101
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Acute Fatty Liver of Pregnancy: Pathophysiology, Anesthetic Implications, and Obstetrical Management. Anesthesiology 2020; 130:446-461. [PMID: 30707120 DOI: 10.1097/aln.0000000000002597] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A narrative review of the pathophysiology, diagnosis, management, delivery implications, obstetric anesthesia care, and potential critical care needs in patients presenting with acute fatty liver of pregnancy.
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102
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Seto MTY, Cheung KW, Hung IFN. Management of viral hepatitis A, C, D and E in pregnancy. Best Pract Res Clin Obstet Gynaecol 2020; 68:44-53. [PMID: 32305262 DOI: 10.1016/j.bpobgyn.2020.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 03/09/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023]
Abstract
Viral hepatitis can cause significant maternal and neonatal morbidity and mortality. Hepatitis A and E mainly present as acute hepatitis during pregnancy, while hepatitis C and D are usually found as chronic infection in pregnant women. Hepatitis A remains self-limiting during pregnancy while hepatitis E has a higher prevalence and manifests with a rigorous course in pregnant women. Screening of hepatitis C during pregnancy and its subsequent management during pregnancy are still a debatable topic. New treatments of hepatitis C and E require further evaluation for use in pregnancy. This review summarizes the prevalence, clinical manifestations, maternal, foetal and neonatal effects, and the management of hepatitis A, C, D and E viral infection during pregnancy.
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Affiliation(s)
- Mimi Tin-Yan Seto
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China.
| | - Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Ivan F N Hung
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
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103
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Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Donahue K, Doubeni CA, Epling JW, Kubik M, Ogedegbe G, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Hepatitis C Virus Infection in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA 2020; 323:970-975. [PMID: 32119076 DOI: 10.1001/jama.2020.1123] [Citation(s) in RCA: 184] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the US and a leading cause of complications from chronic liver disease. HCV is associated with more deaths than the top 60 other reportable infectious diseases combined, including HIV. Cases of acute HCV infection have increased approximately 3.8-fold over the last decade because of increasing injection drug use and improved surveillance. OBJECTIVE To update its 2013 recommendation, the USPSTF commissioned a review of the evidence on screening for HCV infection in adolescents and adults. POPULATION This recommendation applies to all asymptomatic adults aged 18 to 79 years without known liver disease. EVIDENCE ASSESSMENT The USPSTF concludes with moderate certainty that screening for HCV infection in adults aged 18 to 79 years has substantial net benefit. RECOMMENDATION The USPSTF recommends screening for HCV infection in adults aged 18 to 79 years. (B recommendation).
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Affiliation(s)
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | - Karina W Davidson
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York
| | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | | | | | | | | | | | | | | | | | - Lori Pbert
- University of Massachusetts Medical School, Worcester
| | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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104
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Zhao H, Dai Y, Zhou YH. Overview of infection causing hepatitis other than non-A to E hepatitis virus during pregnancy. Best Pract Res Clin Obstet Gynaecol 2020; 68:89-102. [PMID: 32247771 DOI: 10.1016/j.bpobgyn.2020.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 12/20/2022]
Abstract
Abnormal liver function tests during pregnancy are common. While hepatic injury during pregnancy mostly has minimal adverse influence on maternal and fetal outcomes, severe maternal and fetal morbidities, and even death, sometimes occur. Here, we review the epidemiology, clinical features, diagnosis, and management of hepatitis during pregnancy caused by the less common pathogens, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex viruses (HSVs), dengue fever, malaria, leptospirosis, Q fever, typhoid fever, and other occasional infections, as well as the implications on breastfeeding of the infants. Hepatitis during pregnancy with fever and systemic clinical presentations, which are not attributable to the common infectious agents, should raise the suspicion of infection with above-mentioned pathogens, and appropriate laboratory tests are required. Early recognition of severe hepatitis or acute liver failure is critical in initiating appropriate and specific therapy, together with systemic supportive care, to reduce maternal and fetal mortality and long-term sequelae.
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Affiliation(s)
- Hong Zhao
- Department of Infectious Diseases, Nanjing Second Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yimin Dai
- Department of Obstetrics & Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Yi-Hua Zhou
- Departments of Laboratory Medicine and Infectious Diseases, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China.
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105
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The interpretation of liver function tests in pregnancy. Best Pract Res Clin Gastroenterol 2020; 44-45:101667. [PMID: 32359686 DOI: 10.1016/j.bpg.2020.101667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/19/2020] [Accepted: 02/17/2020] [Indexed: 01/31/2023]
Abstract
Abnormal liver tests occur in 3-5% of pregnancies and show many different causes. Although alterations of liver enzymes could be a physiological phenomenon, it may also reflect potential severe liver injury, necessitating further assessment and accurate management. The work-up has to consider liver diseases specific of pregnancy and non pregnancy-related liver damage (coincidental and pre-existing to pregnancy). Pre-existing liver diseases during pregnancy are relatively uncommon, as pregnant women are generally young and healthy. Liver diseases unique to pregnancy are intrahepatic cholestasis of pregnancy, the HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) and acute fatty liver of pregnancy. These disorders may result in foetal distress, severe liver damage and sometime hepatic failure; for these reasons the diagnostic work-up and treatment must be very fast. This review focuses on the management of pregnant women with altered liver function tests. Furthermore, the main liver diseases specific of pregnancy are described.
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106
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Bowie JM, Calvo RY, Bansal V, Wessels LE, Butler WJ, Sise CB, Shaw JG, Sise MJ. Association of complicated gallstone disease in pregnancy and adverse birth outcomes. Am J Surg 2020; 220:745-750. [PMID: 32067705 DOI: 10.1016/j.amjsurg.2020.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/20/2020] [Accepted: 01/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Complicated gallstone disease (CGD) is a common condition requiring intervention during pregnancy to avert adverse birth outcomes (ABO). METHODS Cohort study using the California OSHPD 2007-2014 database. Records of pregnant patients were analyzed for gallbladder calculus within four months of delivery. Biliary system interventions were evaluated as the primary exposure. RESULTS Of 7,597 patients, those with CGD had a greater likelihood of biliary system procedures than those with uncomplicated gallstone disease (36.6% vs. 2.5%, p < 0.001). Patients with CGD also had increased odds of ABO (OR 2.02, 95% CI, 1.48-2.76). Compared to patients without biliary system procedures, those with interventions for gallstones had an OR of 3.46 (95% CI, 2.48-4.82) for ABO. After adjustment, biliary system intervention for CGD had an even greater risk of ABO (OR 4.26, 95% CI, 2.86-6.35). CONCLUSIONS The risk of ABO is significantly increased in women with CGD and intervention for gallstones.
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Affiliation(s)
- Jason M Bowie
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Richard Y Calvo
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Vishal Bansal
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Lyndsey E Wessels
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - William J Butler
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - C Beth Sise
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Jennifer G Shaw
- Department of Obstetrics and Gynecology, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA
| | - Michael J Sise
- Trauma Service, Scripps Mercy Hospital, 4077 Fifth Avenue, San Diego, CA, 92103, USA.
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107
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Triunfo S, Tomaselli M, Ferraro MI, Latartara E, Sassara GM, Carrozza C. Does mild intrahepatic cholestasis of pregnancy require an aggressive management? Evidence from a prospective observational study focused on adverse perinatal outcomes and pathological placental findings. J Matern Fetal Neonatal Med 2020; 35:212-222. [PMID: 31957515 DOI: 10.1080/14767058.2020.1714583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: To ascertain the most effective approach in pregnancies complicated by mild intrahepatic cholestasis of pregnancy (mICP) by evaluating rates of adverse perinatal outcomes (APOs) and pathological placental findings.Methods: A total of 89 pregnancies complicated by mICP (defined as total serum bile acids (TSBAs) levels <40 µmol/L) were included. One-drug (ursodeoxycholic acid [UDCA]) (n = 49, 55.1%) and combined (UDCA plus S-adenosyl methionine (SAMe)) (n = 40, 44.9%) therapies were compared.Results: No differences were found in demographic, obstetric, and placental characteristics. In UDCA plus SAMe group, premature delivery was a common clinical decision (14.3 versus 25%, p-value = .201), with increased rates of instrumental vaginal delivery (VD; 28.6 versus 40%, p-value = .522), but similar cesarean section (CS) rates (26.5 versus 25%, p-value = .498). Mean placental weight was comparable (UDCA, mean 595.7 g, SD 213.1 g versus UDCA plus SAMe, mean 586.4 g, SD 102.9 g, p-value = .875). A total of 110 lesions were identified, 64 in 25 placentas of patients assigned to the UDCA and 46 in 15 placentas of patients managed by UDCA plus SAMe. Placental findings attributable to maternal malperfusion were found in 41/25 and 32/15 cases treated by UCDA and UDCA plus SAMe (165 versus 213%, p-value = .774), pathological fetal vascular supply in 17/25 and 8/15 placentas (68 versus 53%, p-value = .777), and inflammatory lesions in 6/25 and 6/15 cases (24 versus 40%, p-value = .757).Conclusions: Pregnancies complicated by mICP and managed by UDCA alone present similar APO rates and placental histopathology if compared with those treated by UDCA plus SAMe, failing to recognize advantages in the combined therapy. Further prospective studies and data sharing from ongoing RTCs could drive changes in therapeutic plan.
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Affiliation(s)
- Stefania Triunfo
- Department of Woman, Child Health and Public Health, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Italian Society of Ultrasound in Obstetrics and Gynaecology (SIEOG), Placenta Research Group, Rome, Italy
| | - Marta Tomaselli
- Department of Woman, Child Health and Public Health, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Immacolata Ferraro
- Department of Human Pathology in Adulthood and Childhood, Unit of Gynecology and Obstetrics, Policlinico Universitario "G. Martino", Università di Messina, Messina, Italy
| | - Elisabetta Latartara
- Department of Woman, Child Health and Public Health, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Maria Sassara
- Department of Woman, Child Health and Public Health, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cinzia Carrozza
- Unit of Chemistry, Biochemistry and Clinical Molecular Biology, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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108
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Abstract
Liver disease in pregnancy may present as a disorder that is unique to pregnancy or as an acute or chronic liver disease occurring coincidentally in pregnancy. Hepatic diseases that are unique to pregnancy include hyperemesis gravidarum; preeclampsia/eclampsia; the syndrome of hemolysis, elevated liver enzymes, and low platelets; intrahepatic cholestasis of pregnancy; and acute fatty liver of pregnancy. Acute and chronic forms of primary hepatic disorders that are seen in pregnancy include viral hepatitis, autoimmune hepatitis, nonalcoholic fatty liver disease, and cirrhosis. Because of the need to consider both maternal and fetal health, there are special considerations for the implementation of diagnostic strategies and pharmacologic therapies for liver disease that occurs in pregnancy. An understanding of the pathogenesis and expression of liver diseases in pregnancy has been evolving, and various diagnostic and prognostic tools have been studied in order to determine noninvasive approaches to identifying and staging of such diseases. Investigations have also been underway to evaluate the safety and utility of existing and new therapeutic agents that previously were thought to not be compatible with pregnancy. This review will explore updates in the epidemiology, diagnosis, and management of various liver diseases seen in pregnancy.
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Affiliation(s)
- Carla W Brady
- Division of Gastroenterology Duke University Medical Center Durham NC
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109
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Li W, Shu S, Cheng L, Hao X, Wang L, Wu Y, Yuan Z, Zhou J. Fasting serum total bile acid level is associated with coronary artery disease, myocardial infarction and severity of coronary lesions. Atherosclerosis 2019; 292:193-200. [PMID: 31811964 DOI: 10.1016/j.atherosclerosis.2019.11.026] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 11/17/2019] [Accepted: 11/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Bile acids play important roles in lipid metabolism. Several studies have found that patients with coronary artery disease (CAD) have lower bile acid fecal excretion compared to individuals without CAD. However, few studies have focused on the roles of more accessible serum total bile acids (TBA) in the progression of CAD. The aim of this study was to explore the potential relationship between fasting serum TBA and the presence of CAD, myocardial infarction (MI) and severity of coronary lesions. METHODS A total of 7438 consecutive patients with suspected CAD, who had undergone coronary angiography, were enrolled. The severity of coronary lesions was evaluated using the Gensini score (GS). The relationships between fasting serum TBA and the presence and severity of CAD were evaluated. RESULTS CAD patients had lower serum TBA than individuals without CAD, and patients with MI had lower TBA than those without CAD. Spline analyses showed an L-shaped relationship of the fasting serum TBA with the presence and severity of CAD, and the breakpoint approximated the normal upper limit (10 μmol/L). A lower TBA concentration (less than the median 3.6 μmol/L) was independently and significantly associated with the presence and severity of CAD, especially for the presence of MI (odds ratios 2.04, 95% confidence interval (1.71-2.44), C-index 0.9269). CONCLUSIONS Fasting serum TBA level is highly associated with the presence and severity of CAD in patients undergoing coronary angiography for suspected CAD.
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Affiliation(s)
- Wenyuan Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Shan Shu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Lele Cheng
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xiang Hao
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Lijun Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yue Wu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zuyi Yuan
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Key Laboratory of Molecular Cardiology of Shaanxi Province, Xi'an, Shaanxi, China; Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, China.
| | - Juan Zhou
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Key Laboratory of Molecular Cardiology of Shaanxi Province, Xi'an, Shaanxi, China.
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110
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The Hepatobiliary System: An Overview of Normal Function and Diagnostic Testing in Pregnancy. Clin Obstet Gynecol 2019; 63:122-133. [PMID: 31770121 DOI: 10.1097/grf.0000000000000504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pregnancy is associated with physiological adaptions that affect every organ system. Changes in liver function in pregnancy have important effects on nutrient metabolism, protein synthesis, and the biotransformation of substances in preparation for excretion. A clear understanding of the anatomic and functional changes of the hepatobiliary system is necessary for the diagnosis and evaluation of disease, as well as understanding how these changes predispose women to pregnancy-specific hepatic conditions. In this review, the effect of gestational changes in hepatobiliary function on laboratory tests and the role of diagnostic imaging of the liver and gallbladder in pregnancy will be discussed.
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111
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Di Mascio D, Quist-Nelson J, Riegel M, George B, Saccone G, Brun R, Haslinger C, Herrera C, Kawakita T, Lee RH, Benedetti Panici P, Berghella V. Perinatal death by bile acid levels in intrahepatic cholestasis of pregnancy: a systematic review. J Matern Fetal Neonatal Med 2019; 34:3614-3622. [PMID: 31744346 DOI: 10.1080/14767058.2019.1685965] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Intrahepatic cholestasis of pregnancy (ICP) is characterized by the elevation of total bile acids (TBAs). The primary concern in women with ICP is the increased risk of stillbirth. ICP is generally considered as "mild" when TBA levels range from 10 to 39 µmol/L and "severe" with levels greater than 40 µmol/L, although levels of TBA ≥100 µmol/L have been also considered as a further threshold of severity.Objective: To quantify the association between different severities of ICP (TBA 10-39, 40-99, and ≥100 µmol/L) and perinatal death.Data sources: Medline, Embase, Scopus, Web of Sciences, and ClinicalTrial.gov were searched from the inception of each database to February 2019.Methods of study selection: Randomized, cohort, case-control, or case series studies reporting maternal and perinatal outcomes on women with ICP by the three prespecified TBA levels (10-39, 40-99, and ≥100 µmol/L) were included. We excluded multiple gestations and trials which included an intervention. The analysis was performed with Pearson chi-square and Fisher's exact test as appropriate. Continuous outcomes were compared using metaregression with inverse variance weighting using reported sample sizes and standard deviations. Pairwise comparisons used a Bonferroni correction to control for multiple testing.Tabulation, integration, and results: Six articles including 1280 singleton pregnancies affected by ICP were included in the systematic review. Out of the 1280 singleton pregnancies affected by ICP included, 118 had ICP with TBA ≥100 µmol/L. Perinatal death was more common in women with TBA ≥100 µmol/L (0.4% for TBA 10-39 μmol/L versus 0.3% for TBA 40-99 μmol/L versus 6.8% for TBA ≥ 100 μmol/L, p < .0001). Of the 8 perinatal deaths in the TBA ≥100 µmol/L group, 3 occurred ≥34 weeks. TBA ≥100 µmol/L increased the risk of spontaneous preterm birth (PTB) (5.4% versus 8.6% versus 18.2% respectively, p < .0001) and iatrogenic PTB (10.8% versus 21.6% versus 35.8% respectively, p<.0001) as well as meconium-stained amniotic fluid (9.0% versus 18.4% versus 31.6% respectively, p < .0001).Conclusions: Maternal TBA ≥100 µmol/L is associated with a 6.8% incidence of perinatal death, most of which (5.9% overall) are stillbirths, while TBA <100 µmol/L are associated with an incidence of perinatal death of 0.3%. It may be reasonable to consider late preterm delivery (at about 35-36 weeks) in women with TBA ≥100 µmol/L.
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Affiliation(s)
- Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Johanna Quist-Nelson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College - Thomas Jefferson University, Philadelphia, PA, USA
| | - Melissa Riegel
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College - Thomas Jefferson University, Philadelphia, PA, USA
| | - Brandon George
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Romana Brun
- Division of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | | | - Christina Herrera
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA.,Intermountain Healthcare Division of Maternal Fetal Medicine, Salt Lake City, UT, USA.,Division of Maternal Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tetsuya Kawakita
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Richard H Lee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Pierluigi Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Vincenzo Berghella
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College - Thomas Jefferson University, Philadelphia, PA, USA
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112
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Zullo F, Saccone G, Donnarumma L, Marino I, Guida M, Berghella V. Pregnancy after liver transplantation: a case series and review of the literature. J Matern Fetal Neonatal Med 2019; 34:3269-3276. [PMID: 31635500 DOI: 10.1080/14767058.2019.1680632] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate maternal and perinatal outcomes in pregnant women after liver transplantation with a case series and literature systematic review. METHODS This was a single-center case-series study performed at University of Naples Federico II. All consecutive women with liver transplantation who reported pregnancy at our institution were included in a dedicated database. In addition, a systematic literature review was performed, including case series, population-based studies, and national registries, including maternal and perinatal outcomes of pregnant women with liver transplant. Studies with fewer than 10 cases and surveys were excluded. The primary outcome was perinatal death, defined as either stillbirth (defined as intrauterine fetal death after 20 weeks of gestation) or neonatal death (death of a live-born infant within the first 28 d of life). RESULTS During the study period, two women who underwent liver transplantation had a pregnancy in our Institution. Both of them underwent liver transplantation for biliary atresia at 1 year of age. One of them received cyclosporin as immunosuppressive regime during pregnancy, while the other one received tacrolimus. Both of them had a pregnancy with no major complications and delivered by cesarean section at term a baby with normal weight. One of them developed thrombocytopenia. Seventeen articles were included in this systematic review. Preterm birth at less than 37 weeks of gestations occurred in 279 women (33.6%). One-hundred women (14.9%) experienced preeclampsia, and 206 women (49.2%) delivered by cesarean delivery. Graft rejection related to pregnancy occurred in 73 women (8.3%). 117 women (12.9%) experienced miscarriage, and 22 (2.3%) IUFD. Fifty-two women (9.52%) underwent elective I-TOP. 195 fetuses (33.4%) were LBW. Eight neonatal deaths were recorded (1.3%). CONCLUSION The maternal and perinatal outcome is usually favorable, but with an increased risk of preeclampsia, preterm birth, and perinatal morbidity and mortality. However, appropriate counseling about risks and complications is essential but women shouldn't be advised against pregnancy.
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Affiliation(s)
- Fabrizio Zullo
- Department of Clinical and Experimental Medicine, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Laura Donnarumma
- Department of Clinical and Experimental Medicine, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Ignazio Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maurizio Guida
- Department of Clinical and Experimental Medicine, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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113
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Abstract
BACKGROUND Portal hypertension in pregnancy is associated with elevated risk of variceal hemorrhage. Ectopic varices, those located outside the esophagus or stomach, are rare but have a high risk of associated maternal morbidity or mortality. CASE A 31-year-old woman, gravida 2 para 0010, with cirrhosis and portal hypertension was found to have abdominal wall ectopic varices on third-trimester obstetric ultrasonography. Computed tomography angiography confirmed these findings. Given concern for catastrophic hemorrhage during delivery, she underwent transjugular intrahepatic portosystemic shunt placement at 35 weeks of gestation, with reduction in the pressure gradient within the portosystemic circulation. She subsequently underwent an uncomplicated cesarean delivery. CONCLUSION Identification of ectopic varices on obstetric ultrasonography may allow for treatment before delivery, decreasing the risk of serious maternal morbidity or mortality.
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114
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss current and new knowledge regarding liver disease in pregnancy and pregnancy post-liver transplantation. RECENT FINDINGS Severe liver disease associated with pregnancy is rare. Liver biopsy is rarely needed for diagnosis but is safe in selected cases. Intrahepatic cholestasis of pregnancy (ICP) with serum bile acids level > 40 μmol/L is associated with adverse fetal outcomes. Ursodeoxycholic acid should be initiated at diagnosis. Portal hypertension can worsen during pregnancy and screening endoscopy should be performed in the 2nd trimester. Maternal hepatitis B antiviral therapy can be considered in the 3rd trimester if HVB DNA > 200,000 IU/ml. Tacrolimus is the optimal immunosuppressive therapy during pregnancy post-transplantation. Preconception renal function predicts pregnancy outcome. Overall, the outcome of pregnancy post-transplantation is good but there is an increased risk of preterm delivery, low birth weight, hypertension, and pre-eclampsia. Liver disease of pregnancy can be divided into diseases unique to pregnancy, exacerbated by pregnancy or coexisting with pregnancy. Overall, the outcome of pregnancy post-liver transplantation is good.
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Yaccob A, Mari A. Practical clinical approach to the evaluation of hepatobiliary disorders in inflammatory bowel disease. Frontline Gastroenterol 2019; 10:309-315. [PMID: 31281626 PMCID: PMC6583566 DOI: 10.1136/flgastro-2018-101037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/06/2018] [Accepted: 09/22/2018] [Indexed: 02/04/2023] Open
Abstract
Hepatobiliary disorders are frequent extraintestinal manifestations in inflammatory bowel disease (IBD) and may appear at any time point during the natural course of the disease. Conceptually, these manifestations can be categorised as: (1) disorders that have an association with IBD; (2) diseases directly and structurally related to intestinal inflammation; (3) diseases related to the adverse effects of IBD treatment; and (4) disorders stemming from the metabolic derangements caused by IBD. The clinical presentations of these disorders range from a mild transient elevation of liver enzymes to liver failure and death. Given this wide differential diagnosis and spectrum of severity, it is understandable that the evaluation of patients with IBD with a hepatobiliary abnormality is often challenging. In this review, we present a concise summary of the common hepatic manifestations seen in patients with IBD and focus on the relevant practical issues encountered by gastroenterologists caring for patients with IBD. A practical clinical approach to the evaluation of liver enzyme abnormalities in patients with IBD is provided based on the predominant enzyme elevation pattern (hepatocellular vs cholestatic), before presenting a working scheme for the prevention of hepatitis B virus (HBV) reactivation in patients with IBD receiving immunosuppressive medications. Finally, we specify several laboratory alterations seen in patients with IBD that can potentially interfere with the interpretation of liver function tests, before defining the specific circumstances when a referral for a hepatological consultation is required for further assessment.
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Affiliation(s)
- Afif Yaccob
- Liver Disease Center, Rambam Healthcare Campus, Haifa, Israel
| | - Amir Mari
- Gastroenterology and Hepatology Institute, Hillel Yaffe Medical Centre, Hadera, Israel
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Sawas T, Simonetto DA. Should Pregnancy After Liver Transplantation Bring Joy or Fear? Clin Gastroenterol Hepatol 2019; 17:1251-1252. [PMID: 30802605 DOI: 10.1016/j.cgh.2019.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 02/08/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Tarek Sawas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Zhang Y, Shi D, Abagyan R, Dai W, Dong M. Population Scale Retrospective Analysis Reveals Potential Risk of Cholestasis in Pregnant Women Taking Omeprazole, Lansoprazole, and Amoxicillin. Interdiscip Sci 2019; 11:273-281. [PMID: 31106388 PMCID: PMC7172024 DOI: 10.1007/s12539-019-00335-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 04/29/2019] [Accepted: 05/06/2019] [Indexed: 12/18/2022]
Abstract
In nearly 50% of patients with drug-induced liver injury, the bile flow is impaired known as cholestasis. Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease that happens in pregnancy. Some of the clinical symptoms include pruritus, dark urine, and abnormal liver function tests. A rise of serum bile acids is the most accurate diagnostic evidence. ICP may lead to premature birth, fetal distress, and even postpartum hemorrhage or stillbirth in some severe cases. Higher bile acid levels (> 40 μmol/L) are associated with higher rates of adverse fetal outcomes. Due to the multifactorial nature of ICP, its etiology is still not fully understood. Therefore, the current treatments of ICP are limited to control symptoms and protect fetuses. Among various causing factors, drug exposure during pregnancy is one common factor, and it can be prevented if we know drugs with increasing risk of cholestasis. Here we analyzed over 9.5 million FDA adverse effect reports to identify drugs with increasing risks of cholestasis as an adverse effect. Patients treated for cholestasis or liver diseases were removed. The odds ratio analysis reveals that lansoprazole (LSPZ), omeprazole (OMPZ) and amoxicillin (AMXC) are associated with an increased risk of cholestasis. LSPZ is associated with increased reported cholestasis by a factor of 2.32 (OR with 95% confidence interval [2.21, 2.43]). OMPZ is associated with increased reported cholestasis by a factor of 2.61 [2.54, 2.69]. AMXC is associated with increased reported cholestasis adverse effect by a factor of 6.79 [6.49, 7.11]. The risk of cholestasis associated with these three drugs is further increased in pregnant women. These findings justify careful reassessment of the safety of the three identified drugs.
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Affiliation(s)
- Yonghong Zhang
- Medicine Engineering Research Center, College of Pharmacy, Chongqing Medical University, No. 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China.
| | - Da Shi
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA, 92093, USA
| | - Ruben Abagyan
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA, 92093, USA
| | - Weina Dai
- Medicine Engineering Research Center, College of Pharmacy, Chongqing Medical University, No. 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Mingyang Dong
- Medicine Engineering Research Center, College of Pharmacy, Chongqing Medical University, No. 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
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Preeclampsia Induced Liver Dysfunction Complicated by Disseminated Intravascular Coagulopathy and Placental Abruption: A Case Report and Review of the Literature. Case Rep Anesthesiol 2019; 2019:4305849. [PMID: 31080676 PMCID: PMC6475561 DOI: 10.1155/2019/4305849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/03/2019] [Accepted: 03/18/2019] [Indexed: 01/17/2023] Open
Abstract
A 33-year-old primigravida at 32-week gestation was admitted to labor and delivery complaining of severe right upper quadrant pain and worsening coagulopathy. We report the anesthetic and obstetrical management of a complex case of a parturient with a mixed picture of hemolysis, elevated liver enzymes and low platelets who was delivered under general anesthesia further complicated by Disseminated Intravascular Coagulopathy (DIC) and placental abruption.
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Arora A, Kumar A, Anand AC, Puri P, Dhiman RK, Acharya SK, Aggarwal K, Aggarwal N, Aggarwal R, Chawla YK, Dixit VK, Duseja A, Eapen CE, Goswami B, Gujral K, Gupta A, Jindal A, Kar P, Kumari K, Madan K, Malhotra J, Malhotra N, Pandey G, Pandey U, Puri RD, Rai RR, Rao PN, Sarin SK, Sharma A, Sharma P, Shenoy KT, Singh KR, Singh SP, Suri V, Trehanpati N, Wadhawan M. Indian National Association for the Study of the Liver-Federation of Obstetric and Gynaecological Societies of India Position Statement on Management of Liver Diseases in Pregnancy. J Clin Exp Hepatol 2019; 9:383-406. [PMID: 31360030 PMCID: PMC6637074 DOI: 10.1016/j.jceh.2019.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/25/2019] [Indexed: 12/12/2022] Open
Abstract
Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.
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Key Words
- ABCB4, ATP-binding cassette subfamily B member 4
- AFLP, Acute fatty liver of pregnancy
- ALF, Acute liver failure
- ALP, Alkaline phosphatase
- ALT, Alanine transferase
- ART, Antiretroviral therapy
- AST, Aspartate aminotransferase
- BCS, Budd-Chiari syndrome
- CT, Computerized tomography
- DIC, Disseminated intravascular coagulation
- DNA, Deoxyribonucleic acid
- DPTA, Diethylenetriamine pentaacetic acid
- ERCP, Endoscopic retrograde cholangiopancreatography
- FDA, Food and Drug Administration
- FOGSI, Federation of Obstetric and Gynaecological Societies of India
- GGT, Gamma-glutamyl transpeptidase
- GI, Gastrointestinal
- GRADE, Grading of Recommendations Assessment Development and Evaluation
- HBIG, Hepatitis B immune globulin
- HBV, Hepatitis B virus
- HBeAg, Hepatitis B envelope antigen
- HBsAg, Hepatitis B surface antigen
- HCV, Hepatitis C virus
- HELLP syndrome
- HELLP, Hemolysis, elevated liver enzymes, low platelet count
- HG, Hyperemesis gravidarum
- HIV, Human immunodeficiency virus
- HV, Hepatic vein
- ICP, Intrahepatic cholestasis of pregnancy
- INASL, Indian National Association for the Study of Liver
- IVF, In vitro fertilization
- LFT, Liver function test
- MDR, Multidrug resistance
- MRI, Magnetic resonance imaging
- MTCT, Mother-to-child transmission
- NA, Nucleos(t)ide analog
- PIH, Pregnancy-induced hypertension
- PT, Prothrombin time
- PUQE, Pregnancy-Unique Quantification of Emesis
- PegIFN, Pegylated interferon
- RNA, Ribonucleic acid
- TAF, Tenofovir alafenamide
- TDF, Tenofovir disoproxil fumarate
- TIPS, Transjugular intrahepatic portosystemic shunt
- UDCA, Ursodeoxycholic acid
- UGI, Upper gastrointestinal
- ULN, Upper limit of normal
- acute fatty liver of pregnancy
- hyperemesis gravidarum
- intrahepatic cholestasis of pregnancy
- liver diseases in pregnancy
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Affiliation(s)
- Anil Arora
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil C. Anand
- Kalinga Institute of Medical Sciences, KIIT University, Bubaneswar, India
| | - Pankaj Puri
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subrat K. Acharya
- Kalinga Institute of Medical Sciences, KIIT University, Bubaneswar, India
| | - Kiran Aggarwal
- Department of Obstetrics and Gynecology, LHMC & Associated Hospitals, New Delhi, India
| | - Neelam Aggarwal
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Yogesh K. Chawla
- Kalinga Institute of Medical Sciences, KIIT University, Bubaneswar, India
| | - Vinod K. Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Bhabadev Goswami
- Department of Gastroenterology, Guwahati Medical College, Assam, India
| | - Kanwal Gujral
- Institute of Obstetrics and Gynecology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anoop Gupta
- Delhi IVF and Fertility Research Centre, New Delhi, India
| | - Ankur Jindal
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Premashish Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Patparganj, New Delhi
| | - Krishna Kumari
- Max Cure Suyosha Woman & Child Hospital, Hyderabad, India
| | - Kaushal Madan
- Max Smart Super Speciality Hospital, Saket, New Delhi, India
| | | | | | - Gaurav Pandey
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Uma Pandey
- Dept of Obstetrics & Gynecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ratna D. Puri
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Ramesh R. Rai
- Department of Gastroenterology, NIMS Medical College and Hospital, Jaipur, India
| | - Padaki N. Rao
- Department of Hepatology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Shiv K. Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Aparna Sharma
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Praveen Sharma
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Koticherry T. Shenoy
- Sree Gokulam Medical College and Research Foundation, Venjaramoodu, Thiruvananthapuram, India
| | - Karam R. Singh
- Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, India
| | | | - Vanita Suri
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
Liver diseases during pregnancy pose a unique clinical challenge because they can affect the lives of both the mother and unborn child. Although severe liver disease is rare, pregnancy-related liver disease affects approximately 3% of pregnancies and can be fatal. Timely recognition and diagnosis are essential in order to institute appropriate management strategies. This article provides an overview of liver diseases during pregnancy and is divided into 2 sections: (1) liver diseases specific to pregnancy, and (2) preexisting or coincident liver diseases during pregnancy.
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Affiliation(s)
- Karen Ma
- Section of Gastroenterology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 207, Chicago, IL 60612, USA
| | - Daniel Berger
- Section of Gastroenterology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 207, Chicago, IL 60612, USA
| | - Nancy Reau
- Section of Hepatology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 319, Chicago, IL 60612, USA.
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121
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Ovadia C, Seed PT, Sklavounos A, Geenes V, Di Ilio C, Chambers J, Kohari K, Bacq Y, Bozkurt N, Brun-Furrer R, Bull L, Estiú MC, Grymowicz M, Gunaydin B, Hague WM, Haslinger C, Hu Y, Kawakita T, Kebapcilar AG, Kebapcilar L, Kondrackienė J, Koster MPH, Kowalska-Kańka A, Kupčinskas L, Lee RH, Locatelli A, Macias RIR, Marschall HU, Oudijk MA, Raz Y, Rimon E, Shan D, Shao Y, Tribe R, Tripodi V, Yayla Abide C, Yenidede I, Thornton JG, Chappell LC, Williamson C. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet 2019; 393:899-909. [PMID: 30773280 PMCID: PMC6396441 DOI: 10.1016/s0140-6736(18)31877-4] [Citation(s) in RCA: 260] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcomes, but the association with the concentration of specific biochemical markers is unclear. We aimed to quantify the adverse perinatal effects of intrahepatic cholestasis of pregnancy in women with increased serum bile acid concentrations and determine whether elevated bile acid concentrations were associated with the risk of stillbirth and preterm birth. METHODS We did a systematic review by searching PubMed, Web of Science, and Embase databases for studies published from database inception to June 1, 2018, reporting perinatal outcomes for women with intrahepatic cholestasis of pregnancy when serum bile acid concentrations were available. Inclusion criteria were studies defining intrahepatic cholestasis of pregnancy based upon pruritus and elevated serum bile acid concentrations, with or without raised liver aminotransferase concentrations. Eligible studies were case-control, cohort, and population-based studies, and randomised controlled trials, with at least 30 participants, and that reported bile acid concentrations and perinatal outcomes. Studies at potential higher risk of reporter bias were excluded, including case reports, studies not comprising cohorts, or successive cases seen in a unit; we also excluded studies with high risk of bias from groups selected (eg, a subgroup of babies with poor outcomes were explicitly excluded), conference abstracts, and Letters to the Editor without clear peer review. We also included unpublished data from two UK hospitals. We did a random effects meta-analysis to determine risk of adverse perinatal outcomes. Aggregate data for maternal and perinatal outcomes were extracted from case-control studies, and individual patient data (IPD) were requested from study authors for all types of study (as no control group was required for the IPD analysis) to assess associations between biochemical markers and adverse outcomes using logistic and stepwise logistic regression. This study is registered with PROSPERO, number CRD42017069134. FINDINGS We assessed 109 full-text articles, of which 23 studies were eligible for the aggregate data meta-analysis (5557 intrahepatic cholestasis of pregnancy cases and 165 136 controls), and 27 provided IPD (5269 intrahepatic cholestasis of pregnancy cases). Stillbirth occurred in 45 (0·83%) of 4936 intrahepatic cholestasis of pregnancy cases and 519 (0·32%) of 163 947 control pregnancies (odds ratio [OR] 1·46 [95% CI 0·73-2·89]; I2=59·8%). In singleton pregnancies, stillbirth was associated with maximum total bile acid concentration (area under the receiver operating characteristic curve [ROC AUC]) 0·83 [95% CI 0·74-0·92]), but not alanine aminotransferase (ROC AUC 0·46 [0·35-0·57]). For singleton pregnancies, the prevalence of stillbirth was three (0·13%; 95% CI 0·02-0·38) of 2310 intrahepatic cholestasis of pregnancy cases in women with serum total bile acids of less than 40 μmol/L versus four (0·28%; 0·08-0·72) of 1412 cases with total bile acids of 40-99 μmol/L (hazard ratio [HR] 2·35 [95% CI 0·52-10·50]; p=0·26), and versus 18 (3·44%; 2·05-5·37) of 524 cases for bile acids of 100 μmol/L or more (HR 30·50 [8·83-105·30]; p<0·0001). INTERPRETATION The risk of stillbirth is increased in women with intrahepatic cholestasis of pregnancy and singleton pregnancies when serum bile acids concentrations are of 100 μmol/L or more. Because most women with intrahepatic cholestasis of pregnancy have bile acids below this concentration, they can probably be reassured that the risk of stillbirth is similar to that of pregnant women in the general population, provided repeat bile acid testing is done until delivery. FUNDING Tommy's, ICP Support, UK National Institute of Health Research, Wellcome Trust, and Genesis Research Trust.
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Affiliation(s)
- Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, King's College London, London, UK
| | | | - Victoria Geenes
- Department of Women and Children's Health, King's College London, London, UK
| | - Chiara Di Ilio
- Department of Women and Children's Health, King's College London, London, UK
| | - Jenny Chambers
- Department of Women and Children's Health, King's College London, London, UK; Women's Health Research Centre, Imperial College London, London, UK
| | - Katherine Kohari
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Yannick Bacq
- Department of Hepatology and Gastroenterology, University Hospital of Tours, Tours, France
| | - Nuray Bozkurt
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, Ankara, Turkey
| | - Romana Brun-Furrer
- Division of Obstetrics, University Hospital of Zurich, Zurich, Switzerland
| | - Laura Bull
- Department of Medicine and Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Maria C Estiú
- Ramón Sardá Mother's and Children's Hospital, Buenos Aires, Argentina
| | - Monika Grymowicz
- Department of Gynecological Endocrinology, Warsaw Medical University, Warsaw, Poland
| | - Berrin Gunaydin
- Department of Anesthesiology and Reanimation, Gazi University School of Medicine, Ankara, Turkey
| | - William M Hague
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | | | - Yayi Hu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ayse G Kebapcilar
- Department of Gynecology and Obstetrics, Selcuk University, Konya, Turkey
| | | | - Jūratė Kondrackienė
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Maria P H Koster
- Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, Netherlands
| | - Aneta Kowalska-Kańka
- Obstetrics and Gynaecology Clinic, Institute of Mother and Child, Warsaw, Poland
| | - Limas Kupčinskas
- Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Richard H Lee
- Obstetrics and Gynecology, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - Anna Locatelli
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, Monza, Italy
| | - Rocio I R Macias
- National Institute for the Study of Liver and Gastrointestinal Diseases, Institute of Biomedical Research of Salamanca, University of Salamanca, Salamanca, Spain
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Martijn A Oudijk
- Department of Obstetrics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Yael Raz
- Department of Obstetrics and Gynecology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Eli Rimon
- Department of Obstetrics and Gynecology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Dan Shan
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yong Shao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rachel Tribe
- Department of Women and Children's Health, King's College London, London, UK
| | - Valeria Tripodi
- School of Pharmacy and Biochemistry, University of Buenos Aires, Buenos Aires, Argentina
| | - Cigdem Yayla Abide
- Clinic of Obstetrics and Gynecology, Zeynep Kamil Women and Children's Health Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ilter Yenidede
- Clinic of Obstetrics and Gynecology, Zeynep Kamil Women and Children's Health Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
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Noninvasive Tests for Prognosticating Outcomes in Patients With Chronic Liver Disease in Pregnancy: Ready for Prime Time? Am J Gastroenterol 2019; 114:209-211. [PMID: 30730857 PMCID: PMC6548179 DOI: 10.14309/ajg.0000000000000101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rates of cirrhosis and pregnancy in women of reproductive age are increasing, making pregnancy-specific prognostic markers of disease severity increasingly important. Gonsalkorala et al. describe albumin-bilirubin score and aspartate aminotransferase-to-platelet ratio index as superior prognostic tools to the Model for End-Stage Liver Disease (MELD) score in predicting live births and gestation beyond 37 weeks in pregnant women with cirrhosis, among 165 pregnancies in women with chronic liver disease. However, further efforts are needed to identify diagnostic and prognostic tools during pregnancy, as well as to refine and implement a multidisciplinary team-centered approach to the care of women with chronic liver disease during pregnancy.
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Non-Invasive Markers (ALBI and APRI) Predict Pregnancy Outcomes in Women With Chronic Liver Disease. Am J Gastroenterol 2019; 114:267-275. [PMID: 29973705 DOI: 10.1038/s41395-018-0181-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Rates of pregnancy in women with cirrhosis are increasing. Risk of hepatic decompensation during pregnancy, therefore, merits tailored obstetric and hepatology care. Prognostic markers that determine pregnancy outcomes are lacking. METHODS Medical records of women who attended hepatology clinic at King's College Hospital with chronic liver disease (CLD) who became pregnant from 1983 to 2017 were reviewed. Information on demographics, clinical history, serology, and outcome of pregnancy was collected. RESULTS In all, 165 pregnancies occurred in 100 women with CLD including 80 pregnancies in 48 women with cirrhosis. Median age of conception in cirrhotic and non-cirrhotic women were 26 years (16-44) and 28 years (16-51) respectively (p = 0.015). Whilst women with cirrhosis had similar live birth rate to non-cirrhotic women (75 vs. 85% p = 0.119), they were significantly less likely to proceed beyond 37 weeks gestation (45 vs. 58% p = 0.033). Women who received preconception counseling were more likely to have stable liver disease at conception (100 vs 86% p = 0.02). Compared with preconception MELD (model for end stage liver disease), preconception Albumin-Bilirubin score (ALBI) more accurately predicted live birth with an area under the receiver-operator curve (AUROC) of 0.741 (p < 0.001), and preconception AST to platelet ratio index (APRI) more accurately predicted ability to proceed beyond 37 weeks gestation with an AUROC of 0.700 (p < 0.001). CONCLUSIONS Most women with cirrhosis who conceived achieved a successful pregnancy outcome. ALBI and APRI scores can prognosticate pregnancy outcomes in women with CLD. Preconception counseling by a hepatologist or specialist obstetrician improved patient care in this group.
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Nusrat S, Syed T, Nusrat S, Chen S, Chen WJ, Bielefeldt K. Assessment of Pharmaceutical Company and Device Manufacturer Payments to Gastroenterologists and Their Participation in Clinical Practice Guideline Panels. JAMA Netw Open 2018; 1:e186343. [PMID: 30646328 PMCID: PMC6324539 DOI: 10.1001/jamanetworkopen.2018.6343] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Payments from pharmaceutical and device manufacturers to physicians may influence the advice physicians give patients and peers. OBJECTIVES To investigate the nature and amounts of monetary and other benefits that gastroenterologists received and to determine the participation of those receiving benefits in the formulation of clinical practice guidelines. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed information from the Centers for Medicare & Medicaid Services Open Payments database, including all reports about payments that pharmaceutical and device manufacturers gave to adult or pediatric gastroenterologists in 2016. PubMed was used to examine the professional affiliations and publication records of top payment recipients. Panelists of clinical guidelines who also received personal financial rewards listed in the Open Payments database were identified. MAIN OUTCOMES AND MEASURES Payments made to gastroenterologists by pharmaceutical company and device manufacturers. RESULTS Of 15 497 gastroenterologists, 13 467 (86.9%) received a total of 432 463 payments accounting for a total expenditure of $67 144 862. Direct financial payments for consultations, talks, or other services were made to 2055 physicians and were responsible for 4.2% of payments (18 179 of 432 463), but for 62.7% of total expenditures ($42 086 207 of $67 144 862). Although a significant number of submissions were for food and beverages, they constituted only a small amount of total expenditure. For gastroenterologists treating adult patients, 10 products were linked to 63.8% of payments (11 221 of 17 588) related to direct financial rewards and 37.1% of the total expenditures ($24 892 643 of $67 144 862). Twenty-nine of 36 clinical practice guidelines included panelists who had received honoraria or consultation fees from industry sources, with amounts exceeding $10 000 in 8 of them (22%). CONCLUSIONS AND RELEVANCE Most gastroenterologists accept meals or gifts from industry, with 2055 of 15 497 gastroenterologists receiving direct payments and 8 of 36 clinical practice guidelines panelists having received more than $10 000. Considering the known impact of such benefits on prescribing patterns and other professional behaviors, policy makers should consider revising regulations governing interactions with industry and disclosure formats alerting others to their potential biasing impact.
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Affiliation(s)
- Salman Nusrat
- Section of Digestive Diseases and Nutrition, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
- Section of Digestive Diseases and Nutrition, Department of Medicine, Veterans Affairs Medical Center, Oklahoma City, Oklahoma
| | - Taseen Syed
- Section of Digestive Diseases and Nutrition, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
- Section of Digestive Diseases and Nutrition, Department of Medicine, Veterans Affairs Medical Center, Oklahoma City, Oklahoma
| | - Sanober Nusrat
- Section of Digestive Diseases and Nutrition, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
- Section of Digestive Diseases and Nutrition, Department of Medicine, Veterans Affairs Medical Center, Oklahoma City, Oklahoma
| | - Sixia Chen
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Science Center, Oklahoma City
| | - Wei-Jen Chen
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Science Center, Oklahoma City
| | - Klaus Bielefeldt
- Section of Gastroenterology, Department of Medicine, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah
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Bicocca MJ, Sperling JD, Chauhan SP. Intrahepatic cholestasis of pregnancy: Review of six national and regional guidelines. Eur J Obstet Gynecol Reprod Biol 2018; 231:180-187. [DOI: 10.1016/j.ejogrb.2018.10.041] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/11/2018] [Accepted: 10/22/2018] [Indexed: 12/27/2022]
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126
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Gryspeerdt F, Aerts R. Laparoscopic liver resection for hemorrhagic hepatocellular adenoma in a pregnant patient. Acta Chir Belg 2018; 118:322-325. [PMID: 28982300 DOI: 10.1080/00015458.2017.1379790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Hepatocellular adenoma (HCA) is a benign neoplasm of the liver, however, with a potential for life-threatening hemorrhage. The unpredictable course during pregnancy poses a clinical dilemma in the pregnant patient. Intra-peritoneal rupture may lead to life-threatening situations with adverse outcome for mother and unborn child. A pre-emptive strategy with adequate treatment before pregnancy is strongly advised. However, the strategy for treating symptomatic HCA during pregnancy remains challenging as experience is limited. CASE PRESENTATION A 31-year-old pregnant patient at the gestational age of 17 weeks presented with an acute episode of right upper abdomen pain. MR-imaging revealed a lesion of 9 cm located in segment III with stigmata of recent hemorrhage. At 18 weeks of gestation, she underwent a semi-elective laparoscopic left lateral sectionectomy. RESULTS Surgery and postoperative recovery were uneventful. Patient was discharged at POD +6. At 40 weeks of gestation, she went in spontaneous labor and delivered a healthy baby. Histological examination confirmed a HCA, inflammatory subtype, showing features of hemorrhage. CONCLUSION In the pregnant patient, HCA represents a significant diagnostic and therapeutic challenge. Anatomically favorable located lesions can be safely managed with laparoscopic liver resection. We suggest that laparoscopic liver resection should be considered as part of the currently available strategies for HCA during pregnancy.
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Affiliation(s)
- F. Gryspeerdt
- Department of Abdominal Surgery, UZ Leuven, Leuven, Belgium
| | - R. Aerts
- Department of Abdominal Surgery, UZ Leuven, Leuven, Belgium
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Ludvigsson JF, Marschall HU, Hagström H, Höijer J, Stephansson O. Pregnancy outcome in women undergoing liver biopsy during pregnancy: A nationwide population-based cohort study. Hepatology 2018; 68:625-633. [PMID: 28653764 DOI: 10.1002/hep.29345] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/23/2017] [Accepted: 06/22/2017] [Indexed: 12/17/2022]
Abstract
Liver biopsy is an important procedure in the investigation of liver disease. We examined pregnancy outcomes in women who underwent liver biopsy during pregnancy. In a nationwide population-based cohort study we linked data from the Swedish Medical Birth Registry (for births between 1992 and 2011) with those from the Swedish Patient Registry. We identified 23 pregnancies exposed to liver biopsy. We calculated relative risks (RRs) for adverse pregnancy outcomes according to liver biopsy status using 1,953,887 unexposed pregnancies with and without a record of liver disease as reference. Our main outcome measures were stillbirth and preterm birth. There were no stillbirths in pregnancies exposed to liver biopsies compared with 0.3% stillbirths in unexposed pregnancies, and 3/23 (13%) exposed pregnancies were preterm (RR, 2.6; 95% confidence interval, 0.9-7.5). Compared to women with a record of liver disease, preterm birth was not increased in those exposed to liver biopsy (RR, 0.9; 95% confidence interval, 0.1-6.0). Except for an increased risk of small for gestational age birth in pregnancies exposed to liver biopsy (RR, 5.2; 95% confidence interval, 1.8-14.8), other adverse pregnancy outcomes were independent of liver biopsy status when the analysis was restricted to women with a diagnosis of liver disease. Compared with unexposed sibling pregnancies, pregnancies with a liver biopsy were 7 days shorter, but birth weights did not differ between the siblings (-67 g; P > 0.05). CONCLUSION Apart from a moderately increased risk of preterm birth and small for gestational age, there was no association between liver biopsy during pregnancy and adverse pregnancy outcome; potential excess risks should be weighed against the advantages of having a liver biopsy that may influence clinical management of the patient and indirectly fetal health. (Hepatology 2017).
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, UK
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Hanns-Ulrich Marschall
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Hannes Hagström
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Solna, Sweden
- Center of Digestive Diseases, Division of Hepatology, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Höijer
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Solna, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Heneghan MA, Cannon MD. Hepatic diagnostics in pregnancy: Biopsy, biomarkers, and beyond. Hepatology 2018; 68:401-403. [PMID: 29486519 DOI: 10.1002/hep.29859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 02/21/2018] [Accepted: 02/23/2018] [Indexed: 12/19/2022]
Affiliation(s)
| | - Mary D Cannon
- Institute of Liver Studies, King's College Hospital, London, UK
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129
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Gomes CF, Sousa M, Lourenço I, Martins D, Torres J. Gastrointestinal diseases during pregnancy: what does the gastroenterologist need to know? Ann Gastroenterol 2018; 31:385-394. [PMID: 29991883 PMCID: PMC6033757 DOI: 10.20524/aog.2018.0264] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 02/26/2018] [Indexed: 12/15/2022] Open
Abstract
Pregnancy is characterized by numerous physiological changes that may lead to a diversity of symptoms and frequently to gastrointestinal complaints, such as heartburn, nausea and vomiting, or constipation. Chronic gastrointestinal diseases require treatment maintenance during this period, raising the challenging question whether outcomes beneficial to the mother may be harmful for the fetus. In addition, certain diseases, such as acute fatty liver of pregnancy, only develop during pregnancy and may require urgent procedures, such as fetus delivery. Even though they are not present in our day-to-day practice, knowledge of pregnancy-related diseases is fundamental and collaboration between gastroenterologists and obstetricians is often necessary. Herein, we review pregnancy-related diseases and systematize the most appropriate treatment choices according to the recent literature and guidelines, so that the article can serve as a guide to the gastroenterologist regarding the medical approach to pregnancy-related gastrointestinal and liver diseases and their therapeutic management.
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Affiliation(s)
- Catarina Frias Gomes
- Surgical Department, Gastroenterology Division (Catarina Frias Gomes, Joana Torres), Hospital Beatriz Ângelo, Loures, Portugal
| | - Mónica Sousa
- Medicine Department, Internal Medicina Division (Mónica Sousa);), Hospital Beatriz Ângelo, Loures, Portugal
| | - Inês Lourenço
- Surgical Department, Gynaecology and Obstetrics Division (Inês Lourenço, Diana Martins), Hospital Beatriz Ângelo, Loures, Portugal
| | - Diana Martins
- Surgical Department, Gynaecology and Obstetrics Division (Inês Lourenço, Diana Martins), Hospital Beatriz Ângelo, Loures, Portugal
| | - Joana Torres
- Surgical Department, Gastroenterology Division (Catarina Frias Gomes, Joana Torres), Hospital Beatriz Ângelo, Loures, Portugal
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Guo Q, Yang Z, Guo J, Zhang L, Gao L, Zhou B, Shi Q. Hepatic infarction induced by HELLP syndrome: a case report and review of the literature. BMC Pregnancy Childbirth 2018; 18:191. [PMID: 29848304 PMCID: PMC5977550 DOI: 10.1186/s12884-018-1799-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/30/2018] [Indexed: 12/27/2022] Open
Abstract
Background HELLP syndrome is a rare disease in China, and 20% of patients with severe preeclampsia have been accompanied with HELLP syndrome, which is characterized by the presence of hemolysis, elevated liver enzymes and low platelet count. Case presentation In this case, we reported that a patient with preeclampsia was diagnosed with HELLP syndrome. Furthermore, hepatic infarction also was found via the computed tomographic (CT) images, which showed peripheral wedge-shaped inhomogeneous low attenuation in the right hepatic lobes via plain CT scan, and the low-density shadow and mottled appearance in the same areas where vessels were seen coursing through them via contrast-enhanced CT scan. Conclusions Besides typical clinical manifestations of the pregnant patient with preeclampsia, the typical laboratory evidences were elevated liver enzymes and thrombocytopenia. The abdominal CT scan showed imaging features of hepatic infarction, which was helpful to identify the rare complication of HELLP syndrome. Thus, we diagnosed a patient with HELLP syndrome with hepatic infarction, though the patient had no chance to do the liver biopsy.
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Affiliation(s)
- Qinyue Guo
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Zhengfei Yang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jian Guo
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Lei Zhang
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Lan Gao
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China
| | - Bo Zhou
- Department of Respiratory Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
| | - Qindong Shi
- Department of Critical Care Medicine, the First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, 710061, Shaanxi, China.
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Abstract
Acute liver failure (ALF) is a rare but highly fatal condition. The most common causes include drug-induced and viral hepatitis, but other less common etiologies, especially autoimmune hepatitis, Budd-Chiari syndrome, and Wilson disease, need to be considered. Because diagnosis is frequently tied to potential for reversibility of ALF and prognosis, early identification in a timely manner is crucial. Other causes of ALF are more easily recognizable based on specific circumstances, such as ALF in pregnancy or ischemic hepatitis. Ultimately, maintaining a wide differential diagnosis in patients with ALF is essential to identifying the proper treatment and prognosis.
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Affiliation(s)
- Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
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Dibba P, Cholankeril R, Li AA, Patel M, Fayek M, Dibble C, Okpara N, Hines A, Ahmed A. Hepatitis C in Pregnancy. Diseases 2018; 6:E31. [PMID: 29702563 PMCID: PMC6023348 DOI: 10.3390/diseases6020031] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023] Open
Abstract
The prevalence of hepatitis C in pregnancy is as high as 3.6% in large cohorts. The prevalence of hepatitis C acquired by vertical transmission is 0.2% to 0.4% in the United States and Europe. Although screening is not recommended in the absence of certain risk factors, the importance of understanding hepatitis C in pregnancy lies in its association with adverse maternal and neonatal outcomes. There is potential for those infants infected by vertical transmission to develop chronic hepatitis C, cirrhosis or hepatocellular carcinoma. The risk of vertical transmission is increased when mothers are co-infected with Human Immunodeficiency Virus (HIV) or possess a high viral load. There is no clear data supporting that mode of delivery increases or reduces risk. Breastfeeding is not associated with increased risk of transmission. Premature rupture of membranes, invasive procedures (such as amniocentesis), intrapartum events, or fetal scalp monitoring may increase risk of transmission. In pregnant patients, hepatitis C is diagnosed with a positive ELISA-3 and detectable Hepatitis C Virus (HCV) RNA viral load. Infants born to HCV-infected mothers should be tested for either HCV RNA on at least two separate occasions. Although prevention is not possible, there may be a role for newer direct acting anti-viral medications in the future.
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Affiliation(s)
- Pratima Dibba
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Rosann Cholankeril
- Department of Medicine, Roger Williams Medical Center, Providence, RI 02908, USA.
| | - Andrew A Li
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
| | - Meera Patel
- Department of Hematology/Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA.
| | - Mariam Fayek
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Christy Dibble
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Nnenna Okpara
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Autumn Hines
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
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Cervino L, Hynicka LM. Direct-Acting Antivirals to Prevent Vertical Transmission of Viral Hepatitis C: When Is the Optimal Time to Treat? Ann Pharmacother 2018; 52:1152-1157. [PMID: 29681166 DOI: 10.1177/1060028018772181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To describe the most current evidence for the use of direct-acting antivirals (DAAs) to treat hepatitis C along the pregnancy-pediatric continuum in the United States. DATA SOURCES The MEDLINE/PubMed databases were searched (January 1995 to February 2018) for articles in English using the terms: hepatitis C, vertical transmission, pregnancy, pediatrics, ribavirin, interferon, direct acting antivirals, daclatasvir, dasabuvir, elbasvir, glecaprevir, grazoprevir, ledipasvir, ombitasvir, paritaprevir, pibrentasvir, simeprevir, sofosbuvir, and velpatasvir. STUDY SELECTION AND DATA EXTRACTION All relevant studies, meta-analyses, systematic reviews, guidelines, and review articles were evaluated for inclusion. References from pertinent articles were assessed for additional content that was not found during the initial search. DATA SYNTHESIS The primary route of transmission for hepatitis C virus (HCV) in pediatric patients is vertical transmission (VT), with the rate estimated to be 5.8%. Screening for HCV during pregnancy is not routinely part of clinical care, and the data for the use of DAAs in pregnancy is limited. A significant number of infected infants will clear the HCV infection spontaneously, and ledipasvir/sofosbuvir and sofosbuvir have recently been Food and Drug Administration approved for use in pediatric patients older than 12 years. CONCLUSIONS Data to determine the best treatment point along the pregnancy-pediatric continuum are limited; however, given the lack of human data for use of DAAs during pregnancy, low rate of VT, high rate of spontaneous pediatric clearance, and recent approval of DAAs for pediatric patients, treatment of chronically infected children seems to be the optimal strategy currently.
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Affiliation(s)
- Leigh Cervino
- 1 School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Lauren M Hynicka
- 1 School of Pharmacy, University of Maryland, Baltimore, MD, USA
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Lelei-Mailu FJ, Mariara CM. Pregnancy in a patient with portal hypertension secondary to liver cirrhosis. BMJ Case Rep 2018; 2018:bcr-2017-223076. [PMID: 29507022 DOI: 10.1136/bcr-2017-223076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This case report is of a 32-year-old woman of African descent on follow-up for pregnancy in the background of portal hypertension due to liver cirrhosis. She had initially been treated for chronic hepatitis B infection with lamivudine and tenofovir, complicated by portal hypertension and variceal bleeding that thrice required banding. Her pregnancy was uneventful until 31 weeks gestation when she presented with dyspnoea. On examination and investigation, she had oedema, bilateral pleural effusions and ascites. Multidisciplinary discussions involving surgery, anaesthesia, obstetrics, neonatology and medicine were held. A consensus outpatient and inpatient management plan was implemented. At 36 weeks, following non-reassuring fetal cardiotocography, she underwent induction of labour. An assisted vacuum delivery was conducted in a controlled setting. She gave birth to a live female infant who had an APGAR score of 9 at 5 min. Both she and the baby had an uneventful postpartum period.
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135
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Rao S, Jim B. Acute Kidney Injury in Pregnancy: The Changing Landscape for the 21st Century. Kidney Int Rep 2018; 3:247-257. [PMID: 29725629 PMCID: PMC5932309 DOI: 10.1016/j.ekir.2018.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 01/26/2018] [Accepted: 01/28/2018] [Indexed: 12/27/2022] Open
Abstract
Pregnancy-related acute kidney injury (Pr-AKI) remains a large public health problem, with decreasing incidences in developing countries but seemingly increasing incidences in the United States and Canada. These epidemiologic changes are reflective of the advances in medical and obstetric care, as well as changes in underlying maternal risk factors. The risk factors associated with advanced maternal age, such as hypertension, diabetes, chronic kidney disease, and those associated with reproductive technologies such as multiple gestations, are increasing. Traditional causes of Pr-AKI, such as septic abortions and puerperal sepsis, have been replaced by hypertensive diseases, such as preeclampsia and thrombotic microangiopathies comprising thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). In this review, we discuss the global impact of Pr-AKI on maternal and fetal outcomes, the predominant etiologies, and key clinical features to distinguish diagnoses, such as preeclampsia/hemolysis elevated liver function test and low platelet (HELLP) syndrome, acute fatty liver disease of pregnancy (AFLP), and other thrombotic microangiopathies. New insights into the pathogenesis of preeclampsia, TTP/aHUS, and AFLP that have unearthed possible therapeutic targets are summarized. We also delve into special consideration needed to give to pyelonephritis and postobstructive causes of Pr-AKI. With each diagnosis, we offer the latest treatment recommendations, such as the positive reports from the use of eculizumab to treat aHUS. In the end, we hope to arm the clinician with the best tools to understand and address this morbid problem that does not seem to be disappearing.
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Affiliation(s)
- Swati Rao
- Division of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Belinda Jim
- Division of Nephrology, Department of Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, New York, USA
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136
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Zhuang X, Cui AM, Wang Q, Cheng XY, Shen Y, Cai WH, Li HB, Zhang S, Qin G. Liver Dysfunction during Pregnancy and Its Association of With Preterm Birth in China: A Prospective Cohort Study. EBioMedicine 2017; 26:152-156. [PMID: 29174520 PMCID: PMC5832609 DOI: 10.1016/j.ebiom.2017.11.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 11/04/2017] [Accepted: 11/16/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Liver dysfunction is common in pregnancy but its association with adverse pregnancy outcomes such as preterm birth (PTB) remains unclear. METHODS A prospective cohort of HBV-infected or uninfected pregnant women attending antenatal care was recruited at Nantong Maternal and Child Health Hospital between January 1, 2012, and June 30, 2016. Liver function tests (LFTs) were monitored through pregnancy. The primary outcomes were PTB and very PTB (delivery prior 37 and 32weeks' gestation respectively). Poisson regression was used to estimate adjusted risk ratios (RR) for women with HBV infection and LFT abnormalities. RESULTS Among 36,755 pregnant women (1,113 HBV carriers and 35,642 non-HBV subjects), 3,519 (9.57%) had abnormal LFTs. The commonest cause for liver dysfunction during pregnancy was non-alcoholic fatty liver diseases (NAFLD, 51.3%). Abnormal aspartate aminotransferase (AST), gamma-glutamyltransferase (GGT) and two folds upper limit of normal total bilirubin (RR and 95%CI: 2.73, 1.30-5.76; 2.24, 1.35-3.31; 2.01, 1.22-3.31 respectively), rather than HBsAg positivity, were identified as independent risk factors for preterm birth. Besides, GGT abnormality was associated with increased risk of very PTB. CONCLUSIONS We suggest that surveillance of LFTs among pregnant women should be warranted, given the increased risk of PTB.
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Affiliation(s)
- Xun Zhuang
- Department of Epidemiology and Biostatistics, School of Public Health, Nantong University, Nantong, China
| | - Ai-Min Cui
- Department of Obstetrics and Gynaecology, Nantong Maternal and Child Health Hospital Affiliated to Nantong University, Nantong, China
| | - Qin Wang
- Department of Nursing, Nantong Health College of Jiangsu Province, Nantong, China
| | - Xiao-Yan Cheng
- Department of Obstetrics and Gynaecology, Nantong Maternal and Child Health Hospital Affiliated to Nantong University, Nantong, China
| | - Yi Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Nantong University, Nantong, China
| | - Wei-Hua Cai
- Department of Nursing, Nantong Health College of Jiangsu Province, Nantong, China
| | - Hai-Bo Li
- Department of Clinical Laboratory, Nantong Maternal and Child Health Hospital Affiliated to Nantong University, Nantong, China
| | - Sheng Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Nantong University, Nantong, China
| | - Gang Qin
- Center for Liver Diseases, Nantong Third People's Hospital Affiliated to Nantong University, Nantong, China..
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137
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Acute Fatty Liver Disease of Pregnancy: Updates in Pathogenesis, Diagnosis, and Management. Am J Gastroenterol 2017; 112:838-846. [PMID: 28291236 DOI: 10.1038/ajg.2017.54] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 02/03/2017] [Indexed: 12/11/2022]
Abstract
Acute fatty liver of pregnancy (AFLP) is an obstetric emergency characterized by maternal liver failure and may have complications for the mother and fetus, including death. This review examines recent literature on the epidemiology, pathogenesis, diagnosis, and treatment of acute fatty liver of pregnancy. Pathogenesis of this disease has been linked to defects in fatty acid metabolism during pregnancy, especially in the setting of fetal genetic defects in fatty acid oxidation. The value of screening all patients for these genetic defects remains to be determined. Distinguishing AFLP from other high-risk liver diseases of pregnancy that have overlap features, such as HELLP and preeclampsia, can be challenging. Although sensitive diagnostic tools such as the Swansea criteria have been developed, further work is needed to diagnose AFLP more quickly. Although survival rates have improved in the past 30 years, delay in diagnosis and treatment of AFLP has life-threatening consequences; an algorithmic approach to AFLP may be a valuable resource for clinicians. Future epidemiological and long-term studies will improve our prediction of women at risk for developing AFLP and determine the long-term consequences of this condition.
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138
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Zheng YF. Effect of nursing intervention under medical guidance on pregnancy outcome in patients with liver dysfunction in late pregnancy. Shijie Huaren Xiaohua Zazhi 2017; 25:732-737. [DOI: 10.11569/wcjd.v25.i8.732] [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
AIM To compare the pregnancy outcome between pregnant women with liver dysfunction in late pregnancy who received different nursing interventions and explore the effect of nursing intervention on the outcome of pregnancy, in order to reduce the risk of pregnant women and ensure maternal and child safety.
METHODS From October 2014 to October 2015, 160 pregnant women with liver dysfunction in late pregnancy treated at our hospital were divided into an experimental group (84 cases) and a control group (76 cases). The control group was given routine nursing, and the intervention group was given routine nursing under medical guidance. Preterm birth, cesarean delivery, polyhydramnios, hypertension, urinary tract infection, postpartum hemorrhage, fetal distress and the incidence of neonatal asphyxia and neonatal hyperbilirubinemia were compared between the two groups.
RESULTS After nursing intervention, premature birth, cesarean delivery, polyhydramnios, hypertension, urinary tract infection, postpartum hemorrhage, fetal distress and other symptoms of pregnancy were significantly reduced in the experimental group than in the control group (P < 0.05). The incidence of neonatal asphyxia and neonatal hyperbilirubinemia rate were significantly lower in the experimental group than in the control group (P < 0.05).
CONCLUSION For patients with liver dysfunction in late pregnancy, nursing intervention under medical guidance can improve the pregnancy outcome.
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Affiliation(s)
- Erica R Cohen
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, 8730 Alden Dr, Thalians Bldg, Los Angeles, CA, 90048, USA.
| | - Tram T Tran
- Liver Transplant, Cedars Sinai Medical Center, 8900 Beverly Boulevard, Los Angeles, CA, 90048, USA
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140
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Twin pregnancies after assisted reproductive technologies: the role of maternal age on pregnancy outcome. Eur J Obstet Gynecol Reprod Biol 2016; 206:198-203. [DOI: 10.1016/j.ejogrb.2016.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/13/2016] [Indexed: 11/17/2022]
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141
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Liver Disease in Pregnancy: Beyond the Guidelines. Am J Gastroenterol 2016; 111:1042-3. [PMID: 27356837 DOI: 10.1038/ajg.2016.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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142
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Affiliation(s)
- Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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