrated more commonly in male offspring compared with females, with these sex-specific outcomes partly attributed to different placenta-regulated growth strategies of the male and female fetus. Pregnancy is known to be a major risk factor for unmasking a number of conditions and can be considered a 'second hit' for women who were born small. As such, female offspring often develop impairments of physiology for the first time during pregnancy that present as pregnancy complications. Numerous maternal stressors can further increase the risk of developing a maternal complication during pregnancy. Importantly, these maternal complications can have long-term consequences for both the mother after pregnancy and the developing fetus. Conditions such as preeclampsia, gestational diabetes and hypertension as well as thyroid, liver and kidney diseases are all conditions that can complicate pregnancy and have long-term consequences for maternal and offspring health. Babies born to mothers who develop these conditions are often at a greater risk of developing disease in adulthood. This has implications as a mechanism for transmission of disease across generations. In this review, we discuss the evidence surrounding long-term intergenerational implications of being born small and/or experiencing stress during pregnancy on programming outcomes.
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Affiliation(s)
- Jean N Cheong
- Department of Physiology, Faculty of Medicine, Dentistry and Health Sciences, School of Biomedical Sciences, University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Mary E Wlodek
- Department of Physiology, Faculty of Medicine, Dentistry and Health Sciences, School of Biomedical Sciences, University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Karen M Moritz
- School of Biomedical Sciences, University of Queensland, St Lucia, Queensland, 4072, Australia
| | - James S M Cuffe
- School of Biomedical Sciences, University of Queensland, St Lucia, Queensland, 4072, Australia
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106
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Vogin G, Golfier F, Hajri T, Leroux A, Weber B. A HELLP syndrome complicates a gestational trophoblastic neoplasia in a perimenopausal woman: a case report. BMC Cancer 2016; 16:573. [PMID: 27485461 PMCID: PMC4970248 DOI: 10.1186/s12885-016-2641-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 07/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HELLP syndrome is a combination of symptoms described as hemolysis, elevated liver enzymes and low platelets, that complicates 0.01-0.6 % of pregnancies. HELLP syndrome has been scarcely reported associated with partial moles, another rare complication of pregnancy. This manuscript describes the only reported case of HELLP syndrome associated with a complete invasive hydatiform mole. CASE PRESENTATION We report a perimenopausal patient in prolonged remission from an uncommon high-risk invasive complete mole. The diagnosis was set in a context of early onset preeclampsia and HELLP syndrome. The development of life-threatening complications required primary hysterectomy. Postoperative hCG quickly returned to normal with EMA/CO multi-agent chemotherapy. CONCLUSION Our patient is in prolonged remission from a complete mole complicated with EOP and HELLP syndrome. This exceptional case of complicated gestational trophoblastic neoplasia reflects a very rare condition in which several risk factors for placental ischemia are associated. Emergency hysterectomy should be considered as salvage initial treatment in such life-threatening situations.
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Affiliation(s)
- Guillaume Vogin
- Department of Radiation Oncology, Institut de Cancérologie de Lorraine, Avenue de Bourgogne, 54500 Vandoeuvre Les Nancy, France
| | - François Golfier
- Department of Obstetrics and Gynaecology, Lyon Sud University Hospital, Lyon, France
- French Trophoblastic Disease Reference Centre, Lyon Sud University Hospital, Lyon, France
| | - Touria Hajri
- French Trophoblastic Disease Reference Centre, Lyon Sud University Hospital, Lyon, France
| | - Agnès Leroux
- Department of Pathology, Institut de Cancérologie de Lorraine, Vandoeuvre les Nancy, France
| | - Béatrice Weber
- Department of Radiation Oncology, Institut de Cancérologie de Lorraine, Avenue de Bourgogne, 54500 Vandoeuvre Les Nancy, France
- Department of Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre les Nancy, France
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107
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Zhou F, Gao B, Deng C, Huang G, Xu T, Wang X. Dynamic expression of corticotropin-releasing hormone and urocortin in estrogen induced-cholestasis pregnant rat. Reprod Toxicol 2016; 65:179-186. [PMID: 27492720 DOI: 10.1016/j.reprotox.2016.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 07/25/2016] [Accepted: 07/29/2016] [Indexed: 12/27/2022]
Abstract
Intrahepatic cholestasis of pregnancy(ICP) is complicated by acute placental-fetal hypoxia. Corticotropin-releasing hormone(CRH) and urocortin(UCN) are vasodilatory regulators of blood flow in the placenta. An ethinylestradiol(EE)-induced cholestasis rat model was reproduced and serum/placental CRH/UCN were detected during 14-21days of gestation(DG). Maternal serum or placental CRH/UCN levels in the control rats were relatively consistent during 14-21DG. Serum CRH was reduced in the EE-treated rats compared with the control rats at 21DG. Regarding serum UCN, we observed a decrease at 17DG as well as an increase at 21DG in the EE-treated rats compared with the controls. Moreover, we observed a noticeable reduction of placental CRH/UCN expression at 17 or 19DG in the EE-treated rats compared with the control rats. The serum bile acids levels exhibited an inverse correlation with placental CRH/UCN expression. EE-induced cholestasis rats might serve as a good model to further investigate the pathological mechanism underlying CRH/UCN dysregulation in ICP.
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Affiliation(s)
- Fan Zhou
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Bingxin Gao
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Chunyan Deng
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Guiqiong Huang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Ting Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China.
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108
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Wang HY, Jiang Q, Shi H, Xu YQ, Shi AC, Sun YL, Li J, Ning Q, Shen GX. Effect of caesarean section on maternal and foetal outcomes in acute fatty liver of pregnancy: a systematic review and meta-analysis. Sci Rep 2016; 6:28826. [PMID: 27387594 PMCID: PMC4937371 DOI: 10.1038/srep28826] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/02/2016] [Indexed: 12/20/2022] Open
Abstract
Several studies have reported a positive association between caesarean section for expeditious pregnancy termination and perinatal outcomes in acute fatty liver of pregnancy (AFLP); however, the risks remain unclear and independent studies have reported conflicting findings. In this meta-analysis, we aimed to confirm the relationship between caesarean section and perinatal outcomes in AFLP. The PubMed, Embase, and China National Knowledge Infrastructure databases were searched (until July 17, 2015) for observational clinical studies focusing on the association between caesarean section and perinatal outcomes in AFLP. Data were extracted and processed independently by 2 authors. We also compared caesarean section with vaginal delivery to further investigate this relationship. We observed that 2 of the 3 primary outcomes in caesarean section exhibited positive effects-the maternal mortality rate was 44% lower (relative risk [RR], 0.56 [0.41-0.76]) and perinatal mortality rate was also reduced (RR, 0.52 [0.38-0.71]), compared to those for vaginal delivery. We did not find any associations between caesarean section and perinatal outcomes in AFLP in terms of neonatal mortality type and maternal multiple organ complications. These findings emphasise the significant prognostic value and clinical implications of caesarean section in AFLP, and suggest that the adverse outcomes should be reduced.
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Affiliation(s)
- Hong-Yan Wang
- Department of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Gastroenterology, Shenzhen Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, Shenzhen, China
| | - Qing Jiang
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Allergy, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hao Shi
- Department of Epidemiology and Biostatistics, and the Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun-Qing Xu
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ai-Chao Shi
- Department of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuan-Li Sun
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jian Li
- Department of Gastroenterology, Shenzhen Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, Shenzhen, China
| | - Qin Ning
- Department of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guan-Xin Shen
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Abstract
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.
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Affiliation(s)
- Hanns-Ulrich Marschall
- a Department of Molecular and Clinical Medicine, University of Gothenburg, Sahlgrenska Academy, Institute of Medicine, S-41345 Gothenburg, Sweden
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110
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Gao J, Xu B, Zhang X, Cui Y, Deng L, Shi Z, Shao Y, Ding M. Association between serum bile acid profiles and gestational diabetes mellitus: A targeted metabolomics study. Clin Chim Acta 2016; 459:63-72. [PMID: 27246871 DOI: 10.1016/j.cca.2016.05.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/10/2016] [Accepted: 05/27/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Given the potential influence of aberrant bile acid metabolism on glucose homeostasis, we hypothesized that serum bile acid metabolism is altered in gestational diabetes mellitus (GDM). We characterized the metabolic profiling changes of serum bile acids in GDM and to find the potential biomarkers for the diagnosis and differential diagnosis of GDM. METHODS Based on ultrahigh performance liquid chromatography/hybrid quadrupole time-of-flight mass spectrometry, a targeted metabolomics study that involved targeted and untargeted screening techniques was performed to explore the changes in serum bile acid metabolism of GDM cases, intrahepatic cholestasis of pregnancy (ICP) cases and healthy controls. RESULTS There were 3 significantly different profiling of serum bile acids for GDM, ICP and controls. Compared to the controls, GDM individuals demonstrated significant increases in 8 bile acid species, including 2 dihydroxy conjugated, 1 trihydroxy unconjugated and 5 sulfated bile acids. β-muricholic acid (β-MCA) and di-2 were well-suited to use as the metabolic markers for the diagnosis and differential diagnosis of GDM, respectively. CONCLUSIONS These preliminary findings revealed the protective effect of body against cytotoxicity via elimination of increased sulfated bile acids and aberrant enzyme activity participated in the cycle β-MCA→hyodeoxycholic acid (HDCA) of the bile acid metabolism pathway for the women with GDM, which gave us further insights into the etiology and pathophysiology of GDM.
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Affiliation(s)
- Jieying Gao
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Biao Xu
- Department of Clinical Laboratory, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Xiaoqing Zhang
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Yue Cui
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Linlin Deng
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Zhenghu Shi
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Yong Shao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Min Ding
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China.
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111
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Ekiz A, Kaya B, Avci ME, Polat I, Dikmen S, Yildirim G. Alanine aminotransferase as a predictor of adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy. Pak J Med Sci 2016; 32:418-22. [PMID: 27182252 PMCID: PMC4859035 DOI: 10.12669/pjms.322.9057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective: To evaluate the associations between adverse perinatal outcomes and serum transaminase levels at the time of diagnosis in patients with intrahepatic cholestasis of pregnancy. Methods: We performed a retrospective analysis of patients hospitalized for evaluation of intrahepatic cholestasis of pregnancy from January 2013 to June 2014 in a tertiary center. Seventy-one patients were divided into two groups according to the presence (Group I) or absence of adverse perinatal outcomes (Group II). Results: The mean aminotransferase levels and conjugated bilirubin levels at the time of diagnosis were significantly higher in Group I than in Group II. Receiver operating characteristic curve analysis revealed that the alanine aminotransferase level could predict adverse perinatal outcomes with 76.47% sensitivity and 78.38% specificity, and the cut-off value was 95 IU/L. Among patients with intrahepatic cholestasis of pregnancy, those with adverse perinatal outcomes were significantly older, had an earlier diagnosis, and had higher alanine aminotransferase levels. Using the 95-IU/L cut-off value, patients with intrahepatic cholestasis of pregnancy had a 3.54-fold increased risk for adverse perinatal outcomes. Conclusions: Patients with intrahepatic cholestasis of pregnancy and high alanineaminotransferase levels should be followed up for possible adverse perinatal outcomes.
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Affiliation(s)
- Ali Ekiz
- Ali Ekiz, Department of Maternal-Fetal Medicine Unit, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Basak Kaya
- Basak Kaya, Department of Maternal-Fetal Medicine Unit, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Muhittin Eftal Avci
- Muhittin Eftal Avci, Department of Maternal-Fetal Medicine Unit, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Ibrahim Polat
- Ibrahim Polat, Department of Maternal-Fetal Medicine Unit, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Selin Dikmen
- Selin Dikmen, Department of Obstetrics and Gynecology, Gokhan Yildirim, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Gokhan Yildirim
- Department of Maternal-Fetal Medicine Unit, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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112
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Abstract
Pregnancy associated liver diseases affect up to 3% of pregnant women and are the most frequent cause of liver dysfunction in pregnancy. When severe, they are associated with significant morbidity and mortality for both mother and infant. A rapid evaluation to distinguish them from non-pregnancy related liver dysfunction is essential, in order to facilitate appropriate management. Liver disease unrelated to pregnancy can present de novo in pregnancy, or pregnancy can occur in women with preexisting liver pathology (Table 1). Research and subsequent advances in medical care have resulted in improved but still not satisfactory maternal and fetal outcomes. In this review we provide an overview of the liver diseases specific to the pregnant state and an update on their pathogenesis, treatment and outcomes. The risks of pregnancy in women with pre-existent liver pathology is detailed and recent advances in our understanding of specific risks and outcomes are discussed.
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113
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AISF position paper on liver disease and pregnancy. Dig Liver Dis 2016; 48:120-37. [PMID: 26747754 DOI: 10.1016/j.dld.2015.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/29/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
Abstract
The relationship between liver disease and pregnancy is of great clinical impact. Severe liver disease in pregnancy is rare; however, pregnancy-related liver disease is the most frequent cause of liver dysfunction during pregnancy and represents a severe threat to foetal and maternal survival. A rapid differential diagnosis between liver disease related or unrelated to pregnancy is required in women who present with liver dysfunction during pregnancy. This report summarizes the recommendation of an expert panel established by the Italian Association for the Study of the Liver (AISF) on the management of liver disease during pregnancy. The article provides an overview of liver disease occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and an assessment of the available treatment options. The report contains in three sections: (1) specific liver diseases of pregnancy; (2) liver disease occurring during pregnancy; and (3) pregnancy in patients with pre-existing chronic liver disease. Each topic is discussed considering the most relevant data available in literature; the final statements are formulated according to both scientific evidence and clinical expertise of the involved physicians, and the AISF expert panel recommendations are reported.
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114
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Abstract
Intrahepatic cholestasis of pregnancy (ICP) is characterized by maternal pruritus, and elevated serum transaminases and bile acids. Genetic defects in at least 6 canalicular transporters have been found. Association studies stress the variability of genotypes, different penetrance, and influence of environmental factors. Serum autotaxin is a sensitive, specific, and robust diagnostic marker. Elevated maternal bile acids correlate with fetal complications. Long-term sequelae for mothers include the gallstone risk and chronic liver disease. There is an association between ICP and hepatitis C. Current treatment is ursodeoxycholic acid, owing to benefits on pruritus, liver function, safety, and decreased rates of adverse effects.
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Affiliation(s)
- Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani, 2, Padova 35128, Italy.
| | - Maria Teresa Gervasi
- Department of Obstetrics and Gynecology, Azienda Ospedaliera, Via Giustiniani, 2, Padova 35128, Italy
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Biberoglu E, Kirbas A, Daglar K, Kara O, Karabulut E, Yakut HI, Danisman N. Role of inflammation in intrahepatic cholestasis of pregnancy. J Obstet Gynaecol Res 2016; 42:252-7. [DOI: 10.1111/jog.12902] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/04/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Ebru Biberoglu
- Department of Perinatology; Zekai Tahir Burak Women's Health Education and Research Hospital; Ankara Turkey
| | - Ayse Kirbas
- Department of Perinatology; Zekai Tahir Burak Women's Health Education and Research Hospital; Ankara Turkey
| | - Korkut Daglar
- Department of Perinatology; Zekai Tahir Burak Women's Health Education and Research Hospital; Ankara Turkey
| | - Ozgur Kara
- Department of Perinatology; Zekai Tahir Burak Women's Health Education and Research Hospital; Ankara Turkey
| | - Erdem Karabulut
- Department of Biostatistics; Hacettepe University Faculty of Medicine; Ankara Turkey
| | - Halil Ibrahim Yakut
- Department of Perinatology; Zekai Tahir Burak Women's Health Education and Research Hospital; Ankara Turkey
| | - Nuri Danisman
- Department of Perinatology; Zekai Tahir Burak Women's Health Education and Research Hospital; Ankara Turkey
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Metsälä J, Stach-Lempinen B, Gissler M, Eriksson JG, Koivusalo S. Risk of Pregnancy Complications in Relation to Maternal Prepregnancy Body Mass Index: Population-Based Study from Finland 2006-10. Paediatr Perinat Epidemiol 2016; 30:28-37. [PMID: 26447743 DOI: 10.1111/ppe.12248] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Overweight and obesity are well-known risk factors for several pregnancy-related complications, but the nature of the association between maternal adiposity and these complications has been less studied. The objective of the present study was to examine the shape and the magnitude of the association between maternal prepregnancy body mass index and the risk of gestational diabetes, pre-eclampsia of different severity, gestational hypertension, and obstetric cholestasis among Finnish primiparae women. METHODS Data on all primiparae women who delivered a singleton newborn in Finland between 2006 and 2010 were identified from the Finnish Medical Birth Register and the Finnish Hospital Discharge Register (n = 119 485). Associations were analysed using restricted cubic spline regression and logistic regression models. RESULTS There was a nonlinear dose-dependent association between body mass index and the risk of gestational diabetes, pre-eclampsia, and gestational hypertension, and the risk was increased already among normal weight primiparae women. However, in the presence of pre-existing hypertension or diabetes body mass index was not associated with the risk of pre-eclampsia. CONCLUSIONS Efforts to reduce prepregnancy overweight and obesity need to be intensified, and also, measures to better identify those normal weight women who are at increased risk of gestational diabetes, pre-eclampsia and gestational hypertension should be developed.
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Affiliation(s)
- Johanna Metsälä
- Department of Obstetrics and Gynecology, South Karelia Central Hospital, Lappeenranta, Finland
| | - Beata Stach-Lempinen
- Department of Obstetrics and Gynecology, South Karelia Central Hospital, Lappeenranta, Finland
| | - Mika Gissler
- Department of Information, National Institute for Health and Welfare, Helsinki, Finland.,Nordic School of Public Health, Gothenburg, Sweden
| | - Johan G Eriksson
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland.,Unit of General Practice, Helsinki University Central Hospital, Helsinki, Finland.,Folkhälsan Research Centre, Helsinki, Helsingfors Universitet, Helsinki, Finland.,Department of Chronic Disease Prevention, National Institute for Health and Welfare, Helsinki, Finland
| | - Saila Koivusalo
- Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Helsinki, Finland
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Mishra N, Mishra VN, Thakur P. Study of Abnormal Liver Function Test during Pregnancy in a Tertiary Care Hospital in Chhattisgarh. J Obstet Gynaecol India 2015; 66:129-35. [PMID: 27651591 DOI: 10.1007/s13224-015-0830-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/23/2015] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Abnormal liver function tests (LFTs) in pregnancy require proper interpretation in order to avoid pitfalls in the diagnosis. The underlying disorder can have a significant effect on the outcome of both mother and foetus. The present study was done with the objective to study the clinical profile, incidence and possible causes of derangements of liver function tests. MATERIAL AND METHOD Eighty pregnant women with abnormal liver dysfunction were studied prospectively. Women with chronic liver disease and drug-induced abnormal liver function test were excluded. All available LFTs including LDH were studied along with some more definitive tests to aid identification of underlying cause. Foetomaternal outcome was noted in all. RESULT The incidence of abnormal LFT was 0.9 %. 13/80 (16.75 %) women had liver disorder not specific to pregnancy, whereas 67/80 (83.25 %) women had pregnancy-specific liver dysfunction. Of these, 65(81.25 %) women with liver dysfunction had pre-eclampsia including 11 (13.75 %) with HELLP and six women with eclampsia. 48/65 (60 %) women had pre-eclampsia in the absence of HELLP syndrome or eclampsia. The mean value for bilirubin (mg %) in hypertensive disorders of pregnancy ranged from 1.64 to 3.8, between 5 and 10 for ICP and AFLP and >10 in infective hepatitis. Transaminases were highest in infective hepatitis, whereas alkaline phosphate was highest in ICP. Total 27 (33.75 %) women suffered from adverse outcome with four (5 %) maternal deaths and 23 (28.75 %) major maternal morbidities. 33/80 (41.25 %) women had intrauterine death. 26.25 % babies were small for date. CONCLUSION Pregnancy-specific disorders are the leading cause of abnormal liver function test during pregnant state particularly in the third trimester. Pre-eclampsia-related disorder is the commonest. Gestational age of pregnancy and relative values of various liver function tests in different pregnancy-specific and pregnancy nonspecific disorders appear to be the best guide to clinch the diagnosis.
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Affiliation(s)
- Nalini Mishra
- Department of Obstetrics and Gynaecology, Pt. J N M Medical College & BRAM Hospital Raipur (C.G.), 27/272 New Shantinagar, Raipur, C.G. 492001 India
| | - V N Mishra
- Department of Medicine, Pt. J N M Medical College & BRAM Hospital Raipur (C.G.), Raipur, India
| | - Parineeta Thakur
- Department of Obstetrics and Gynaecology, Pt. J N M Medical College & BRAM Hospital Raipur (C.G.), Raipur, India
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Bhat KJ, Shovkat R, Samoon HJ. Postpartum Acute Liver Dysfunction: A Case of Acute Fatty Liver of Pregnancy Developing Massive Intrahepatic Calcification. Gastroenterology Res 2015; 8:313-315. [PMID: 27785315 PMCID: PMC5051032 DOI: 10.14740/gr693w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2015] [Indexed: 12/27/2022] Open
Abstract
The function of the liver is particularly affected by the unique physiologic milieu of the pregnancy. Pregnancy-related liver diseases encompass a spectrum of different etiologies that are related to gestation or one of its complications. Hepatic calcification, a rare entity, is usually associated with infectious, vascular, or neoplastic lesions in the liver. To the best of our knowledge, only one case of rapidly occurring pregnancy-related intrahepatic calcification has been documented in a patient with severe eclampsia or hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. Here we present a case of immediate "postpartum" acute fatty liver of pregnancy (AFLP) in a 23-year-old hypertensive primigravida, complicated by acute renal dysfunction who developed dense intrahepatic calcification in less than a month after the initial diagnosis. A multidisciplinary approach for the management was used, to which the patient responded aptly. This case illustrates the first description of intrahepatic calcification in AFLP syndrome and highlights some of the challenges met in making the final diagnosis.
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Affiliation(s)
- Khalid Javid Bhat
- Department of Internal Medicine, GMC & Hospitals, Srinagar, Kashmir 190010, India
| | - Rabia Shovkat
- Department of Internal Medicine, ASCOMS & Hospitals, Sidhra, Jammu, Jammu & Kashmir, 180017, India
| | - Hamad Jeelani Samoon
- Department of Internal Medicine, Safdarjang Hospital, Ansari Nagar, New Delhi 110029, India
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Vomissements incoercibles de la grossesse : mise au point. Presse Med 2015; 44:1226-34. [DOI: 10.1016/j.lpm.2015.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 06/01/2015] [Accepted: 06/03/2015] [Indexed: 12/27/2022] Open
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Meng J, Wang S, Gu Y, Lv H, Jiang J, Wang X. Prenatal predictors in postpartum recovery for acute fatty liver of pregnancy: experiences at a tertiary referral center. Arch Gynecol Obstet 2015; 293:1185-91. [DOI: 10.1007/s00404-015-3941-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 10/23/2015] [Indexed: 12/19/2022]
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Bouyou J, Gaujoux S, Marcellin L, Leconte M, Goffinet F, Chapron C, Dousset B. Abdominal emergencies during pregnancy. J Visc Surg 2015; 152:S105-15. [PMID: 26527261 DOI: 10.1016/j.jviscsurg.2015.09.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Abdominal emergencies during pregnancy (excluding obstetrical emergencies) occur in one out of 500-700 pregnancies and may involve gastrointestinal, gynecologic, urologic, vascular and traumatic etiologies; surgery is necessary in 0.2-2% of cases. Since these emergencies are relatively rare, patients should be referred to specialized centers where surgical, obstetrical and neonatal cares are available, particularly because surgical intervention increases the risk of premature labor. Clinical presentations may be atypical and misleading because of pregnancy-associated anatomical and physiologic alterations, which often result in diagnostic uncertainty and therapeutic delay with increased risks of maternal and infant morbidity. The most common abdominal emergencies are acute appendicitis (best treated by laparoscopic appendectomy), acute calculous cholecystitis (best treated by laparoscopic cholecystectomy from the first trimester through the early part of the third trimester) and intestinal obstruction (where medical treatment is the first-line approach, just as in the non-pregnant patient). Acute pancreatitis is rare, usually resulting from trans-ampullary passage of gallstones; it usually resolves with medical treatment but an elevated risk of recurrent episodes justifies laparoscopic cholecystectomy in the 2nd trimester and endoscopic sphincterotomy in the 3rd trimester. The aim of the present work is to review pregnancy-induced anatomical and physiological modifications, to describe the main abdominal emergencies during pregnancy, their specific features and their diagnostic and therapeutic management.
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Affiliation(s)
- J Bouyou
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, Hôpital Cochin, AP-HP, Paris, France
| | - S Gaujoux
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, Hôpital Cochin, AP-HP, Paris, France; Faculté de médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - L Marcellin
- Faculté de médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Département de gynécologie-obstétrique II et médecine de la reproduction, Hôpital Cochin-Port Royal, AP-HP, Paris, France; DHU Risques et Grossesse, Université Paris Descartes, Paris, France
| | - M Leconte
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, Hôpital Cochin, AP-HP, Paris, France; Faculté de médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - F Goffinet
- Faculté de médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Maternité, Hôpital Cochin-Port Royal, Paris, France; DHU Risques et Grossesse, Université Paris Descartes, Paris, France
| | - C Chapron
- Faculté de médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Département de gynécologie-obstétrique II et médecine de la reproduction, Hôpital Cochin-Port Royal, AP-HP, Paris, France
| | - B Dousset
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, Hôpital Cochin, AP-HP, Paris, France; Faculté de médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
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124
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Shekhar S, Diddi G. Liver disease in pregnancy. Taiwan J Obstet Gynecol 2015; 54:475-82. [DOI: 10.1016/j.tjog.2015.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 12/17/2022] Open
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125
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Prevalence of Budd-Chiari Syndrome during Pregnancy or Puerperium: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract 2015; 2015:839875. [PMID: 26457079 PMCID: PMC4592727 DOI: 10.1155/2015/839875] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 08/24/2014] [Accepted: 08/30/2014] [Indexed: 02/07/2023] Open
Abstract
Women during pregnancy or puerperium are likely to develop Budd-Chiari syndrome (BCS). However, the reported prevalence of pregnancy-related BCS varied considerably among studies. Our study aims to systematically review this issue. Overall, 817 papers were initially identified via the PubMed, EMBASE, China National Knowledge Infrastructure, and Chinese Scientific and Technological Journal databases. Twenty of them were eligible. The prevalence of pregnancy-related BCS varied from 0% to 21.5%. The pooled prevalence was 6.8% (95% CI: 3.9–10.5%) in all BCS patients, 6.3% (95% CI: 3.8–9.4%) in primary BCS patients, and 13.1% (95% CI: 7.1–20.7%) in female BCS patients. Among them, one study was carried out in Africa with a prevalence of 10.6%; 14 studies in Asian countries with a pooled prevalence of 7.1% (95% CI: 3.1–12.6%); and 5 studies in European countries with a pooled prevalence of 5.0% (95% CI: 3.1–7.3%). The pooled prevalence was 6.7% (95% CI: 2.6–12.3%) in studies published before 2005 and 7.3% (95% CI: 4.2–12.5%) in those published after 2005. In conclusion, pregnancy is a relatively common risk factor for BCS, but there is a huge variation in the prevalence among studies. Physicians should be aware of pregnancy-related BCS.
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Nakanishi Y, Saxena R. Pathophysiology and Diseases of the Proximal Pathways of the Biliary System. Arch Pathol Lab Med 2015; 139:858-66. [PMID: 26125426 DOI: 10.5858/arpa.2014-0229-ra] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Diseases of the proximal pathways of the biliary system can be divided into those that affect the interlobular bile ducts and those that affect the bile canaliculi. The former include primary biliary cirrhosis, small-duct variant of primary sclerosing cholangitis, graft-versus-host disease, and drug-induced liver injury, whereas the latter include progressive familial intrahepatic cholestasis, benign recurrent intrahepatic cholestasis, intrahepatic cholestasis of pregnancy, and drug-induced liver injury. OBJECTIVE To summarize the current state of knowledge of diseases of the proximal pathways of the biliary system, with special emphasis on clinical presentation, pathological features, and differential diagnosis. DATA SOURCES Clinicopathological information was extracted from pertinent published literature. CONCLUSIONS Care of the patient with cholestasis hinges on identifying the etiology. Diagnostic steps in cholestatic conditions comprise a thorough patient history, abdominal imaging, distinct serological studies, and liver biopsy. Primary biliary cirrhosis is characterized by distinctive serological and histological findings. The small-duct variant of primary sclerosing cholangitis is very rare and difficult to diagnose; imaging of the bile ducts is not helpful. Graft-versus-host disease is characterized by damage and loss of intrahepatic bile ducts. Drugs can cause injury variably at the level of bile canaliculus or the interlobular bile duct. Loss of bile ducts may be seen with primary biliary cirrhosis, primary sclerosing cholangitis, graft-versus-host disease, and drug-induced liver injury. Progressive familial intrahepatic cholestasis and progressive familial intrahepatic cholestasis represent 2 extreme ends of the spectrum of abnormalities in transporters responsible for bile formation. Intrahepatic cholestasis of pregnancy has a variable incidence in different parts of the world and may be due to abnormalities in transporter molecules.
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Affiliation(s)
| | - Romil Saxena
- From the Department of Pathology, Indiana University School of Medicine, Indianapolis
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127
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Intrahepatic cholestasis of pregnancy and cancer, immune-mediated and cardiovascular diseases: A population-based cohort study. J Hepatol 2015; 63:456-61. [PMID: 25772037 DOI: 10.1016/j.jhep.2015.03.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 02/08/2015] [Accepted: 03/04/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND & AIMS Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease in pregnancy. It is associated with hepatobiliary diseases that might predispose to cancer and also with gestational diabetes and preeclampsia. In this study, we examined associations between ICP and cancer, and immune-mediated and cardiovascular diseases. METHODS By linking the Swedish Medical Birth Register and the Swedish Patient Register, we identified 11,388 women with ICP and 113,893 matched women without ICP who gave birth between 1973 and 2009. Diagnoses of cancer and immune-mediated and cardiovascular diseases both before and after delivery were obtained from the Patient Register. The main outcome measures were hazard ratios (HRs), calculated through Cox regression, for the indicated diseases after delivery. RESULTS ICP was not associated with later overall cancer (HR 1.07, 95% confidence interval [CI] 0.94-1.21), but it was associated with later liver and biliary tree cancer (HR 3.61, 95% CI 1.68-7.77, and 2.62, 95% CI 1.26-5.46, respectively). ICP was also associated with later immune-mediated diseases (HR 1.28, 95% CI 1.19-1.38), and specifically diabetes mellitus (HR 1.47, 95% CI 1.26-1.72), thyroid disease (HR 1.30, 95% CI 1.14-1.47), psoriasis (HR 1.27, 95% CI 1.07-1.51), inflammatory polyarthropathies (HR 1.32, 95% CI 1.11-1.58) and Crohn's disease (HR 1.55, 95% CI 1.14-2.10), but not ulcerative colitis (HR 1.21, 95% CI 0.93-1.58). Women with ICP also had a small increased risk of later cardiovascular disease (HR 1.12, 95% CI 1.06-1.19). CONCLUSIONS Women with ICP have increased risk of later hepatobiliary cancer and immune-mediated and cardiovascular diseases.
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Ozkan S, Ceylan Y, Ozkan OV, Yildirim S. Review of a challenging clinical issue: Intrahepatic cholestasis of pregnancy. World J Gastroenterol 2015; 21:7134-7141. [PMID: 26109799 PMCID: PMC4476874 DOI: 10.3748/wjg.v21.i23.7134] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/04/2015] [Accepted: 04/17/2015] [Indexed: 02/07/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a reversible pregnancy-specific cholestatic condition characterized by pruritus, elevated liver enzymes, and increased serum bile acids. It commences usually in the late second or third trimester, and quickly resolves after delivery. The incidence is higher in South American and Scandinavian countries (9.2%-15.6% and 1.5%, respectively) than in Europe (0.1%-0.2%). The etiology is multifactorial where genetic, endocrine, and environmental factors interact. Maternal outcome is usually benign, whereas fetal complications such as preterm labor, meconium staining, fetal distress, and sudden intrauterine fetal demise not infrequently lead to considerable perinatal morbidity and mortality. Ursodeoxycholic acid is shown to be the most efficient therapeutic agent with proven safety and efficacy. Management of ICP consists of careful monitoring of maternal hepatic function tests and serum bile acid levels in addition to the assessment of fetal well-being and timely delivery after completion of fetal pulmonary maturity. This review focuses on the current concepts about ICP based on recent literature data and presents an update regarding the diagnosis and management of this challenging issue.
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129
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Kamimura K, Abe H, Kawai H, Kamimura H, Kobayashi Y, Nomoto M, Aoyagi Y, Terai S. Advances in understanding and treating liver diseases during pregnancy: A review. World J Gastroenterol 2015; 21:5183-5190. [PMID: 25954092 PMCID: PMC4419059 DOI: 10.3748/wjg.v21.i17.5183] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/14/2015] [Accepted: 03/27/2015] [Indexed: 02/06/2023] Open
Abstract
Liver disease in pregnancy is rare but pregnancy-related liver diseases may cause threat to fetal and maternal survival. It includes pre-eclampsia; eclampsia; haemolysis, elevated liver enzymes, and low platelets syndrome; acute fatty liver of pregnancy; hyperemesis gravidarum; and intrahepatic cholestasis of pregnancy. Recent basic researches have shown the various etiologies involved in this disease entity. With these advances, rapid diagnosis is essential for severe cases since the decision of immediate delivery is important for maternal and fetal survival. The other therapeutic options have also been shown in recent reports based on the clinical trials and cooperation and information sharing between hepatologist and gynecologist is important for timely therapeutic intervention. Therefore, correct understandings of diseases and differential diagnosis from the pre-existing and co-incidental liver diseases during the pregnancy will help to achieve better prognosis. Therefore, here we review and summarized recent advances in understanding the etiologies, clinical courses and management of liver disease in pregnancy. This information will contribute to physicians for diagnosis of disease and optimum management of patients.
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130
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English N, Rao J. Acute fatty liver of pregnancy with hypoglycaemia, diabetes insipidus and pancreatitis, preceded by intrahepatic cholestasis of pregnancy. BMJ Case Rep 2015; 2015:bcr-2015-209649. [PMID: 25878236 DOI: 10.1136/bcr-2015-209649] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We present the case of a 33-year-old woman in her first pregnancy. She presented with pruritus at 34 weeks gestation. A diagnosis of intrahepatic cholestasis of pregnancy was made based on elevated bile acids and elevated liver transaminases. She re-presented 4 days later, jaundiced with abdominal pain and nausea, and was hypertensive. Her bilirubin was now elevated and her creatinine had doubled. The differential diagnosis-included pre-eclampsia and Hemolysis Elevated Liver enzymes Low Platelet count (HELLP) syndrome, and delivery was expedited. Postnatally, the patient became coagulopathic, though not thrombocytopaenic; she had persistent hypoglycaemia, hyponatraemia, developed acute pancreatitis and had profound ascites and peripheral oedema. Management was supportive with multidisciplinary care and over a period of 3 weeks she made a full clinical and biochemical recovery.
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Affiliation(s)
- Nicola English
- Department of Obstetrics & Gynaecology, King Edwards Memorial Hospital, Subiaco, Western Australia, Australia Department of Obstetrics & Gynaecology, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Jegajeeva Rao
- Department of Obstetrics & Gynaecology, Joondalup Health Campus, Joondalup, Western Australia, Australia Faculty of Medicine, University of New South Wales, UNSW Sydney, New South Wales, Australia
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Pandey CK, Karna ST, Pandey VK, Tandon M. Acute liver failure in pregnancy: Challenges and management. Indian J Anaesth 2015; 59:144-9. [PMID: 25838585 PMCID: PMC4378074 DOI: 10.4103/0019-5049.153035] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Acute liver failure (ALF) in pregnancy negatively affects both maternal and foetal outcome. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver functions leading to significant morbidity and even mortality. In this comprehensive review, we searched articles published as review articles, clinical trials, and case series in the Medline from 1970 to 2012. The overall outcome of ALF in pregnancy depends on the aetiology, timely diagnosis, prompt management, and early referral to a centre equipped in managing medical or obstetric complication. The foetal outcome is affected by the stage of pregnancy in which the mother has a deterioration of the liver function, with a worst prognosis associated with first or second-trimester liver failure. When ALF complicates pregnancy, liver transplantation is the one of the viable options. Management protocols need to be individualised for each case keeping in mind the risk versus benefit to both the mother and the foetus.
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Affiliation(s)
- Chandra Kant Pandey
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Sunaina Tejpal Karna
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Vijay Kant Pandey
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Manish Tandon
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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133
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Chevalier N, Anty R, Gilly O, Paul C, Panaïa-Ferrari P, Brucker-Davis F. Severe hyperemesis gravidarum associated with gestational thyrotoxicosis and acute biliary pancreatitis. Eur J Obstet Gynecol Reprod Biol 2015; 187:74-5. [PMID: 25758559 DOI: 10.1016/j.ejogrb.2015.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 02/01/2015] [Accepted: 02/11/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Nicolas Chevalier
- Department of Endocrinology, Diabetology and Reproductive Medicine, L'Archet University Hospital, Nice, France
| | - Rodolphe Anty
- Department of Hepato-Gastroenterology, L'Archet University Hospital, Nice, France
| | - Olivier Gilly
- Department of Endocrinology, Diabetology and Reproductive Medicine, L'Archet University Hospital, Nice, France
| | - Charlotte Paul
- Department of Endocrinology, Diabetology and Reproductive Medicine, L'Archet University Hospital, Nice, France
| | | | - Françoise Brucker-Davis
- Department of Endocrinology, Diabetology and Reproductive Medicine, L'Archet University Hospital, Nice, France.
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134
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Analysis of the serum bile Acid composition for differential diagnosis in patients with liver disease. Gastroenterol Res Pract 2015; 2015:717431. [PMID: 25821461 PMCID: PMC4363704 DOI: 10.1155/2015/717431] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 02/07/2015] [Accepted: 02/09/2015] [Indexed: 12/14/2022] Open
Abstract
Objectives. We determined the serum bile acid (BA) composition in patients with liver diseases and healthy volunteers to investigate the relationship between the etiologies of liver disease and BA metabolism. Material and Methods. Sera from 150 patients with liver diseases and 46 healthy volunteers were obtained. The serum concentrations of the 16 different BAs were determined according to the LC-MS/MS method and were compared between the different liver diseases. Results. A total of 150 subjects, including patients with hepatitis C virus (HCV) (n = 44), hepatitis B virus (HBV) (n = 23), alcoholic liver disease (ALD) (n = 21), biliary tract disease (n = 20), nonalcoholic fatty liver disease (NAFLD) (n = 13), and other liver diseases (n = 29), were recruited. The levels of UDCA and GUDCA were significantly higher in the ALD group, and the levels of DCA and UDCA were significantly lower in the biliary tract diseases group than in viral hepatitis group. In the UDCA therapy (-) subgroup, a significantly lower level of TLCA was observed in the ALD group, with lower levels of CDCA, DCA, and GLCA noted in biliary tract diseases group compared to viral hepatitis group. Conclusions. Analysis of the BA composition may be useful for differential diagnosis in liver disease.
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135
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Bissonnette J, Durand F, de Raucourt E, Ceccaldi PF, Plessier A, Valla D, Rautou PE. Pregnancy and vascular liver disease. J Clin Exp Hepatol 2015; 5:41-50. [PMID: 25941432 PMCID: PMC4415189 DOI: 10.1016/j.jceh.2014.12.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 12/30/2014] [Indexed: 12/12/2022] Open
Abstract
Vascular disorders of the liver frequently affect women of childbearing age. Pregnancy and the postpartum are prothrombotic states. Pregnancy seems to be a trigger for Budd-Chiari syndrome in patients with an underlying prothrombotic disorder. Whether pregnancy is a risk factor for other vascular liver disorders is unknown. In women with a known vascular liver disorder and a desire for pregnancy, stabilisation of the liver disease, including the use of a portal decompressive procedure when indicated, should be reached prior to conception. The presence of esophageal varices should be screened and adequate prophylaxis of bleeding applied in a manner similar to what is recommended for patients with cirrhosis. Most women likely benefit from anticoagulation during pregnancy and the postpartum. Labor and delivery are best managed by a multidisciplinary team with experience in this situation. Assisted vaginal delivery is the preferred mode of delivery. Although the risk of miscarriage and premature birth is heightened, current management of these diseases makes it very likely to see the birth of a live baby when pregnancy reaches 20 weeks of gestation.
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Affiliation(s)
- Julien Bissonnette
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - François Durand
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
- INSERM, U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Paris-Diderot-Paris 7, Hôpital Bichat, Paris, France
| | - Emmanuelle de Raucourt
- Laboratoire d'hématologie biologique, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Pierre-François Ceccaldi
- Service d'Obstétrique-Gynécologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Aurélie Plessier
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
- INSERM, U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Paris-Diderot-Paris 7, Hôpital Bichat, Paris, France
| | - Dominique Valla
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
- INSERM, U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Paris-Diderot-Paris 7, Hôpital Bichat, Paris, France
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
- INSERM, U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Paris-Diderot-Paris 7, Hôpital Bichat, Paris, France
- INSERM, U970, Paris Cardiovascular Research Center—PARCC, and Université Paris Descartes, Sorbonne Paris Cité, UMR-S970, Paris, France
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Garcia-Flores J, Cañamares M, Cruceyra M, Garicano A, Espada M, Lopez A, Tamarit I. Clinical value of maternal bile Acid quantification in intrahepatic cholestasis of pregnancy as an adverse perinatal outcome predictor. Gynecol Obstet Invest 2015; 79:222-8. [PMID: 25720981 DOI: 10.1159/000370003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 11/18/2014] [Indexed: 11/19/2022]
Abstract
AIMS To evaluate the correlation between perinatal outcome and bile acid levels in intrahepatic cholestasis of pregnancy (ICP), and to evaluate variations in the mean bile acid level when stratifying by maternal and perinatal factors. A comparison between mild and severe ICP was made. METHODS A prospective observational study was performed in pregnant patients who underwent blood tests for bile acids due to persistent pruritus. Based on bile acid levels, maternal and neonatal data were obtained and were compared between patients presenting with ICP and gestational pruritus (normal bile acid level). RESULTS A total of 145 patients were included, 47 of whom were diagnosed as ICP (52 newborns) and 98 as gestational pruritus (102 newborns). The ICP group had a higher rate of NICU admission (14/42 vs. 6/98, p < 0.001) and global neonatal morbidity (13/42 vs. 9/98, p = 0.002), but these differences were no longer seen after adjusting for gestational age, singleton pregnancies and induction of labour. Patients presenting with severe ICP (maximum bile acids levels above 40 µmol/l) showed a higher rate of meconium-stained amniotic fluid (0/28 vs. 4/14, p = 0.009), NICU admission (9/34 vs. 11/17, p = 0.01) and neonatal global morbidity (5/32 vs. 8/17, p = 0.02). CONCLUSIONS ICP patients have higher rates of adverse neonatal outcomes when compared to those with gestational pruritus. Some of this neonatal morbidity may be secondary to late spontaneous preterm deliveries, multiple gestation and a policy of elective induction of labour after 37 weeks of gestation. A comparison of outcomes among patients with mild and severe ICP shows that the severely affected group has higher rates of meconium-stained amniotic fluid and neonatal morbidity.
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Affiliation(s)
- Jose Garcia-Flores
- Obstetrics and Gynecology Department, Hospital Universitario Quiron Madrid, Madrid, Spain
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137
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Wu WB, Xu YY, Cheng WW, Wang YX, Liu Y, Huang D, Zhang HJ. Agonist of farnesoid X receptor protects against bile acid induced damage and oxidative stress in mouse placenta--a study on maternal cholestasis model. Placenta 2015; 36:545-51. [PMID: 25747729 DOI: 10.1016/j.placenta.2015.02.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 01/21/2015] [Accepted: 02/09/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific disorder, which is characterized by raised serum bile acid level and potential adverse fetal outcome. Farnesoid X receptor (FXR), also known as a bile acid receptor, was found to be expressed in placenta with low level. Whether activation of FXR by specific agonists could regulate the pathogenesis of ICP is still unclear. METHODS A model of maternal cholestasis was induced by administration of 17α-ethynylestradiol (E2) in pregnant mice for 6 days. We explored the regulatory effect of WAY-362450 (W450), a highly selective and potent FXR agonist on placenta. RESULTS In this study, we demonstrated that administration of E2 increased bile acid levels in mouse serum, liver and amniotic fluid. Bile acid levels were significantly decreased after W450 treatment. W450 protected against the impairment of placentas induced by E2, including severe intracellular edema and apoptosis of trophoblasts. Moreover, W450 significantly induced the expressions of FXR target bile acid transport gene ATP-binding cassette, sub-family B (MDR/TAP), member 11 (Abcb11;Bsep) in placenta. W450 could also attenuate placental oxidative stress and increase the expressions of antioxidant enzymes Prdx1 and Prdx3. DISCUSSION AND CONCLUSION In conclusion, our data demonstrated that FXR agonist W450 modulated bile acid balance and protected against placental oxidative stress. Thus, our results support that potent FXR agonists might represent promising drugs for the treatment of ICP.
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Affiliation(s)
- W B Wu
- Departments of Pathology and Bio-Bank, the International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Y Y Xu
- Departments of Pathology and Bio-Bank, the International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - W W Cheng
- Department of Obstetrics and Gynecology, the International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Y X Wang
- Departments of Pathology and Bio-Bank, the International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Y Liu
- Departments of Pathology and Bio-Bank, the International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - D Huang
- Department of Obstetrics and Gynecology, the International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - H J Zhang
- Departments of Pathology and Bio-Bank, the International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China.
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138
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Xiong HF, Liu JY, Guo LM, Li XW. Acute fatty liver of pregnancy: Over six months follow-up study of twenty-five patients. World J Gastroenterol 2015; 21:1927-1931. [PMID: 25684961 PMCID: PMC4323472 DOI: 10.3748/wjg.v21.i6.1927] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/29/2014] [Accepted: 09/05/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the prognosis of patients with acute fatty liver of pregnancy (AFLP) 6 mo or longer after discharge.
METHODS: The records of pregnant patients diagnosed with AFLP at Beijing Ditan Hospital over a 16-year period were reviewed in November 2012. Patients were monitored using abdominal ultrasound, liver and kidney functions, and routine blood examination.
RESULTS: A total of 42 patients were diagnosed with AFLP during the study period, and 25 were followed. The mean follow-up duration was 54.5 mo (range: 6.5-181 mo). All patients were in good physical condition, but one patient had gestational diabetes. The renal and liver functions normalized in all patients after recovery, including in those with pre-existing liver or kidney failure. The ultrasound findings were normal in 12 patients, an increasingly coarsened echo-pattern and increased echogenicity of the liver in 10 patients, and mild to moderate fatty liver infiltration in 3 patients. Cirrhosis or liver nodules were not observed in any patient.
CONCLUSION: Acute liver failure and acute renal failure in AFLP patients is reversible. Patients do not require any specific long-term follow-up after recovery from AFLP if their liver function tests have normalized and they remain well.
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139
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Chen Y, Vasilenko A, Song X, Valanejad L, Verma R, You S, Yan B, Shiffka S, Hargreaves L, Nadolny C, Deng R. Estrogen and Estrogen Receptor-α-Mediated Transrepression of Bile Salt Export Pump. Mol Endocrinol 2015; 29:613-26. [PMID: 25675114 DOI: 10.1210/me.2015-1014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Among diseases unique to pregnancy, intrahepatic cholestasis of pregnancy is the most prevalent disorder with elevated serum bile acid levels. We have previously shown that estrogen 17β-estradiol (E2) transrepresses bile salt export pump (BSEP) through an interaction between estrogen receptor (ER)-α and farnesoid X receptor (FXR) and transrepression of BSEP by E2/ERα is an etiological contributing factor to intrahepatic cholestasis of pregnancy. Currently the mechanistic insights into such transrepression are not fully understood. In this study, the dynamics of coregulator recruitment to BSEP promoter after FXR activation and E2 treatment were established with quantitative chromatin immunoprecipitation assays. Coactivator peroxisome proliferator-activated receptor-γ coactivator-1 was predominantly recruited to the BSEP promoter upon FXR activation, and its recruitment was decreased by E2 treatment. Meanwhile, recruitment of nuclear receptor corepressor was markedly increased upon E2 treatment. Functional evaluation of ERα and ERβ chimeras revealed that domains AC of ERα are the determinants for ERα-specific transrepression on BSEP. Further studies with various truncated ERα proteins identified the domains in ERα responsible for ligand-dependent and ligand-independent transrepression. Truncated ERα-AD exhibited potent ligand-independent transrepressive activity, whereas ERα-CF was fully capable of transrepressing BSEP ligand dependently in vitro in Huh 7 cells and in vivo in mice. Both ERα-AD and ERα-CF proteins were associated with FXR in the coimmunoprecipitation assays. In conclusion, E2 repressed BSEP expression through diminishing peroxisome proliferator-activated receptor-γ coactivator-1 recruitment with a concurrent increase in nuclear receptor corepressor recruitment to the BSEP promoter. Domains AD and CF in ERα mediated ligand-independent and ligand-dependent transrepression on BSEP, respectively, through interacting with FXR.
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Affiliation(s)
- Yuan Chen
- Department of Biomedical and Pharmaceutical Sciences, Center for Pharmacogenomics and Molecular Therapy, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island 02881
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Obstetrical and neonatal outcomes among women infected with hepatitis C and their infants. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 36:785-794. [PMID: 25222357 DOI: 10.1016/s1701-2163(15)30480-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES (1) To describe obstetrical and neonatal outcomes among a cohort of hepatitis C virus (HCV) infected women, comparing HCV RNA positive to HCV RNA negative women; (2) to characterize virologic and hepatic parameters associated with HCV infection during pregnancy; and (3) to describe the rate of HCV vertical transmission. METHODS We prospectively enrolled 145 HCV-positive pregnant women across British Columbia between 2000 and 2003. Participating women were monitored during pregnancy and their infants were followed to assess them for HCV infection. Maternal HCV RNA was assessed close to delivery. RESULTS Seventy percent of women reported injection drug use as their primary risk factor for HCV acquisition. Observed rates of intrauterine fetal death, preterm delivery, small for gestational age, and low birth weight infants were 3.4%, 17.9%, 11.3%, and 12.5%, respectively, without a significant association with maternal HCV RNA status. The rate of cholestasis was 5.6% in the HCV RNA-positive group (6/108) and 2.8% in the HCV RNA-negative group (1/37) (P = 0.496). Serum alanine aminotransferase levels decreased significantly through pregnancy, and were significantly higher in HCV RNA-positive women than in HCV RNA-negative women after controlling for cholestasis, co-infections, and alcohol consumption. Among the HCV RNA-positive women, the median FIB-4 score was 0.67 (IQR 0.56 to 0.76) in the first trimester, 0.74 (IQR 0.52 to 1.18) in the second trimester, and 0.89 (IQR 0.52 to 1.09) in the third trimester (P = 0.02). The median HCV viral load at delivery was 424 561 IU/mL. The vertical transmission rate was 4.7% in HCV RNA-positive women, with no cases in HCV RNA-negative women. CONCLUSION Because of the high rates of poor obstetrical outcomes found in this prospective cohort, population-level screening for HCV in pregnancy should be considered.
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141
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Sellier P, Maylin S, Amarsy R, Mazeron MC, Larrouy L, Haïm-Boukobza S, Lopes A, Moreno MD, Ricbourg A, Simoneau G, Magnier JD, Mercier-Delarue S, Delcey V, Evans J, Cambau E, Barranger E, Simon F, Bergmann JF. Untreated highly viraemic pregnant women from Asia or sub-Saharan Africa often transmit hepatitis B virus despite serovaccination to newborns. Liver Int 2015; 35:409-16. [PMID: 24698736 DOI: 10.1111/liv.12561] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/28/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Mother-to-child (MTC) hepatitis B virus (HBV) transmission has been mainly studied in Asia. The geographical origins of women and HBV genotypes differ in Europe. The aims were to determine the rate and risk factors of MTC HBV transmission from women with high HBV DNA loads in a maternity hospital in Paris, France. METHODS Retrospective study of HIV-negative, HBs Ag-positive pregnant women with HBV DNA loads above 5 Log10 I.U/ml who were not given lamivudine or tenofovirDF during pregnancy between 2004 and 2011. RESULTS Among 11 417 pregnant women, 437 (4%) showed a positive HBs Ag. Among these women, 52 had HBV DNA loads above 5 Log10 I.U/ml: 41, 10 and 1 born in Asia, sub-Saharan Africa and Europe respectively. Among the 52 women, 40 were eligible for the analysis: no antiviral therapy during pregnancy; children over 9 months old. Twenty-eight (70%) women were assessed, corresponding to 41 childbirths. Eleven children (27%) had positive HBs Ag, 14 (34%) had positive HBc and HBs Ab, 16 (39%) had positive HBs Ab only. The risk of having positive HBs Ag, according to maternal HBV DNA loads, was 14% for HBV DNA loads less or equal to 8 Log10 I.U/ml, 42% for HBV DNA loads over 8 Log10 I.U/ml, P = 0.04, but not related to the women's origin, HBV genotype. CONCLUSIONS This study confirms that serovaccination does not fully protect newborns from MTC HBV transmission, when maternal HBV DNA loads exceed 5 Log10 I.U/ml, regardless of the women's origin or HBV genotype.
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Affiliation(s)
- Pierre Sellier
- Service de Médecine Interne A (Pr J.F. Bergmann), Hôpital Lariboisière, Paris, France
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Panackel C, Thomas R, Sebastian B, Mathai SK. Recent advances in management of acute liver failure. Indian J Crit Care Med 2015; 19:27-33. [PMID: 25624647 PMCID: PMC4296407 DOI: 10.4103/0972-5229.148636] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Acute liver failure (ALF) is a life-threatening illness, where a previously normal liver fails within days to weeks. Sudden loss of synthetic and detoxification function of liver results in jaundice, encephalopathy, coagulopathy, and multiorgan failure. The etiology of ALF varies demographically. The mortality of ALF is as high as 40-50%. The initial care of patients with ALF depends on prompt recognition of the condition and early detection of etiology. Management includes intensive care support, treatment of specific etiology if present and early detection of candidates for liver transplantation. Liver transplantation remains the only therapeutic intervention with proven survival benefit in patients with irreversible ALF. Living related liver transplantation, auxiliary liver transplantation, and ABO-incompatible liver transplantation are coming up in a big way. Liver assist devices and hepatocyte transplant remain experimental and further advances are required. Public health measures to control hepatitis A, B, E, and drug-induced liver injury will reduce the incidence and mortality of ALF.
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Affiliation(s)
- Charles Panackel
- From: Department of Gastroenterology and Liver Transplantation, Medical Trust Hospital, Cochin, Ernakulam, Kerala, India
| | - Rony Thomas
- From: Department of Gastroenterology and Liver Transplantation, Medical Trust Hospital, Cochin, Ernakulam, Kerala, India
| | - Benoy Sebastian
- From: Department of Gastroenterology and Liver Transplantation, Medical Trust Hospital, Cochin, Ernakulam, Kerala, India
| | - Sunil K. Mathai
- From: Department of Gastroenterology and Liver Transplantation, Medical Trust Hospital, Cochin, Ernakulam, Kerala, India
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143
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Abstract
Acute fatty liver of pregnancy, although rare, is usually a third trimester of pregnancy occurrence that may be life threatening for both the pregnant woman and the fetus. Often, the onset resembles gastroenteritis or cholecystitis and correct diagnosis is delayed. Because it can also present with preeclampsia and eclampsia, it may be mistakenly diagnosed as hemolysis, elevated liver enzymes, low platelet syndrome. This article presents diagnostic differences between liver conditions that can complicate pregnancy and management strategies for treating and maintaining the well-being of pregnant women, fetuses, and infants who are affected by acute fatty liver of pregnancy. Early recognition and rapid intervention from antepartum diagnosis through delivery and the postpartum period are required by the nursing team and medical providers to reduce maternal and neonatal morbidity and mortality.
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144
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Song X, Vasilenko A, Chen Y, Valanejad L, Verma R, Yan B, Deng R. Transcriptional dynamics of bile salt export pump during pregnancy: mechanisms and implications in intrahepatic cholestasis of pregnancy. Hepatology 2014; 60:1993-2007. [PMID: 24729004 PMCID: PMC4194188 DOI: 10.1002/hep.27171] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 04/07/2014] [Accepted: 04/09/2014] [Indexed: 12/19/2022]
Abstract
UNLABELLED Bile salt export pump (BSEP) is responsible for biliary secretion of bile acids, a rate-limiting step in the enterohepatic circulation of bile acids and transactivated by nuclear receptor farnesoid X receptor (FXR). Intrahepatic cholestasis of pregnancy (ICP) is the most prevalent disorder among diseases unique to pregnancy and primarily occurs in the third trimester of pregnancy, with a hallmark of elevated serum bile acids. Currently, the transcriptional regulation of BSEP during pregnancy and its underlying mechanisms and involvement in ICP are not fully understood. In this study the dynamics of BSEP transcription in vivo in the same group of pregnant mice before, during, and after gestation were established with an in vivo imaging system (IVIS). BSEP transcription was markedly repressed in the later stages of pregnancy and immediately recovered after parturition, resembling the clinical course of ICP in human. The transcriptional dynamics of BSEP was inversely correlated with serum 17β-estradiol (E2) levels before, during, and after gestation. Further studies showed that E2 repressed BSEP expression in human primary hepatocytes, Huh 7 cells, and in vivo in mice. Such transrepression of BSEP by E2 in vitro and in vivo required estrogen receptor α (ERα). Mechanistic studies with chromatin immunoprecipitation (ChIP), protein coimmunoprecipitation (Co-IP), and bimolecular fluorescence complementation (BiFC) assays demonstrated that ERα directly interacted with FXR in living cells and in vivo in mice. CONCLUSION BSEP expression was repressed by E2 in the late stages of pregnancy through a nonclassical E2/ERα transrepressive pathway, directly interacting with FXR. E2-mediated repression of BSEP expression represents an etiological contributing factor to ICP and therapies targeting the ERα/FXR interaction may be developed for prevention and treatment of ICP.
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Affiliation(s)
| | | | - Yuan Chen
- Department of Biomedical and Pharmaceutical Sciences, Center for Pharmacogenomics and Molecular Therapy, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI 02881
| | - Leila Valanejad
- Department of Biomedical and Pharmaceutical Sciences, Center for Pharmacogenomics and Molecular Therapy, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI 02881
| | - Ruchi Verma
- Department of Biomedical and Pharmaceutical Sciences, Center for Pharmacogenomics and Molecular Therapy, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI 02881
| | - Bingfang Yan
- Department of Biomedical and Pharmaceutical Sciences, Center for Pharmacogenomics and Molecular Therapy, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI 02881
| | - Ruitang Deng
- Department of Biomedical and Pharmaceutical Sciences, Center for Pharmacogenomics and Molecular Therapy, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI 02881
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Jin J, Pan SL, Huang LP, Yu YH, Zhong M, Zhang GW. Risk factors for adverse fetal outcomes among women with early- versus late-onset intrahepatic cholestasis of pregnancy. Int J Gynaecol Obstet 2014; 128:236-40. [PMID: 25468047 DOI: 10.1016/j.ijgo.2014.09.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 09/02/2014] [Accepted: 10/28/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine risk factors for adverse fetal outcomes (AFOs) among women with intrahepatic cholestasis of pregnancy (ICP) on the basis of time of onset. METHODS In a retrospective analysis, data were obtained for all women with ICP admitted to two centers in Guangzhou, China, between February 1, 1993, and January 31, 2014. Patients were divided into group A (early-onset ICP) and group B (late-onset ICP), and were further divided on the basis of severity. The frequency of AFOs was assessed. RESULTS Among 371 eligible women, 57 (15.4%) were in group A and 314 (84.6%) in group B. AFOs affected 20 (35.1%) women in group A and 67 (21.3%) in group B (P=0.024), and 12 (54.5%) of 22 women in group A and 21 (29.6%) of 71 in group B with severe ICP (P=0.032). Independent risk factors for AFO in group A were increased levels of serum bile acid (P=0.016) and alkaline phosphatase (P=0.004). Independent risk factors in group B were increased levels of alkaline phosphatase (P<0.001) and gamma-glutamyl transpeptidase (P=0.001). CONCLUSION Early-onset ICP is associated with a higher frequency of AFO than is late-onset ICP, especially in severe disease. The risk factors differ between early-onset and late-onset ICP.
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Affiliation(s)
- Jin Jin
- Department of Gynaecology and Obstetrics, NanFang Hospital, Southern Medical University, Guangzhou, China
| | - Shi-lei Pan
- Department of Gynaecology and Obstetrics, ZhuJiang Hospital, Southern Medical University, Guangzhou, China
| | - Li-ping Huang
- Department of Gynaecology and Obstetrics, NanFang Hospital, Southern Medical University, Guangzhou, China
| | - Yan-hong Yu
- Department of Gynaecology and Obstetrics, NanFang Hospital, Southern Medical University, Guangzhou, China
| | - Mei Zhong
- Department of Gynaecology and Obstetrics, NanFang Hospital, Southern Medical University, Guangzhou, China
| | - Guo-wei Zhang
- Department of Hepatobiliary Surgery, NanFang Hospital, Southern Medical University, Guangzhou, China.
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Wahbi A, Graveleau J, Néel A, Joubert M, Masseau A, Joly GM, Hamidou M. [Macrovesicular hepatic steatosis revealing pregnancy hemophagocytic lymphohistiocytosis]. Rev Med Interne 2014; 36:555-7. [PMID: 25304169 DOI: 10.1016/j.revmed.2014.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 07/04/2014] [Accepted: 09/15/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION We report a case of post-partum hemophagocytic lymphohistiocytosis with marked macrovesicular hepatic steatosis. CASE REPORT A 39-year-old woman was admitted for hemophagocytic lymphohistiocytosis with a serum ferritin level of 103,380 μg/L. Thoracic abdominal and pelvic CT-scan showed hepatomegaly with marked steatosis. Liver biopsy confirmed macrovesicular steatosis. The diagnosis was a primary hemophagocytic lymphohistiocytosis. After treatment failure including corticosteroids, intravenous immunoglobulin, tetracycline, acyclovir, antituberculosis drugs, and anti-IL1R therapy, clinical improvement was obtained with intravenous cyclosporine. At 4-year follow-up, the patient remained asymptomatic. CONCLUSION Several aspects of this report of primary hemophagocytic lymphohistiocytosis are remarkable and include the association with post-partum, the severe radiologic and histologic macrovesicular steatosis, and the dramatic efficacy of cyclosporine.
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Affiliation(s)
- A Wahbi
- Service de médecine interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - J Graveleau
- Service de médecine interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - A Néel
- Service de médecine interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - M Joubert
- Laboratoire d'anatomopathologie, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - A Masseau
- Service de médecine interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - G Magadur Joly
- Service de médecine interne, centre hospitalier de Guingamp, 17, rue de l'Armor, BP 10548, 22205 Guingamp, France
| | - M Hamidou
- Service de médecine interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
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Kamimura K, Abe H, Kamimura N, Yamaguchi M, Mamizu M, Ogi K, Takahashi Y, Mizuno KI, Kamimura H, Kobayashi Y, Takeuchi M, Yoshida K, Yamada K, Enomoto T, Takakuwa K, Nomoto M, Obata M, Katsuragi Y, Mishima Y, Kominami R, Kamimura T, Aoyagi Y. Successful management of severe intrahepatic cholestasis of pregnancy: report of a first Japanese case. BMC Gastroenterol 2014; 14:160. [PMID: 25218883 PMCID: PMC4175624 DOI: 10.1186/1471-230x-14-160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 09/11/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is a cholestasis condition caused by elevated levels of serum bile acids that mainly occurs in the third trimester of pregnancy. Maternal symptoms include pruritus; elevation of transaminases, biliary enzymes, and bilirubin levels; and abnormal liver function tests. Fetal symptoms include spontaneous preterm labor, fetal distress, and intrauterine death. It is more prevalent in the Caucasians and is rarely found in Asian countries, including Japan. The etiology of ICP has been reported as involving various factors such as, environmental factors, hormone balance, and genetic components. The genetic factors include single-nucleotide polymorphisms (SNPs) in the genes of canalicular transporters, including ABCB4 and ABCB11. It has also been reported that the combination of these SNPs induces severe cholestasis and liver dysfunction. CASE PRESENTATION Here, we report for the first time a 24-year Japanese case of severe ICP diagnosed by typical symptoms, serum biochemical analysis, and treated with the administration of ursodeoxycholic acid which improved cholestasis and liver injury and prevented fetal death. The sequence analysis showed SNPs reported their association with ICP in the ABCB11 (rs2287622, V444A) and ABCB4 (rs1202283, N168N) loci. CONCLUSION The risk of ICP has been reported to be population-specific, and it is rare in the Japanese population. Our case was successfully treated with ursodeoxycholic acid and the genetic sequence analysis has supported the diagnosis. Because genetic variation in ABCB4 and ABCB11 has also been reported in the Japanese population, we need to be aware of potential ICP cases in pregnant Japanese women although further studies are necessary.
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Affiliation(s)
- Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 951-8510, Japan.
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Banks N, Bryant J, Fischer R, Huizing M, Gahl WA, Gunay-Aygun M. Pregnancy in autosomal recessive polycystic kidney disease. Arch Gynecol Obstet 2014; 291:705-8. [PMID: 25214022 DOI: 10.1007/s00404-014-3445-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 08/26/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE Autosomal recessive polycystic kidney disease (ARPKD) is the most common childhood-onset ciliopathy. As treatments improve, more women are reaching reproductive age, but little is known about ARPKD and pregnancy. METHODS In our ongoing study on ARPKD and other ciliopathies, 12 females over 18 years of age were identified and systematically evaluated. Six had children; four carried pregnancies and delivered, one used assisted reproductive technology and had a surrogate carry the pregnancy, and one adopted. We report the outcomes of four pregnancies with live birth deliveries and two women who chose alternate family building options. RESULTS Patient one was diagnosed at 6 months, and at age 21 had a pregnancy complicated by transient worsening of renal function (creatinine increase from 1.15 to 1.78 mg/dL). Patient two was diagnosed with ARPKD at age seven and had an uncomplicated pregnancy at age 23. Patient three was diagnosed incidentally with ARPKD at age 23, 3 months after completion of an uncomplicated pregnancy. Patient four who had an uncomplicated pregnancy at age 33 was diagnosed with ARPKD at age 46. CONCLUSIONS Women with ARPKD face reproductive decisions largely bereft of information about the pregnancies of other ARPKD patients. We report four cases of pregnancy and ARPKD to expand current knowledge and encourage further research.
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Affiliation(s)
- Nicole Banks
- Section on Human Biochemical Genetics, Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, 10 Center Drive, Building 10, Room 10C103CA, Bethesda, Maryland, 20892-1851, USA
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Grand’Maison S, Durand M, Mahone M. The Effects of Ursodeoxycholic Acid Treatment for Intrahepatic Cholestasis of Pregnancy on Maternal and Fetal Outcomes: A Meta-Analysis Including Non-Randomized Studies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:632-641. [DOI: 10.1016/s1701-2163(15)30544-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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