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Momtazmanesh S, Shobeiri P, Saghazadeh A, Teunissen CE, Burman J, Szalardy L, Klivenyi P, Bartos A, Fernandes A, Rezaei N. Neuronal and glial CSF biomarkers in multiple sclerosis: a systematic review and meta-analysis. Rev Neurosci 2021; 32:573-595. [PMID: 33594840 DOI: 10.1515/revneuro-2020-0145] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/15/2021] [Indexed: 12/29/2022]
Abstract
Multiple sclerosis (MS) is a neurodegenerative disease associated with inflammatory demyelination and astroglial activation, with neuronal and axonal damage as the leading factors of disability. We aimed to perform a meta-analysis to determine changes in CSF levels of neuronal and glial biomarkers, including neurofilament light chain (NFL), total tau (t-tau), chitinase-3-like protein 1 (CHI3L1), glial fibrillary acidic protein (GFAP), and S100B in various groups of MS (MS versus controls, clinically isolated syndrome (CIS) versus controls, CIS versus MS, relapsing-remitting MS (RRMS) versus progressive MS (PMS), and MS in relapse versus remission. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we included 64 articles in the meta-analysis, including 4071 subjects. For investigation of sources of heterogeneity, subgroup analysis, meta-regression, and sensitivity analysis were conducted. Meta-analyses were performed for comparisons including at least three individual datasets. NFL, GFAP, t-tau, CHI3L1, and S100B were higher in MS and NFL, t-tau, and CHI3L1 were also elevated in CIS patients than controls. CHI3L1 was the only marker with higher levels in MS than CIS. GFAP levels were higher in PMS versus RRMS, and NFL, t-tau, and CHI3L1 did not differ between different subtypes. Only levels of NFL were higher in patients in relapse than remission. Meta-regression showed influence of sex and disease severity on NFL and t-tau levels, respectively and disease duration on both. Added to the role of these biomarkers in determining prognosis and treatment response, to conclude, they may serve in diagnosis of MS and distinguishing different subtypes.
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Affiliation(s)
- Sara Momtazmanesh
- School of Medicine, Tehran University of Medical Sciences (TUMS), Children's Medical Center Hospital, Dr. Qarib St., Keshavarz Blvd, Tehran14194, Iran.,Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Parnian Shobeiri
- School of Medicine, Tehran University of Medical Sciences (TUMS), Children's Medical Center Hospital, Dr. Qarib St., Keshavarz Blvd, Tehran14194, Iran.,Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Amene Saghazadeh
- Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Charlotte E Teunissen
- Neurochemistry Laboratory, Department of Clinical Chemistry, Location VUmc, PK 2 BR 141, Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Joachim Burman
- Department of Neuroscience, Uppsala University Hospital, 75185Uppsala, Sweden
| | - Levente Szalardy
- Department of Neurology, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, 6725Szeged, Hungary
| | - Peter Klivenyi
- Department of Neurology, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, 6725Szeged, Hungary
| | - Ales Bartos
- Department of Neurology, Third Faculty of Medicine, Charles University, Ruska 87, 100 00Prague 10, Czech Republic
| | - Adelaide Fernandes
- Department of Pharmacological Sciences and Medicines, Faculty of Pharmacy, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003Lisbon, Portugal
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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202
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Lee RH, Mara Greenberg, Metz TD, Pettker CM, Pettker CM. Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy: Replaces Consult #13, April 2011. Am J Obstet Gynecol 2021; 224:B2-B9. [PMID: 33197417 DOI: 10.1016/j.ajog.2020.11.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Intrahepatic cholestasis of pregnancy is a hepatic disorder characterized by pruritus and an elevation in serum bile acid levels. Although intrahepatic cholestasis of pregnancy poses little risk for women, this condition carries a significant risk for the fetus, including complications such as preterm delivery, meconium-stained amniotic fluid, and stillbirth. The purpose of this Consult is to review the current literature on intrahepatic cholestasis of pregnancy and provide recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend measurement of serum bile acid and liver transaminase levels in patients with suspected intrahepatic cholestasis of pregnancy (GRADE 1B); (2) we recommend that ursodeoxycholic acid be used as the first-line agent for the treatment of maternal symptoms of intrahepatic cholestasis of pregnancy (GRADE 1A); (3) we suggest that patients with a diagnosis of intrahepatic cholestasis of pregnancy begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal fetal testing results or at the time of diagnosis if the diagnosis is made later in gestation (GRADE 2C); (4) we recommend that patients with total bile acid levels of ≥100 μmol/L be offered delivery at 36 0/7 weeks of gestation, given that the risk of stillbirth increases substantially around this gestational age (GRADE 1B); (5) we recommend delivery between 36 0/7 and 39 0/7 weeks of gestation for patients with intrahepatic cholestasis of pregnancy and total bile acid levels of <100 μmol/L (GRADE 1C); (6) we recommend administration of antenatal corticosteroids for fetal lung maturity for patients delivering before 37 0/7 weeks of gestation if not previously administered (GRADE 1A); (7) we recommend against preterm delivery at <37 weeks of gestation in patients with a clinical diagnosis of intrahepatic cholestasis of pregnancy without laboratory confirmation of elevated bile acid levels (GRADE 1B).
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Affiliation(s)
| | | | | | | | - Christian M Pettker
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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203
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Manna LB, Williamson C. Nuclear receptors, gestational metabolism and maternal metabolic disorders. Mol Aspects Med 2021; 78:100941. [PMID: 33455843 DOI: 10.1016/j.mam.2021.100941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 12/20/2022]
Abstract
Normal pregnancy is characterised by a gradual alteration in metabolism that results in elevated serum bile acids, dyslipidaemia and impaired glucose tolerance in the third trimester. Nuclear receptors play important roles in regulating metabolic pathways that influence alterations in these parameters. There is evidence for altered function of FXR and LXR in gestation; these nuclear receptors play an integral role in bile acid and lipid homeostasis. There is some evidence for influence of clock genes in late pregnancy metabolic changes, and this may be linked to alterations in placental gene expression and function, thereby influencing fetal growth. This article will review the current data from human studies and investigation of animal models to illustrate the role of nuclear receptors (namely LXR, FXR, PPARs and clock genes) in gestational alterations in metabolism and the ways this may influence susceptibility to metabolic disorders of pregnancy such as gestational diabetes mellitus and intrahepatic cholestasis of pregnancy.
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Affiliation(s)
- Luiza Borges Manna
- Division of Women and Children's Health, King's College London, London, United Kingdom
| | - Catherine Williamson
- Division of Women and Children's Health, King's College London, London, United Kingdom.
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204
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Hague WM, Callaway L, Chambers J, Chappell L, Coat S, de Haan-Jebbink J, Dekker M, Dixon P, Dodd J, Fuller M, Gordijn S, Graham D, Heikinheimo O, Hennessy A, Kaaja R, Khong TY, Lampio L, Louise J, Makris A, Markus C, Marschall HU, Middleton P, Mol BW, Morris J, Newnham JP, Ovadia C, Peek M, Shand A, Stark M, Thornton J, Timonen S, Walker S, Warrilow D, Williamson C. A multi-centre, open label, randomised, parallel-group, superiority Trial to compare the efficacy of URsodeoxycholic acid with RIFampicin in the management of women with severe early onset Intrahepatic Cholestasis of pregnancy: the TURRIFIC randomised trial. BMC Pregnancy Childbirth 2021; 21:51. [PMID: 33435904 PMCID: PMC7802989 DOI: 10.1186/s12884-020-03481-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe early onset (less than 34 weeks gestation) intrahepatic cholestasis of pregnancy (ICP) affects 0.1% of pregnant women in Australia and is associated with a 3-fold increased risk of stillbirth, fetal hypoxia and compromise, spontaneous preterm birth, as well as increased frequencies of pre-eclampsia and gestational diabetes. ICP is often familial and overlaps with other cholestatic disorders. Treatment options for ICP are not well established, although there are limited data to support the use of ursodeoxycholic acid (UDCA) to relieve pruritus, the main symptom. Rifampicin, a widely used antibiotic including in pregnant women, is effective in reducing pruritus in non-pregnancy cholestasis and has been used as a supplement to UDCA in severe ICP. Many women with ICP are electively delivered preterm, although there are no randomised data to support this approach. METHODS We have initiated an international multicentre randomised clinical trial to compare the clinical efficacy of rifampicin tablets (300 mg bd) with that of UDCA tablets (up to 2000 mg daily) in reducing pruritus in women with ICP, using visual pruritus scores as a measuring tool. DISCUSSION Our study will be the first to examine the outcomes of treatment specifically in the severe early onset form of ICP, comparing "standard" UDCA therapy with rifampicin, and so be able to provide for the first-time high-quality evidence for use of rifampicin in severe ICP. It will also allow an assessment of feasibility of a future trial to test whether elective early delivery in severe ICP is beneficial. TRIAL IDENTIFIERS Australian New Zealand Clinical Trials Registration Number (ANZCTR): 12618000332224p (29/08/2018). HREC No: HREC/18/WCHN/36. EudraCT number: 2018-004011-44. IRAS: 272398. NHMRC registration: APP1152418 and APP117853.
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Affiliation(s)
- William M Hague
- Robinson Research Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5006, South Australia, Australia.
- Obstetric Medicine, Women's and Babies' Division, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia, 5006, Australia.
| | - Leonie Callaway
- Gynaecology, Oncology & Obstetric Medicine, Royal Brisbane and Women's Hospital, Herston, 4029, Queensland, Australia
- The University of Queensland, Brisbane, 4072, Queensland, Australia
| | - Jennifer Chambers
- Women and Children's Health, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Lucy Chappell
- Women and Children's Health, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Suzette Coat
- Robinson Research Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5006, South Australia, Australia
| | - Jiska de Haan-Jebbink
- Dutch Consortium for Healthcare Evaluation in Obstetrics and Gynaecology (NVOG Consortium), Postbus 20075, Utrecht, 3502 LB, The Netherlands
| | - Marloes Dekker
- The University of Queensland, Brisbane, 4072, Queensland, Australia
| | - Peter Dixon
- Women and Children's Health, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jodie Dodd
- Robinson Research Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5006, South Australia, Australia
| | - Maria Fuller
- Robinson Research Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5006, South Australia, Australia
- SA Pathology, Women's and Children's Hospital, 72 King William Road, North Adelaide, 5006, South Australia, Australia
| | - Sanne Gordijn
- Dutch Consortium for Healthcare Evaluation in Obstetrics and Gynaecology (NVOG Consortium), Postbus 20075, Utrecht, 3502 LB, The Netherlands
| | - Dorothy Graham
- University of Western Australia Division of Obstetrics and Gynaecology, King Edward Memorial Hospital, PO Box 134, Subiaco, Perth, 6904, Western Australia, Australia
| | - Oskari Heikinheimo
- Women's Hospital, University of Helsinki and Helsinki University Hospital, P.O. Box 140, Haartmaninkatu 2, Helsinki, HUS 00029, Finland
| | - Annemarie Hennessy
- School of Medicine, Campbelltown Campus, University of Western Sydney, Narellan Rd, Campbelltown, 2560, NSW, Australia
| | - Risto Kaaja
- Department of Obstetrics and Gynaecology, Turku University Hospital (TYKS), PO Box 52, Turku, 20521, Finland
| | - Teck Yee Khong
- Robinson Research Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5006, South Australia, Australia
- SA Pathology, Women's and Children's Hospital, 72 King William Road, North Adelaide, 5006, South Australia, Australia
| | - Laura Lampio
- School of Medicine, Campbelltown Campus, University of Western Sydney, Narellan Rd, Campbelltown, 2560, NSW, Australia
| | - Jennie Louise
- Robinson Research Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5006, South Australia, Australia
| | - Angela Makris
- Women's Hospital, University of Helsinki and Helsinki University Hospital, P.O. Box 140, Haartmaninkatu 2, Helsinki, HUS 00029, Finland
| | - Corey Markus
- SA Pathology, Women's and Children's Hospital, 72 King William Road, North Adelaide, 5006, South Australia, Australia
- Flinders University International Centre for Point-of-Care Testing, College of Medicine & Public Health, GPO Box 2100, Sturt Road, Bedford Park, South Australia, 5042, Australia
| | | | - Philippa Middleton
- Robinson Research Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5006, South Australia, Australia
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, PO Box 11060, Adelaide, 5001, South Australia, Australia
| | - Ben W Mol
- Obstetrics & Gynaecology Monash Health, Monash University, Clayton, 3800, Victoria, Australia
| | - Jonathan Morris
- Paediatrics and Reproductive Medicine, The University of Sydney, Sydney, 2006, New South Wales, Australia
| | - John P Newnham
- University of Western Australia Division of Obstetrics and Gynaecology, King Edward Memorial Hospital, PO Box 134, Subiaco, Perth, 6904, Western Australia, Australia
| | - Caroline Ovadia
- Women and Children's Health, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Michael Peek
- Obstetrics and Gynaecology, Australian National University Medical School, The Canberra Hospital, PO Box 11, Woden, 2606, Australian Capital Territory, Australia
| | - Antonia Shand
- Paediatrics and Reproductive Medicine, The University of Sydney, Sydney, 2006, New South Wales, Australia
| | - Michael Stark
- Robinson Research Institute, The University of Adelaide, 55 King William Road, North Adelaide, 5006, South Australia, Australia
- Obstetric Medicine, Women's and Babies' Division, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia, 5006, Australia
| | - Jim Thornton
- Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Derby Rd, Nottingham, NG7 2UH, UK
| | - Susanna Timonen
- Department of Obstetrics and Gynaecology, Turku University Hospital (TYKS), PO Box 52, Turku, 20521, Finland
| | - Susan Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, 3084, Victoria, Australia
| | - David Warrilow
- Public Health Virology Laboratory, Public and Environmental Health, Forensic and Scientific Services, Health Support Queensland, Department of Health, 39 Kessels Road, Coopers Plains, 4108, Queensland, Australia
| | - Catherine Williamson
- Women and Children's Health, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
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205
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Sarkar M, Brady CW, Fleckenstein J, Forde KA, Khungar V, Molleston JP, Afshar Y, Terrault NA. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:318-365. [PMID: 32946672 DOI: 10.1002/hep.31559] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Monika Sarkar
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Jean P Molleston
- Indiana University and Riley Hospital for Children, Indianapolis, IN
| | - Yalda Afshar
- University of California, Los Angeles, Los Angeles, CA
| | - Norah A Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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206
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Roediger R, Fleckenstein J. Intrahepatic Cholestasis of Pregnancy: Natural History and Current Management. Semin Liver Dis 2021; 41:103-108. [PMID: 33764488 DOI: 10.1055/s-0040-1722264] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a common disorder in the second half of pregnancy characterized by pruritus and elevated serum bile acids (BAs) with spontaneous resolution after delivery. ICP carries a risk of adverse effects on the fetus which correlates with the degree of BA elevation. ICP occurs in genetically susceptible women as the reproductive hormones increase during pregnancy. Ursodeoxycholic acid is still considered the first-line treatment for ICP though it is of unproven benefit in preventing adverse effects on the fetus. Fetal complications, such as stillbirth, increase with gestational age, so preterm delivery is generally performed in cases of severe ICP, defined as BA levels above 40 μmol/L. ICP may recur in future pregnancies and is associated with an increased risk for future hepatobiliary, immune mediated, and cardiovascular diseases. Children born of mothers with ICP have normal development but may have a risk for subsequent metabolic disease.
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Affiliation(s)
- Rebecca Roediger
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Jaquelyn Fleckenstein
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
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207
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Yakut K, Öcal FD, Öztürk M, Öztürk FH, Oğuz Y, Çelen Ş. Assessment of Mechanical Fetal PR Interval in Intrahepatic Cholestasis of Pregnancy and Its Relationship with the Severity of the Disease. Am J Perinatol 2020; 37:1476-1481. [PMID: 31430816 DOI: 10.1055/s-0039-1694726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study aimed to investigate the fetal atrioventricular conduction system in intrahepatic cholestasis of pregnancy (ICP) by measuring the fetal mechanical PR interval and to explore the significance of predicting the severity of the disease. STUDY DESIGN Forty pregnant women diagnosed with ICP, classified as severe and mild, and 40 healthy pregnant women participated in the study. Fetal mechanical PR interval was calculated, and fetal mechanical PR interval and neonatal outcome were compared between the groups. The relationship between the mechanical PR interval and the severity of ICP was analyzed. RESULTS The fetal mechanical PR interval was significantly longer in the ICP group than in the control group (p < 0.005). Likewise, laboratory parameters such as transaminases (alanine aminotransferase [ALT], aspartate aminotransferase [AST]) and total bilirubin levels were significantly higher in the ICP group (p < 0.005).There were no statistically significant differences in the fetal complications. There was a positive correlation between the severity of disease and fetal PR interval. CONCLUSION A prolonged fetal mechanical PR interval in fetuses of mothers with ICP was demonstrated in this study. It was also shown that there was a positive correlation between fetal PR interval and severity of the disease. The study concluded that fetal mechanical PR interval measurement can be used to predict the severity of disease in ICP.
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Affiliation(s)
- Kadriye Yakut
- Department of Perinatology, Dr. Zekai Tahir Burak Women's Health and Research Hospital, Ankara, Turkey
| | - Fatma Doğa Öcal
- Department of Perinatology, Dr. Zekai Tahir Burak Women's Health and Research Hospital, Ankara, Turkey
| | - Merve Öztürk
- Department of Perinatology, Dr. Zekai Tahir Burak Women's Health and Research Hospital, Ankara, Turkey
| | - Filiz Halici Öztürk
- Department of Perinatology, Dr. Zekai Tahir Burak Women's Health and Research Hospital, Ankara, Turkey
| | - Yüksel Oğuz
- Department of Perinatology, Dr. Zekai Tahir Burak Women's Health and Research Hospital, Ankara, Turkey
| | - Şevki Çelen
- Department of Perinatology, Dr. Zekai Tahir Burak Women's Health and Research Hospital, Ankara, Turkey
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208
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Abstract
Full-term deliveries are defined as occurring between 39 weeks and 40 weeks and 6 days. Because contemporary research suggests improved outcomes with delivery in the term period compared with the early term period, nonindicated delivery should be pursued no earlier than 39 weeks. There are, however, multiple medical, obstetric, and fetal indications for delivery before 39 weeks, and the obstetric provider must weigh the risks and benefits of delivery versus expectant management on both the mother and fetus. This review serves to provide a basic framework of evidentiary support toward optimizing the term delivery.
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Affiliation(s)
- Timothy Wen
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94158, USA
| | - Amy L Turitz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, 622 West 168th Street, New York, NY 10032, USA.
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209
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Liu C, Gao J, Liu J, Wang X, He J, Sun J, Liu X, Liao S. Intrahepatic cholestasis of pregnancy is associated with an increased risk of gestational diabetes and preeclampsia. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1574. [PMID: 33437773 PMCID: PMC7791254 DOI: 10.21037/atm-20-4879] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Previous studies have shown that intrahepatic cholestasis of pregnancy (ICP) is associated with an increased incidence of adverse perinatal outcomes, and this supports the contention that ICP is associated with increased risk for both gestational diabetes mellitus (GDM) and preeclampsia. The purpose of this study was to review adverse maternal and perinatal outcomes of ICP in the Chinese population, and to investigate the association between ICP and GDM, as well as between ICP and preeclampsia. Methods We conducted a retrospective cohort study in which we compared pregnancies affected by ICP with all other deliveries during the study period. Data from women with singleton pregnancies who delivered in 14 representative hospitals in China between October 1, 2016 and September 30, 2017 were collected from our database system. We then performed logistic regression analysis to determine the odds ratios (OR) and 95%CIs of the adverse pregnancy outcomes among women with or without ICP. Results A total of 95,728 singleton births were included in the study, and among these, 911 pregnancies were diagnosed as having ICP, resulting in an incidence of 0.95%. Women with ICP were more likely to have GDM [adjusted odds ratio (aOR), 1.406; 95% CI, 1.179-1.677; P<0.001] and preeclampsia (aOR, 2.241; 95% CI, 1.678-2.992; P<0.001) compared with those who did not have ICP. Women in the ICP group exhibited higher rates of scheduled cesarean deliveries (aOR, 3.527; 95% CI, 2.981-4.173; P<0.001) and cesarean deliveries during labor (aOR, 4.388; 95% CI, 1.815-10.612; P=0.027). Women with ICP were also more likely to have iatrogenic preterm delivery (aOR, 2.449; 95% CI, 1.92-3.122; P<0.001) and admission to the neonatal intensive care unit (aOR, 1.572; 95% CI, 1.318-1.874; P<0.001). There was no increased risk of stillbirth in the cohort of ICP cases (aOR, 0.430; 95% CI, 0.049-3.767; P=0.259). Conclusions ICP was associated with an increased risk of GDM and preeclampsia in singleton pregnancies. Pregnancies with ICP therefore have significantly increased risks of adverse perinatal outcomes.
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Affiliation(s)
- Congcong Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinsong Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xietong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Jing He
- Department of Obstetrics and Gynecology, Women's Hospital School of Medicine Zhejiang University, Hangzhou, China
| | - Jingxia Sun
- Department of Obstetrics and Gynecology, the First Clinical Hospital affiliated to Harbin Medical University, Harbin, China
| | - Xiaowei Liu
- Department of Obstetrics and Gynecology, Beijing Obstetrics and Gynecology Hospital Capital Medical University, Beijing, China
| | - Shixiu Liao
- Department of Obstetrics and Gynecology, Henan Provincial People's Hospital, Zhengzhou, China
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210
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Huang X, Chen S, Chen H, Hu L, Wen L, Wei F, Chen K. ROC Curve Analysis of the Sensitivity and Specificity of Biochemical Detection of Intrahepatic Cholestasis during Pregnancy. Z Geburtshilfe Neonatol 2020; 225:327-332. [PMID: 33246351 DOI: 10.1055/a-1299-2298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Intrahepatic cholestasis of pregnancy (ICP) is associated with an increased risk of adverse pregnancy outcomes in mothers and infants. The aim was to evaluate the sensitivity and specificity of biochemical detection of ICP by ROC curve and to determine the threshold of more reliable experimental indicators. MATERIALS AND METHODS 305 patients and 305 healthy pregnant women were enrolled in the study. RESULTS The average levels of TBA, ALT, and AST in the ICP group were much higher than those in the control group (P<0. 001); the area of both CG and TBA under ROC curve was up to 0.99, the sensitivity was 97.7%, and the specificity was 99.3%. CONCLUSIONS This study did not find any single specificity and sensitivity markers that could be used to reliably diagnose ICP. In the future, we will pay more attention to the correlation between sensitive biochemical indicators and adverse pregnancy outcomes.
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Affiliation(s)
- Xiaoyi Huang
- Guangdong Pharmaceutical University, School of Nursing, Guangdong Pharmaceutical University, Guangzhou, Guangzhou, China
| | - Siyi Chen
- Guangdong Pharmaceutical University, School of Nursing, Guangdong Pharmaceutical University, Guangzhou, Guangzhou, China
| | - Hongyan Chen
- Guangdong Pharmaceutical University, School of Nursing, Guangdong Pharmaceutical University, Guangzhou, Guangzhou, China
| | - Liang Hu
- Shenzhen Longgang District Maternity & Child Healthcare Hospital of Shenzhen City, Shenzhen, China
| | - Lijuan Wen
- Shenzhen Longgang District Maternity & Child Healthcare Hospital of Shenzhen City, Shenzhen, China
| | - Fengxiang Wei
- Shenzhen Longgang District Maternity & Child Healthcare Hospital of Shenzhen City, Shenzhen, China
| | - Ken Chen
- Guangdong Pharmaceutical University, School of Nursing, Guangdong Pharmaceutical University, Guangzhou, Guangzhou, China
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211
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Shao H, Gao S, Ying X, Zhu X, Hua Y. Expression and Regulation of Aquaporins in Pregnancy Complications and Reproductive Dysfunctions. DNA Cell Biol 2020; 40:116-125. [PMID: 33226842 DOI: 10.1089/dna.2020.5983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aquaporins (AQPs), small hydrophobic integral membrane proteins, mediate rapid transport of water and small solutes. The abnormal expressions of AQPs are associated with pregnancy complications and reproductive dysfunctions, including preeclampsia, gestational diabetes mellitus, tubal ectopic pregnancy, intrahepatic cholestasis of pregnancy, preterm birth, chorioamnionitis, polyhydramnios, and oligohydramnios, thus resulting in adverse pregnancy outcomes. This review explains the alterations of AQPs in pregnancy complications and reproductive dysfunctions and summarizes the molecular mechanisms involved in the regulations of AQPs by drugs such as oxytocin, polychlorinated biphenyls, all-trans-retinoic acid, salvia miltiorrhiza, and insulin, or other factors such as oxygen and osmotic pressure. All the research provides evidence that AQPs could be the new therapeutic targets of pregnancy-related diseases.
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Affiliation(s)
- Hailing Shao
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shichu Gao
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xinxin Ying
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xueqiong Zhu
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ying Hua
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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212
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Borkowski K, Newman JW, Aghaeepour N, Mayo JA, Blazenović I, Fiehn O, Stevenson DK, Shaw GM, Carmichael SL. Mid-gestation serum lipidomic profile associations with spontaneous preterm birth are influenced by body mass index. PLoS One 2020; 15:e0239115. [PMID: 33201881 PMCID: PMC7671555 DOI: 10.1371/journal.pone.0239115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/31/2020] [Indexed: 01/11/2023] Open
Abstract
Spontaneous preterm birth (sPTB) is a major cause of infant morbidity and mortality. While metabolic changes leading to preterm birth are unknown, several factors including dyslipidemia and inflammation have been implicated and paradoxically both low (<18.5 kg/m2) and high (>30 kg/m2) body mass indices (BMIs) are risk factors for this condition. The objective of the study was to identify BMI-associated metabolic perturbations and potential mid-gestation serum biomarkers of preterm birth in a cohort of underweight, normal weight and obese women experiencing either sPTB or full-term deliveries (n = 102; n = 17/group). For this purpose, we combined untargeted metabolomics and lipidomics with targeted metabolic profiling of major regulators of inflammation and metabolism, including oxylipins, endocannabinoids, bile acids and ceramides. Women who were obese and had sPTB showed elevated oxidative stress and dyslipidemia characterized by elevated serum free fatty acids. Women who were underweight-associated sPTB also showed evidence of dyslipidemia characterized by elevated phospholipids, unsaturated triglycerides, sphingomyelins, cholesteryl esters and long-chain acylcarnitines. In normal weight women experiencing sPTB, the relative abundance of 14(15)-epoxyeicosatrienoic acid and 14,15-dihydroxyeicosatrienoic acids to other regioisomers were altered at mid-pregnancy. This phenomenon is not yet associated with any biological process, but may be linked to estrogen metabolism. These changes were differentially modulated across BMI groups. In conclusion, using metabolomics we observed distinct BMI-dependent metabolic manifestations among women who had sPTB. These observations suggest the potential to predict sPTB mid-gestation using a new set of metabolomic markers and BMI stratification. This study opens the door to further investigate the role of cytochrome P450/epoxide hydrolase metabolism in sPTB.
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Affiliation(s)
- Kamil Borkowski
- West Coast Metabolomic Center, Genome Center, University of California-Davis, Davis, CA, United States of America
- * E-mail:
| | - John W. Newman
- West Coast Metabolomic Center, Genome Center, University of California-Davis, Davis, CA, United States of America
- United States Department of Agriculture-Agriculture Research Service-Western Human Nutrition Research Center, Davis, CA, United States of America
- Department of Nutrition, University of California-Davis, Davis, CA, United States of America
| | - Nima Aghaeepour
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
- Department of Biomedical Data Sciences, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Jonathan A. Mayo
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Ivana Blazenović
- West Coast Metabolomic Center, Genome Center, University of California-Davis, Davis, CA, United States of America
| | - Oliver Fiehn
- West Coast Metabolomic Center, Genome Center, University of California-Davis, Davis, CA, United States of America
| | - David K. Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Gary M. Shaw
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Suzan L. Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
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213
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Tang G, Seume N, Häger C, Kumstel S, Abshagen K, Bleich A, Vollmar B, Talbot SR, Zhang X, Zechner D. Comparing distress of mouse models for liver damage. Sci Rep 2020; 10:19814. [PMID: 33188220 PMCID: PMC7666197 DOI: 10.1038/s41598-020-76391-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 10/01/2020] [Indexed: 02/07/2023] Open
Abstract
In order to foster animal welfare as well as high quality of research, many countries regulate by law that the severity of animal experiments must be evaluated and considered when performing biomedical research. It is well accepted that multiple parameters rather than a single readout parameter should be applied to describe animal distress or suffering. However, since the performance of readout parameters for animal distress is rarely defined and methods for multivariate analysis have only in rare cases been used, it is not known which methodology is most appropriate to define animal distress. This study used receiver operating characteristic curve analysis to quantify the performance of burrowing activity, body weight change and a distress score of mice after induction of liver damage by bile duct ligation or carbon tetrachloride. In addition, Support Vector Machine classification was used to compare the distress of these mouse models. This approach demonstrated that bile duct ligation causes much more distress than carbon tetrachloride-induced liver damage. This study, therefore, provides a prototype how to compare two animal models by considering several readout parameters. In the future these or similar methods for multivariate analysis will be necessary, when assessing and comparing the severity of animal models.
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Affiliation(s)
- Guanglin Tang
- Rudolf-Zenker, Institute of Experimental Surgery, Rostock University Medical Center, Rostock, Germany
| | - Nico Seume
- Rudolf-Zenker, Institute of Experimental Surgery, Rostock University Medical Center, Rostock, Germany
| | - Christine Häger
- Institute for Laboratory Animal Science, Hannover Medical School, Hanover, Germany
| | - Simone Kumstel
- Rudolf-Zenker, Institute of Experimental Surgery, Rostock University Medical Center, Rostock, Germany
| | - Kerstin Abshagen
- Rudolf-Zenker, Institute of Experimental Surgery, Rostock University Medical Center, Rostock, Germany
| | - André Bleich
- Institute for Laboratory Animal Science, Hannover Medical School, Hanover, Germany
| | - Brigitte Vollmar
- Rudolf-Zenker, Institute of Experimental Surgery, Rostock University Medical Center, Rostock, Germany
| | - Steven R Talbot
- Institute for Laboratory Animal Science, Hannover Medical School, Hanover, Germany.
| | - Xianbin Zhang
- Rudolf-Zenker, Institute of Experimental Surgery, Rostock University Medical Center, Rostock, Germany.
| | - Dietmar Zechner
- Rudolf-Zenker, Institute of Experimental Surgery, Rostock University Medical Center, Rostock, Germany.
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214
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Wu C, Smet ME, Heath S, Curnow J, Lin MW, George J, Alahakoon TI. Pregnancy complicated by refractory severe hypercholanaemia from sodium taurocholate co-transporting polypeptide deficiency. J Obstet Gynaecol Res 2020; 47:822-826. [PMID: 33174277 DOI: 10.1111/jog.14568] [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: 09/21/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
Sodium taurocholate co-transporting polypeptide deficiency is a rare metabolic autosomal recessive condition resulting in critically elevated plasma bile acid levels. Hypercholanaemia in similar conditions such as intrahepatic cholestasis of pregnancy has been associated with an increased risk of adverse obstetric outcomes including stillbirth. We present the first case of Sodium taurocholate co-transporting polypeptide deficiency in a current pregnancy in a patient with one previous stillbirth in the context of severe hypercholanaemia, where conventional treatments for cholestasis including ursodeoxycholic acid, rifampicin and cholestyramine were ineffective. Therapeutic plasma exchange and novel treatment with elobixibat were trialed with mixed results. The pregnancy resulted in an iatrogenic preterm delivery of a live infant at 32 weeks gestation.
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Affiliation(s)
- Christine Wu
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Maria-Elisabeth Smet
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Ultrasound for Women, Chatswood, New South Wales, Australia
| | - Susan Heath
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jennifer Curnow
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Ming-Wei Lin
- Department of Immunology, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jacob George
- Storr Liver Centre, The Westmead Institute for Medical Research, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Thushari I Alahakoon
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Womens Ultrasound, Sydney, New South Wales, Australia
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215
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Fleminger J, Seed PT, Smith A, Juszczak E, Dixon PH, Chambers J, Dorling J, Williamson C, Thornton JG, Chappell LC. Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a secondary analysis of the PITCHES trial. BJOG 2020; 128:1066-1075. [PMID: 33063439 PMCID: PMC8246759 DOI: 10.1111/1471-0528.16567] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate whether a particular group of women with intrahepatic cholestasis of pregnancy (ICP), based on their presenting characteristics, would benefit from treatment with ursodeoxycholic acid (UDCA). DESIGN Secondary analysis of the PITCHES trial (ISRCTN91918806). SETTING United Kingdom. POPULATION OR SAMPLE 527 women with ICP. METHODS Subgroup analyses were performed to determine whether baseline bile acid concentrations or baseline itch scores moderated a woman's response to treatment with UDCA. MAIN OUTCOME MEASURES Bile acid concentration and itch score. RESULTS In women with baseline bile acid concentrations less than 40 μmol/l, treatment with UDCA resulted in increased post-randomisation bile acid concentrations (geometric mean ratio 1.19, 95% CI 1.00-1.41, P = 0.048). A test of interaction showed no significance (P = 0.647). A small, clinically insignificant difference was seen in itch response in women with a high baseline itch score (-6.0 mm, 95% CI -11.80 to -0.21, P = 0.042), with a test of interaction not showing significance (P = 0.640). Further subgroup analyses showed no significance. Across all women there was a weak relationship between bile acid concentrations and itch severity. CONCLUSIONS There was no subgroup of women with ICP in whom a beneficial effect of treatment with UDCA on bile acid concentration or itch score could be identified. This confirms that its routine use in women with this condition for improvement of bile acid concentration or itch score should be reconsidered. TWEETABLE ABSTRACT PITCHES: No group of women with ICP has been found in whom UDCA reduces bile acid concentrations or pruritus.
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Affiliation(s)
- J Fleminger
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - P T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - A Smith
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - E Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - P H Dixon
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | | | - J Dorling
- Division of Neonatal-Perinatal Medicine, IWK Health Centre, Halifax, NS, Canada
| | - C Williamson
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - J G Thornton
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - L C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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216
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Nielsen JH, Lykke JA. Differentiated timing of induction for women with intrahepatic cholestasis of pregnancy-A historical cohort study. Acta Obstet Gynecol Scand 2020; 100:279-285. [PMID: 32970824 DOI: 10.1111/aogs.13998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/07/2020] [Accepted: 09/13/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disease characterized by pruritus and abnormal liver function tests and it has been associated with intrauterine fetal distress and stillbirth. We compared two guidelines of the management of ICP: one mandating induction at 38 weeks of gestation (Rigshospitalet and Hvidovre Hospital before 2012) and another separating ICP into mild and severe forms, and only women with severe ICP were recommended for induction at 38 weeks (Hvidovre Hospital after 2012). MATERIAL AND METHODS We performed a historical cohort study at two Copenhagen Hospitals from 2004 to 2015. We included 62 937 women with singleton deliveries at Rigshospitalet and 71 015 at Hvidovre Hospital, of whom 971 women (1.5%) and 998 women (1.4%) were diagnosed with ICP at Rigshospitalet and Hvidovre Hospital, respectively. Data were retrieved from a local medical database. For the analysis of induction and comparison of obstetrical outcomes we only included pregnancies with an ICP diagnosis and excluded women with other medical conditions that could mandate induction. Main outcome measures were induction and cesarean section rates, asphyxia and stillbirth. RESULTS We found no changes in the rate of spontaneous labor, cesarean section and induction over the years at Rigshospitalet (P = .17) and Hvidovre Hospital (P = .38). For women with intended vaginal delivery we found no change in the final mode of delivery over the years at Rigshospitalet (P = .28) and Hvidovre Hospital (P = .57). CONCLUSIONS The two approaches to the management of mild ICP regarding the timing of induction are comparable. Women with mild ICP and their clinicians should be encouraged to engage in shared decision-making when discussing timing of induction.
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Affiliation(s)
| | - Jacob Alexander Lykke
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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217
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Townsend R, Sileo FG, Allotey J, Dodds J, Heazell A, Jorgensen L, Kim VB, Magee L, Mol B, Sandall J, Smith G, Thilaganathan B, von Dadelszen P, Thangaratinam S, Khalil A. Prediction of stillbirth: an umbrella review of evaluation of prognostic variables. BJOG 2020; 128:238-250. [PMID: 32931648 DOI: 10.1111/1471-0528.16510] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Stillbirth accounts for over 2 million deaths a year worldwide and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth. OBJECTIVES To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development. SEARCH STRATEGY MEDLINE, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019. SELECTION CRITERIA We included systematic reviews of association of individual variables with stillbirth without language restriction. DATA COLLECTION AND ANALYSIS Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded. RESULTS The search identified 1198 citations. Sixty-nine systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n = 5), body mass index (n = 6) and maternal diabetes (n = 5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension. CONCLUSION We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests, which were PAPP-A, PlGF and UtAD. The evidence was limited by high heterogeneity and lack of data on intervention bias. TWEETABLE ABSTRACT Review shows key predictors for use in developing models predicting stillbirth include age, prior pregnancy outcome and PAPP-A, PLGF and Uterine artery Doppler.
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Affiliation(s)
- R Townsend
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - F G Sileo
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J Allotey
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - J Dodds
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Centre for Women's Health, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Heazell
- St Mary's Hospital, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK.,Faculty of Biology, Medicine and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester, UK
| | | | - V B Kim
- The Robinson Institute, University of Adelaide, Adelaide, SA, Australia
| | - L Magee
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
| | - B Mol
- Department of Obstetrics and Gynaecology, School of Medicine, Monash University, Melbourne, Vic., Australia
| | - J Sandall
- Health Service and Population Research Department, Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Department of Women and Children's Health, Faculty of Life Sciences & Medicine, School of Life Course Sciences, King's College London, St Thomas' Hospital, London, UK
| | - Gcs Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Biomedical Research Centre, Cambridge, UK.,Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research (CTR), University of Cambridge, Cambridge, UK
| | - B Thilaganathan
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - P von Dadelszen
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
| | - S Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Khalil
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
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218
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Gao XX, Ye MY, Liu Y, Li JY, Li L, Chen W, Lu X, Nie G, Chen YH. Prevalence and risk factors of intrahepatic cholestasis of pregnancy in a Chinese population. Sci Rep 2020; 10:16307. [PMID: 33004915 PMCID: PMC7530728 DOI: 10.1038/s41598-020-73378-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/07/2020] [Indexed: 12/24/2022] Open
Abstract
Studies on the risk factors for intrahepatic cholestasis of pregnancy (ICP) in a population-based cohort are lacking. We assess the prevalence and risk factors of ICP in a Chinese population. In this study, a cohort study was conducted that included 12,200 eligible pregnant women. The overall incidence of ICP in this cohort was 6.06%. With increasing maternal age, the incidence of ICP decreased in women younger than 30 years of age but increased in those older than 30. With increasing pre-pregnancy BMI, the incidence of ICP decreased if the pre-pregnancy BMI was less than 23 kg/m2 but increased if it was 23 kg/m2 or higher. Further analysis showed that the risk of ICP increased when maternal age was < 25 years (Adjusted RR 2.01; 95% CI 1.64–2.47) or ≥ 35 years (Adjusted RR 1.34; 95% CI 1.02–1.76). Furthermore, an increased risk of ICP was associated with pre-pregnancy underweight (adjusted RR 1.27; 95% CI 1.04–1.56), inadequate gestational weight gain (GWG) (adjusted RR 1.58; 95% CI 1.28–1.96), lower maternal education (adjusted RR 2.96; 95% CI 2.35–3.74), multiparity (adjusted RR 1.54; 95% CI 1.23–1.93), and twin/multiple pregnancies (adjusted RR 2.12; 95% CI 1.25–3.58). Maternal age (< 25 or ≥ 35 years), underweight, inadequate GWG, lower maternal education, multiparity, and twin/multiple pregnancies were identified as risk factors of ICP.
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Affiliation(s)
- Xing-Xing Gao
- Department of Histology and Embryology, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China
| | - Meng-Ying Ye
- Department of Histology and Embryology, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China
| | - Yan Liu
- Department of Histology and Embryology, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China
| | - Jin-Yan Li
- Department of Histology and Embryology, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China
| | - Li Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Anhui Medical University, Hefei, 230022, People's Republic of China
| | - Wei Chen
- Department of Histology and Embryology, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China
| | - Xue Lu
- Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230032, People's Republic of China
| | - Guiying Nie
- Implantation and Placental Development Laboratory, RMIT University, Bundoora, VIC, 3083, Australia. .,Implantation and Placental Development Laboratory, Centre for Reproductive Health, Hudson Institute of Medical Research, Melbourne, 3168, Australia.
| | - Yuan-Hua Chen
- Department of Histology and Embryology, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, People's Republic of China. .,Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230032, People's Republic of China. .,Implantation and Placental Development Laboratory, RMIT University, Bundoora, VIC, 3083, Australia. .,Implantation and Placental Development Laboratory, Centre for Reproductive Health, Hudson Institute of Medical Research, Melbourne, 3168, Australia.
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219
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Çelik S, Guve H, Çalışkan C, Çelik S. The Role of Melatonin, IL-8 and IL-10 in Intrahepatic Cholestasis of Pregnancy. Z Geburtshilfe Neonatol 2020; 225:238-243. [PMID: 32942322 DOI: 10.1055/a-1233-9084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Intrahepatic cholestasis of pregnancy is a pregnancy-specific liver disease that usually emerges during the third trimester of pregnancy. It is characterized by itching and elevated serum total bile acid levels, and it may lead to severe fetal complications. This study aimed to investigate the role of interleukin-8, a pro-inflammatory cytokine; interleukin-10, an anti-inflammatory cytokine; and melatonin in intrahepatic cholestasis of pregnancy. MATERIALS AND METHODS This prospective, case-controlled study was conducted with 51 women with intrahepatic cholestasis of pregnancy (40 mild and 11 severe cases) and 43 healthy pregnant women. Serum interleukin-8, interleukin-10, and melatonin levels were evaluated. RESULTS Melatonin and interleukin -10 were significantly lower in subjects with intrahepatic cholestasis of pregnancy (p=0.001; p=0.001, respectively p<0.05). Interleukin-8 levels were found to be significantly higher in the cholestasis group than control group (p=0.001, p<0.05). CONCLUSIONS Because interleukin-8, interleukin-10, and melatonin were found to be significantly correlated with intrahepatic cholestasis of pregnancy, we believe this finding could shed light on the etiology of the disease.
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Affiliation(s)
- Samettin Çelik
- Obstetrics and Gynecology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Huri Guve
- Department of Obstetrics and Gynecology, Düzce Üniversitesi Tip Fakültesi, Duzce, Turkey
| | - Canan Çalışkan
- Obstetrics and Gynecology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Sebahattin Çelik
- Obstetrics and Gynecology, Balıkesir Devlet Hastanesi, Balıkesir, Turkey
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220
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Stättermayer AF, Halilbasic E, Wrba F, Ferenci P, Trauner M. Variants in ABCB4 (MDR3) across the spectrum of cholestatic liver diseases in adults. J Hepatol 2020; 73:651-663. [PMID: 32376413 DOI: 10.1016/j.jhep.2020.04.036] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/18/2020] [Accepted: 04/22/2020] [Indexed: 12/14/2022]
Abstract
The ATP binding cassette subfamily B member 4 (ABCB4) gene on chromosome 7 encodes the ABCB4 protein (alias multidrug resistance protein 3 [MDR3]), a P-glycoprotein in the canalicular membrane of the hepatocytes that acts as a translocator of phospholipids into bile. Several variants in ABCB4 have been shown to cause ABCB4 deficiency, accounting for a disease spectrum ranging from progressive familial cholestasis type 3 to less severe conditions like low phospholipid-associated cholelithiasis, intrahepatic cholestasis of pregnancy or drug-induced liver injury. Furthermore, whole genome sequencing has shown that ABCB4 variants are associated with an increased incidence of gallstone disease, gallbladder and bile duct carcinoma, liver cirrhosis or elevated liver function tests. Diagnosis of ABCB4 deficiency-related diseases is based on clinical presentation, serum biomarkers, imaging techniques, liver histology and genetic testing. Nevertheless, the clinical presentation can vary widely and clear genotype-phenotype correlations are currently lacking. Ursodeoxycholic acid is the most commonly used medical treatment, but its efficacy has yet to be proven in large controlled clinical studies. Future pharmacological options may include stimulation/restoration of residual function by chaperones (e.g. 4-phenyl butyric acid, curcumin) or induction of ABCB4 transcription by FXR (farnesoid X receptor) agonists or PPARα (peroxisome proliferator-activated receptor-α)-ligands/fibrates. Orthotopic liver transplantation remains the last and often only therapeutic option in cirrhotic patients with end-stage liver disease or patients with intractable pruritus.
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Affiliation(s)
- Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Fritz Wrba
- Institute of Clinical Pathology, Medical University of Vienna, Vienna, Austria
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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221
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García-Romero CS, Guzman C, Cervantes A, Cerbón M. Liver disease in pregnancy: Medical aspects and their implications for mother and child. Ann Hepatol 2020; 18:553-562. [PMID: 31126882 DOI: 10.1016/j.aohep.2019.04.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/15/2019] [Indexed: 02/04/2023]
Abstract
Liver disease during pregnancy is more common than expected and may require specialized intervention. It is important to determine if changes in liver physiology may develop into liver disease, to assure early diagnosis. For adequate surveillance of mother-fetus health outcome, liver disease during pregnancy might require intervention from a hepatologist. Liver diseases have a prevalence of at least 3% of all pregnancies in developed countries, and they are classified into two main categories: related to pregnancy; and those non- related that are present de novo or are preexisting chronic liver diseases. In this review we describe and discuss the main characteristics of those liver diseases associated with pregnancy and only some frequent pre-existing and co-incidental in pregnancy are considered. In addition to the literature review, we compiled the data of liver disease occurring during pregnancies attended at the National Institute of Perinatology in Mexico City in a three-year period. In our tertiary referral women hospital, liver disease was present in 11.24 % of all pregnancies. Associated liver disease was found in 10.8% of all pregnancies, mainly those related to pre-eclampsia (9.9% of pregnancies). Only 0.56% was due to liver disease that was co-incidental or preexisting; the acute or chronic hepatitis C virus was the most frequent in this group (0.12%). When managing pregnancy in referral hospitals in Latin America, it is important to discard liver alterations early for adequate follow up of the disease and to prevent adverse consequences for the mother and child.
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Affiliation(s)
| | - Carolina Guzman
- Laboratorio de Hígado, Páncreas y Motilidad, Unidad de Medicina Experimental, Facultad de Medicina, Universidad Nacional Autonoma de Mexico (UNAM)/Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - Alicia Cervantes
- Servicio de Genética, Hospital General de México Dr. Eduardo Liceaga/Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico.
| | - Marco Cerbón
- Unidad de Investigación en Reproducción Humana, Instituto Nacional de Perinatología-Facultad de Química, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico
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222
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Pataia V, McIlvride S, Papacleovoulou G, Ovadia C, McDonald JAK, Wahlström A, Jansen E, Adorini L, Shapiro D, Marchesi JR, Marschall HU, Williamson C. Obeticholic acid improves fetal bile acid profile in a mouse model of gestational hypercholanemia. Am J Physiol Gastrointest Liver Physiol 2020; 319:G197-G211. [PMID: 32597707 PMCID: PMC7500267 DOI: 10.1152/ajpgi.00126.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is characterized by elevated maternal circulating bile acid levels and associated dyslipidemia. ICP leads to accumulation of bile acids in the fetal compartment, and the elevated bile acid concentrations are associated with an increased risk of adverse fetal outcomes. The farnesoid X receptor agonist obeticholic acid (OCA) is efficient in the treatment of cholestatic conditions such as primary biliary cholangitis. We hypothesized that OCA administration during hypercholanemic pregnancy will improve maternal and fetal bile acid and lipid profiles. Female C57BL/6J mice were fed either a normal chow diet, a 0.5% cholic acid (CA)-supplemented diet, a 0.03% OCA-supplemented diet, or a 0.5% CA + 0.03% OCA-supplemented diet for 1 wk before mating and throughout pregnancy until euthanization on day 18. The effects of CA and OCA feeding on maternal and fetal morphometry, bile acid and lipid levels, and cecal microbiota were investigated. OCA administration during gestation did not alter the maternal or fetal body weight or organ morphometry. OCA treatment during hypercholanemic pregnancy reduced bile acid levels in the fetal compartment. However, fetal dyslipidemia was not reversed, and OCA did not impact maternal bile acid levels or dyslipidemia. In conclusion, OCA administration during gestation had no apparent detrimental impact on maternal or fetal morphometry and improved fetal hypercholanemia. Because high serum bile acid concentrations in ICP are associated with increased rates of adverse fetal outcomes, further investigations into the potential use of OCA during cholestatic gestation are warranted.NEW & NOTEWORTHY We used a mouse model of gestational hypercholanemia to investigate the use of obeticholic acid (OCA), a potent FXR agonist, as a treatment for the hypercholanemia of intrahepatic cholestasis of pregnancy (ICP). The results demonstrate that OCA can improve the fetal bile acid profile. This is relevant not only to women with ICP but also for women who become pregnant while receiving OCA treatment for other conditions such as primary biliary cholangitis and nonalcoholic steatohepatitis.
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Affiliation(s)
- Vanessa Pataia
- 1Department of Women and Children’s Health, King’s College London, London, United Kingdom
| | - Saraid McIlvride
- 1Department of Women and Children’s Health, King’s College London, London, United Kingdom
| | - Georgia Papacleovoulou
- 1Department of Women and Children’s Health, King’s College London, London, United Kingdom
| | - Caroline Ovadia
- 1Department of Women and Children’s Health, King’s College London, London, United Kingdom
| | - Julie A. K. McDonald
- 2MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London, United Kingdom
| | - Annika Wahlström
- 3Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eugène Jansen
- 4Centre for Health Protection, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | | | | | - Julian R. Marchesi
- 6Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom,7School of Biosciences, Cardiff University, Cardiff, United Kingdom
| | - Hanns-Ulrich Marschall
- 3Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Catherine Williamson
- 1Department of Women and Children’s Health, King’s College London, London, United Kingdom
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223
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Walker KF, Chappell LC, Hague WM, Middleton P, Thornton JG. Pharmacological interventions for treating intrahepatic cholestasis of pregnancy. Cochrane Database Syst Rev 2020; 7:CD000493. [PMID: 32716060 PMCID: PMC7389072 DOI: 10.1002/14651858.cd000493.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that can develop in pregnancy. It occurs when there is a build-up of bile acids in the maternal blood. It has been linked to adverse maternal and fetal/neonatal outcomes. As the pathophysiology is poorly understood, therapies have been largely empiric. As ICP is an uncommon condition (incidence less than 2% a year), many trials have been small. Synthesis, including recent larger trials, will provide more evidence to guide clinical practice. This review is an update of a review first published in 2001 and last updated in 2013. OBJECTIVES To assess the effects of pharmacological interventions to treat women with intrahepatic cholestasis of pregnancy, on maternal, fetal and neonatal outcomes. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (13 December 2019), and reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials, including cluster-randomised trials and trials published in abstract form only, that compared any drug with placebo or no treatment, or two drug intervention strategies, for women with a clinical diagnosis of intrahepatic cholestasis of pregnancy. DATA COLLECTION AND ANALYSIS The review authors independently assessed trials for eligibility and risks of bias. We independently extracted data and checked these for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 26 trials involving 2007 women. They were mostly at unclear to high risk of bias. They assessed nine different pharmacological interventions, resulting in 14 different comparisons. We judged two placebo-controlled trials of ursodeoxycholic acid (UDCA) in 715 women to be at low risk of bias. The ten different pharmacological interventions were: agents believed to detoxify bile acids (UCDA) and S-adenosylmethionine (SAMe); agents used to bind bile acids in the intestine (activated charcoal, guar gum, cholestyramine); Chinese herbal medicines (yinchenghao decoction (YCHD), salvia, Yiganling and Danxioling pill (DXLP)), and agents aimed to reduce bile acid production (dexamethasone) Compared with placebo, UDCA probably results in a small improvement in pruritus score measured on a 100 mm visual analogue scale (VAS) (mean difference (MD) -7.64 points, 95% confidence interval (CI) -9.69 to -5.60 points; 2 trials, 715 women; GRADE moderate certainty), where a score of zero indicates no itch and a score of 100 indicates severe itching. The evidence for fetal distress and stillbirth were uncertain, due to serious limitations in study design and imprecision (risk ratio (RR) 0.70, 95% CI 0.35 to 1.40; 6 trials, 944 women; RR 0.33, 95% CI 0.08 to 1.37; 6 trials, 955 women; GRADE very low certainty). We found very few differences for the other comparisons included in this review. There is insufficient evidence to indicate if SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, Salvia, Yinchenghao decoction, Danxioling and Yiganling, or Yiganling alone or in combination are effective in treating women with intrahepatic cholestasis of pregnancy. AUTHORS' CONCLUSIONS When compared with placebo, UDCA administered to women with ICP probably shows a reduction in pruritus. However the size of the effect is small and for most pregnant women and clinicians, the reduction may fall below the minimum clinically worthwhile effect. The evidence was unclear for other adverse fetal outcomes, due to very low-certainty evidence. There is insufficient evidence to indicate that SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, YCHD, DXLP, Salvia, Yiganling alone or in combination are effective in treating women with cholestasis of pregnancy. There are no trials of the efficacy of topical emollients. Further high-quality trials of other interventions are needed in order to identify effective treatments for maternal itching and preventing adverse perinatal outcomes. It would also be helpful to identify those women who are mostly likely to respond to UDCA (for example, whether bile acid concentrations affect how women with ICP respond to treatment with UDCA).
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Affiliation(s)
- Kate F Walker
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
| | - William M Hague
- Women's and Children's Hospital, North Adelaide, Australia
- Robinson Research Institute, The University of Adelaide, North Adelaide, Australia
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
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Berghella V, Bellussi F, Schoen CN. Evidence-based labor management: induction of labor (part 2). Am J Obstet Gynecol MFM 2020; 2:100136. [PMID: 33345875 DOI: 10.1016/j.ajogmf.2020.100136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
Induction of labor is indicated for many obstetrical, maternal, and fetal indications. Induction can be offered for pregnancy at 39 weeks' gestation. No prediction method is considered sensitive or specific enough to determine the incidence of cesarean delivery after induction. A combination of 60- to 80-mL single-balloon Foley catheter for 12 hours and either 25-μg oral misoprostol initially, followed by 25 μg every 2-4 hours, or 50 μg every 4-6 hours (if no more than 3 contractions per 10 minutes or previous uterine surgery), or oxytocin infusion should be recommended for induction of labor. Adding membrane stripping at the beginning of induction should be considered. Once 5-6 cm of cervical dilation is achieved during the induction of labor, consideration can be given to discontinue oxytocin infusion if in use at that time and adequate contractions are present. Induction with oxytocin immediately (as soon as feasible) or up to 12 hours of term prelabor rupture of membranes if labor is not evident is recommended. Outpatient Foley ripening can be considered for low-risk women. Cesarean delivery should not be performed before 15 hours of oxytocin infusion and amniotomy if feasible and ideally after 18-24 hours of oxytocin infusion.
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Affiliation(s)
- Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA.
| | - Federica Bellussi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Corina N Schoen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Massachusetts-Baystate, Springfield, MA
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225
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Bellafante E, McIlvride S, Nikolova V, Fan HM, Manna LB, Chambers J, Machirori M, Banerjee A, Murphy K, Martineau M, Schoonjans K, Marschall HU, Jones P, Williamson C. Maternal glucose homeostasis is impaired in mouse models of gestational cholestasis. Sci Rep 2020; 10:11523. [PMID: 32661285 PMCID: PMC7359298 DOI: 10.1038/s41598-020-67968-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/28/2020] [Indexed: 12/13/2022] Open
Abstract
Women with intrahepatic cholestasis of pregnancy (ICP), a disorder characterised by raised serum bile acids, are at increased risk of developing gestational diabetes mellitus and have impaired glucose tolerance whilst cholestatic. FXR and TGR5 are modulators of glucose metabolism, and FXR activity is reduced in normal pregnancy, and further in ICP. We aimed to investigate the role of raised serum bile acids, FXR and TGR5 in gestational glucose metabolism using mouse models. Cholic acid feeding resulted in reduced pancreatic β-cell proliferation and increased apoptosis in pregnancy, without altering insulin sensitivity, suggesting that raised bile acids affect β-cell mass but are insufficient to impair glucose tolerance. Conversely, pregnant Fxr-/- and Tgr5-/- mice are glucose intolerant and have reduced insulin secretion in response to glucose challenge, and Fxr-/- mice are also insulin resistant. Furthermore, fecal bile acids are reduced in pregnant Fxr-/- mice. Lithocholic acid and deoxycholic acid, the principal ligands for TGR5, are decreased in particular. Therefore, we propose that raised serum bile acids and reduced FXR and TGR5 activity contribute to the altered glucose metabolism observed in ICP.
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MESH Headings
- Animals
- Bile Acids and Salts/blood
- Cholestasis, Intrahepatic/blood
- Cholestasis, Intrahepatic/genetics
- Cholestasis, Intrahepatic/metabolism
- Cholestasis, Intrahepatic/pathology
- Diabetes, Gestational/blood
- Diabetes, Gestational/genetics
- Diabetes, Gestational/metabolism
- Diabetes, Gestational/pathology
- Disease Models, Animal
- Female
- Glucose/metabolism
- Glucose Intolerance/genetics
- Glucose Intolerance/metabolism
- Glucose Intolerance/pathology
- Homeostasis/genetics
- Humans
- Insulin Resistance/genetics
- Insulin-Secreting Cells/metabolism
- Insulin-Secreting Cells/pathology
- Maternal Inheritance/genetics
- Mice
- Pregnancy
- Pregnancy Complications/blood
- Pregnancy Complications/genetics
- Pregnancy Complications/metabolism
- Pregnancy Complications/pathology
- Receptors, Cytoplasmic and Nuclear/genetics
- Receptors, G-Protein-Coupled/genetics
- Risk Factors
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Affiliation(s)
- Elena Bellafante
- School of Life Course Sciences, King's College London, London, UK
| | - Saraid McIlvride
- School of Life Course Sciences, King's College London, London, UK
| | - Vanya Nikolova
- School of Life Course Sciences, King's College London, London, UK
| | - Hei Man Fan
- School of Life Course Sciences, King's College London, London, UK
| | | | - Jenny Chambers
- School of Life Course Sciences, King's College London, London, UK
- Women's Health Research Centre, Imperial College London, London, UK
| | - Mavis Machirori
- Women's Health Research Centre, Imperial College London, London, UK
| | | | - Kevin Murphy
- Department of Medicine, Imperial College London, London, UK
| | - Marcus Martineau
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kristina Schoonjans
- Laboratory of Integrative and Systems Physiology, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Jones
- School of Life Course Sciences, King's College London, London, UK
| | - Catherine Williamson
- School of Life Course Sciences, King's College London, London, UK.
- Maternal and Fetal Disease Group, Hodgkin Building, Guy's Campus, King's College London, London, SE1 1UL, UK.
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226
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Ursodeoxycholic acid improves feto-placental and offspring metabolic outcomes in hypercholanemic pregnancy. Sci Rep 2020; 10:10361. [PMID: 32587408 PMCID: PMC7316783 DOI: 10.1038/s41598-020-67301-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 04/14/2020] [Indexed: 11/08/2022] Open
Abstract
Perturbations in the intrauterine environment can result in lifelong consequences for metabolic health during postnatal life. Intrahepatic cholestasis of pregnancy (ICP) can predispose offspring to metabolic disease in adulthood, likely due to a combination of the effects of increased bile acids, maternal dyslipidemia and deranged maternal and fetal lipid homeostasis. Whereas ursodeoxycholic acid (UDCA) is a commonly used treatment for ICP, no studies have yet addressed whether it can also prevent the metabolic effects of ICP in the offspring and fetoplacental unit. We therefore analyzed the lipid profile of fetal serum from untreated ICP, UDCA-treated ICP and uncomplicated pregnancies and found that UDCA ameliorates ICP-associated fetal dyslipidemia. We then investigated the effects of UDCA in a mouse model of hypercholanemic pregnancy and showed that it induces hepatoprotective mechanisms in the fetal liver, reduces hepatic fatty acid synthase (Fas) expression and improves glucose tolerance in the adult offspring. Finally, we showed that ICP leads to epigenetic changes in pathways of relevance to the offspring phenotype. We therefore conclude that UDCA can be used as an intervention in pregnancy to reduce features of metabolic disease in the offspring of hypercholanemic mothers.
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227
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Alemdaroğlu S, Yılmaz Baran Ş, Durdağ GD, Yuksel Şimşek S, Yetkinel S, Alkaş Yağınç D, Kalaycı H, Şimşek E. Intrahepatic cholestasis of pregnancy: are in vitro fertilization pregnancies at risk? J Matern Fetal Neonatal Med 2020; 34:2548-2553. [PMID: 32419565 DOI: 10.1080/14767058.2020.1765331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIM Single pregnancy patients with intrahepatic cholestasis of pregnancy (ICP) were divided into two groups according to the conception method, as spontaneous and in vitro fertilization (IVF). We aim to compare the maternal, laboratory and perinatal characteristics of both groups. MATERIALS AND METHOD The records of 10,929 patients who gave birth in the center between October 2011 and July 2019 were analyzed retrospectively from the data processing system records. Maternal, laboratory and perinatal characteristics of 109 single pregnancies (spontaneous n: 91; IVF n: 18) diagnosed with ICP were compared. FINDINGS The maternal demographic data of both groups were similar (p: .05). In both groups, gestational week, gestational age at birth, birth weight, neonatal intensive care admission rate, meconium-stained amniotic fluid, umbilical cord pH, the 5-minute APGAR score, and the presence of pregnancy complications were similar (p > .05). RESULT Although ICP is reported with a higher incidence in IVF pregnancies, ICP findings and prognosis are similar to those of spontaneous pregnancies.
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Affiliation(s)
- Songül Alemdaroğlu
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Şafak Yılmaz Baran
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | | | - Seda Yuksel Şimşek
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Selçuk Yetkinel
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Didem Alkaş Yağınç
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Hakan Kalaycı
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Erhan Şimşek
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
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228
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Katarey D, Westbrook RH. Pregnancy-specific liver diseases. Best Pract Res Clin Obstet Gynaecol 2020; 68:12-22. [PMID: 32381461 DOI: 10.1016/j.bpobgyn.2020.03.013] [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: 02/22/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 12/17/2022]
Abstract
Liver disease presenting in pregnancy may be due to a pregnancy-specific liver disorder, due to previously unrecognised pre-existing liver disease, or de novo liver disorders coincidentally presenting in a pregnant woman. The pregnancy-specific liver diseases can span from mild disease with limited impact on maternal and foetal health to severe disorders that can result in significant morbidity and mortality for mother and foetus. Swift identification of these disorders is essential to allow timely and appropriate management via a multi-disciplinary approach. The pregnancy-specific conditions, including their presentation, investigations, and management are reviewed in this chapter in detail.
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Affiliation(s)
- Dev Katarey
- Royal Free Hospital, Pond Street, London, NW3 2QG, United Kingdom
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229
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Intrahepatic Cholestasis in Pregnancy: Review of the Literature. J Clin Med 2020; 9:jcm9051361. [PMID: 32384779 PMCID: PMC7290322 DOI: 10.3390/jcm9051361] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is the most common hepatic disorder related to pregnancy in women. It usually develops within the third trimester of pregnancy and presents with pruritus as well as elevated levels of bile acid and/or alanine aminotransferase. Clinical signs quickly resolve after delivery; however, there is a high risk of the disorder recurring in subsequent pregnancies. ICP is associated with an increased risk of perinatal complications (premature birth, respiratory disorders, even stillbirth). Elevated levels of gestational hormones and genetic predispositions are important factors for the development of ICP; among the latter, mutations in hepatobiliary transport proteins (multidrug resistance protein 3-MDR3, bile salt export pump- BSEP) play a major role. Clinical and biochemical symptoms of ICP include pruritus and increased levels of total bile acids (TBA). Serum levels of TBA should be monitored in ICP patients throughout the pregnancy as concentrations above 40 μmol/L, which define that severe ICP isassociated with an increased risk of fetal complications. Therapeutic management is aimed at reducing the clinical symptoms, normalizing maternal biochemistry and preventing complications to the fetus. Pharmacological treatment of intrahepatic cholestasis of pregnancy consists of the administration of ursodeoxycholic acid to lower the levels of TBA and possibly reduce pruritus. If the treatment fails, premature delivery should be considered.
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230
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You S, Cui AM, Hashmi SF, Zhang X, Nadolny C, Chen Y, Chen Q, Bush X, Hurd Z, Ali W, Qin G, Deng R. Dysregulation of bile acids increases the risk for preterm birth in pregnant women. Nat Commun 2020; 11:2111. [PMID: 32355283 PMCID: PMC7193585 DOI: 10.1038/s41467-020-15923-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 04/03/2020] [Indexed: 12/13/2022] Open
Abstract
Preterm birth (PTB) is the leading cause of perinatal mortality and newborn complications. Bile acids are recognized as signaling molecules regulating a myriad of cellular and metabolic activities but have not been etiologically linked to PTB. In this study, a hospital-based cohort study with 36,755 pregnant women is conducted. We find that serum total bile acid levels directly correlate with the PTB rates regardless of the characteristics of the subjects and etiologies of liver disorders. Consistent with the findings from pregnant women, PTB is successfully reproduced in mice with liver injuries and dysregulated bile acids. More importantly, bile acids dose-dependently induce PTB with minimal hepatotoxicity. Furthermore, restoring bile acid homeostasis by farnesoid X receptor activation markedly reduces PTB and dramatically improves newborn survival rates. The findings thus establish an etiologic link between bile acids and PTB, and open an avenue for developing etiology-based therapies to prevent or delay PTB.
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Affiliation(s)
- Sangmin You
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Ai-Min Cui
- Nantong Maternal and Child Health Hospital, Nantong University, Nantong, China
| | - Syed F Hashmi
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Xinmu Zhang
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Christina Nadolny
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Yuan Chen
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Qiwen Chen
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Xin Bush
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Zachary Hurd
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Winifer Ali
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Gang Qin
- Department of Epidemiology and Biostatistics, School of Public Health, Nantong University, 226006, Nantong, Jiangsu Province, China
| | - Ruitang Deng
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA.
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Rahim MN, Long L, Penna L, Williamson C, Kametas NA, Nicolaides KH, Heneghan MA. Pregnancy in Liver Transplantation. Liver Transpl 2020; 26:564-581. [PMID: 31950556 DOI: 10.1002/lt.25717] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/26/2019] [Indexed: 02/06/2023]
Abstract
Pregnancy after liver transplantation (LT) is increasingly common and is a frequent scenario that transplant physicians, obstetricians, and midwives encounter. This review summarizes the key issues surrounding preconception, pregnancy-related outcomes, immunosuppression, and breastfeeding in female LT recipients. Prepregnancy counseling in these patients should include recommendations to delay conception for at least 1-2 years after LT and discussions about effective methods of contraception. Female LT recipients are generally recommended to continue immunosuppression during pregnancy to prevent allograft rejection; however, individual regimens may need to be altered. Although pregnancy outcomes are overall favorable, there is an increased risk of maternal and fetal complications. Pregnancy in this cohort remains high risk and should be managed vigilantly in a multidisciplinary setting. We aim to review the available evidence from national registries, population-based studies, and case series and to provide recommendations for attending clinicians.
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Affiliation(s)
- Mussarat N Rahim
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Lisa Long
- Department of Obstetrics, King's College Hospital, London, United Kingdom
| | - Leonie Penna
- Department of Obstetrics, King's College Hospital, London, United Kingdom
| | | | - Nikos A Kametas
- Fetal Medicine Research Unit, King's College Hospital, London, United Kingdom
| | - Kypros H Nicolaides
- Fetal Medicine Research Unit, King's College Hospital, London, United Kingdom
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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232
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Kuan K, Reznik SE. Educational Case: Intrauterine Fetal Demise and Intestinal Atresia: An Autopsy Investigation. Acad Pathol 2020; 7:2374289520909498. [PMID: 32232125 PMCID: PMC7092656 DOI: 10.1177/2374289520909498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 01/19/2020] [Accepted: 02/01/2020] [Indexed: 12/26/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.1
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Affiliation(s)
- Kevin Kuan
- Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sandra E Reznik
- Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, USA
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233
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Cauldwell M, Mackie FL, Steer PJ, Henehghan MA, Baalman JH, Brennand J, Johnston T, Dockree S, Hedley C, Jarvis S, Khan S, McAuliffe FM, Mackillop L, Penna L, Smith B, Trivedi P, Verma S, Westbrook R, Winifield S, Williamson C. Pregnancy outcomes in women with primary biliary cholangitis and primary sclerosing cholangitis: a retrospective cohort study. BJOG 2020; 127:876-884. [DOI: 10.1111/1471-0528.16119] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2020] [Indexed: 12/17/2022]
Affiliation(s)
- M Cauldwell
- Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital London UK
| | - FL Mackie
- Academic Department of Obstetrics and Gynaecology Birmingham Women’s and Children’s NHS Foundation Trust Birmingham UK
| | - PJ Steer
- Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital London UK
| | | | - JH Baalman
- UCD Perinatal Research Centre School of Medicine University College Dublin National Maternity Hospital Dublin Ireland
| | - J Brennand
- Department of Obstetrics Queen Elizabeth Hospital Glasgow Glasgow UK
| | - T Johnston
- Academic Department of Obstetrics and Gynaecology Birmingham Women’s and Children’s NHS Foundation Trust Birmingham UK
| | - S Dockree
- Women’s Centre Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - C Hedley
- Department of Obstetrics King’s College Hospital London UK
| | - S Jarvis
- Department of Obstetrics Queen Charlotte’s and Chelsea Hospital London UK
| | - S Khan
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - FM McAuliffe
- UCD Perinatal Research Centre School of Medicine University College Dublin National Maternity Hospital Dublin Ireland
| | - L Mackillop
- Women’s Centre Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - L Penna
- Department of Obstetrics King’s College Hospital London UK
| | - B Smith
- Department of Hepatology Hammersmith Hospital London UK
| | - P Trivedi
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - S Verma
- Department of Clinical and Experimental Medicine Brighton and Sussex Medical School Brighton UK
- Department of Gastroenterology and Hepatology Brighton and Sussex University Hospitals Brighton UK
| | - R Westbrook
- Department of Hepatology Royal Free Hospital London UK
| | - S Winifield
- Department of Obstetrics Leeds Teaching Hospitals Leeds UK
| | - C Williamson
- Department of Women and Children’s Health King’s College London London UK
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234
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Chappell LC, Williamson C, Thornton JG. Ursodeoxycholic acid for adverse perinatal outcomes - Authors' reply. Lancet 2020; 395:780-781. [PMID: 32145786 DOI: 10.1016/s0140-6736(19)32970-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/28/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London SE1 7EH, UK.
| | - Catherine Williamson
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London SE1 7EH, UK
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
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235
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Ursodeoxycholic acid enriches intestinal bile salt hydrolase-expressing Bacteroidetes in cholestatic pregnancy. Sci Rep 2020; 10:3895. [PMID: 32127609 PMCID: PMC7054423 DOI: 10.1038/s41598-020-60821-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/10/2020] [Indexed: 02/07/2023] Open
Abstract
Ursodeoxycholic acid (UDCA) treatment can reduce itch and lower endogenous serum bile acids in intrahepatic cholestasis of pregnancy (ICP). We sought to determine how it could influence the gut environment in ICP to alter enterohepatic signalling. The gut microbiota and bile acid content were determined in faeces from 35 pregnant women (14 with uncomplicated pregnancies and 21 with ICP, 17 receiving UDCA). Faecal bile salt hydrolase activity was measured using a precipitation assay. Serum fibroblast growth factor 19 (FGF19) and 7α-hydroxy-4-cholesten-3-one (C4) concentrations were measured following a standardised diet for 21 hours. Women with a high ratio of Bacteroidetes to Firmicutes were more likely to be treated with UDCA (Fisher’s exact test p = 0.0178) than those with a lower ratio. Bile salt hydrolase activity was reduced in women with low Bacteroidetes:Firmicutes. Women taking UDCA had higher faecal lithocholic acid (p < 0.0001), with more unconjugated bile acids than women with untreated ICP or uncomplicated pregnancy. UDCA-treatment increased serum FGF19, and reduced C4 (reflecting lower bile acid synthesis). During ICP, UDCA treatment can be associated with enrichment of the gut microbiota with Bacteroidetes. These demonstrate high bile salt hydrolase activity, which deconjugates bile acids enabling secondary modification to FXR agonists, enhancing enterohepatic feedback via FGF19.
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236
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Kumar P, Kulkarni A. UDCA therapy in intrahepatic cholestasis of pregnancy? J Hepatol 2020; 72:586-587. [PMID: 31864669 DOI: 10.1016/j.jhep.2019.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 12/04/2022]
Affiliation(s)
- Pramod Kumar
- Department of hepatology and liver transplantation, Asian institute of gastroenterology hospitals, Hyderabad, India.
| | - Anand Kulkarni
- Department of hepatology and liver transplantation, Asian institute of gastroenterology hospitals, Hyderabad, India
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237
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Arthuis C, Diguisto C, Lorphelin H, Dochez V, Simon E, Perrotin F, Winer N. Perinatal outcomes of intrahepatic cholestasis during pregnancy: An 8-year case-control study. PLoS One 2020; 15:e0228213. [PMID: 32074108 PMCID: PMC7029845 DOI: 10.1371/journal.pone.0228213] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/10/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Previous studies of fetal effects have suggested that intrahepatic cholestasis of pregnancy is associated with a higher rate of adverse neonatal outcomes including preterm birth, neonatal respiratory distress syndrome, meconium-stained amniotic fluid, neonatal intensive care unit admission, and stillbirth. The objective was to compare the neonatal and maternal consequences in pregnancies affected by intrahepatic cholestasis and normal pregnancies. MATERIAL AND METHODS This case-control study compares pregnancies affected by intrahepatic cholestasis (pruritus and bile acid ≥ 10 μmol/L) with low-risk pregnancies managed between December 2006 and December 2014 at a French university hospital center. RESULTS There were 83 (59.3%) cases of mild cholestasis (10≤ BA ≤39 μmol/L), 46 (32.8%) of moderate cholestasis (40≤ BA ≤99 μmol/L), and 11 (7.9%) of severe cholestasis (BA ≥100 μmol/L). No in utero fetal deaths occurred in the 140 women with cholestasis or the 560 controls analyzed. The rate of respiratory distress syndrome was higher in neonates of women with intrahepatic cholestasis (17.1% vs. 4.6%, P<0.001; crude OR 4.46 (CI95% 2.49-8.03)). This risk was also significant after adjustment for gestational age at birth and mode of delivery, adjusted OR 2.56 (CI95%1.26-5.18). The postpartum hemorrhage rate was twice as high among the case mothers (25% versus 14.1% for controls, P = 0.002). CONCLUSION After adjustment on the confounding factors we found a higher rate of respiratory distress syndrome and neonatal morbidity among neonates of the cholestasis group.
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Affiliation(s)
- Chloé Arthuis
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
- Department of Gynecology and Obstetrics, University Hospital Center Nantes, Nantes, France
- * E-mail:
| | - Caroline Diguisto
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
| | - Henri Lorphelin
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
| | - Vincent Dochez
- Department of Gynecology and Obstetrics, University Hospital Center Nantes, Nantes, France
| | - Emmanuel Simon
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
| | - Franck Perrotin
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
| | - Norbert Winer
- Department of Gynecology and Obstetrics, University Hospital Center Nantes, Nantes, France
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238
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Dąbrowski K, Kierach R, Grabarek BO, Boroń D, Kukla M. Effect of ursodeoxycholic acid therapy due to pregnant intrahepatic cholestasis on chemerin and irisin levels. Dermatol Ther 2020; 33:e13272. [PMID: 32061000 DOI: 10.1111/dth.13272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/08/2020] [Accepted: 02/11/2020] [Indexed: 12/15/2022]
Abstract
The purpose of the work was to assess changes in chemerin and irisin levels in women with diagnosed intrahepatic cholestasis of pregnant women treated with ursodeoxycholic acid. The study group consisted of 50 patients with diagnosed and confirmed intrahepatic cholestasis of pregnant women at 24-25 weeks of pregnancy treatment by ursodeoxycholic acid (UDCA). The study also included a group of 40 pregnant women, without concomitant intrahepatic cholestasis of pregnancy (ICP). In the pregnant ICP group, whole blood was collected 4 times: before the first dose of drug, 4 and 8 weeks after the first dose, and day after delivery. It was observed that statistically significant differences in the concentration of irisine occur between the time before starting treatment and the 8-week therapy and 1 day after delivery. The Pearson correlation analysis (r's) showed two statistically significant relationships (p < .05). The first of these can be found between the concentration of irisine and chemerin in the group of nonpregnant women and the second in the group of patients with intrahepatic pregnant cholestasis before the first dose of UDCA. A significant relationship between irisin and chemerin concentrations was confirmed in the group of pregnant ICP patients during UDCA acid therapy and among healthy pregnant women.
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Affiliation(s)
| | - Rafał Kierach
- Gynecology and Obstetrics Ward District Railway Hospital, Katowice, Poland
| | - Beniamin O Grabarek
- Maria Sklodowska-Curie National Research Institute of Oncology, Krakow Branch, Kraków, Poland.,Department of Histology, Cytophysiology and Embryology in Zabrze, University of Technology, Faculty of Medicine, Katowice, Poland
| | - Dariusz Boroń
- Department of Histology, Cytophysiology and Embryology in Zabrze, University of Technology, Faculty of Medicine, Katowice, Poland.,Faculty of Health Science, Public Higher Medical Professional School, Opole, Poland.,Department of Gynecology and Obstetrics with Gynecologic Oncology, Ludwik Rydygier Memorial Specialized Hospital, Kraków, Poland
| | - Michał Kukla
- Department of Endoscopy, University Hospital, Kraków, Poland
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239
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Birchall C, Prentice D, Pauli J. Elevated international normalized ratio (INR) and new diagnosis of hepatitis C associated with severe intrahepatic cholestasis of pregnancy (ICP): A case report. Case Rep Womens Health 2020; 26:e00178. [PMID: 32055455 PMCID: PMC7005562 DOI: 10.1016/j.crwh.2020.e00178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 01/20/2020] [Accepted: 01/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background Severe intrahepatic cholestasis of pregnancy (ICP), defined as a serum bile acid (SBA) level > 100 μmol/l, remains poorly understood in its mechanism and implications. Case A patient with a missed diagnosis of mild ICP went on to develop clinical jaundice and liver function abnormalities in the setting of newly diagnosed hepatitis C and severe ICP on repeat SBA testing. Conclusion This case highlights and adds to the growing body of evidence supporting the need for universal screening for hepatitis C in ICP patients and the potential role for repeat SBA testing, which would be a notable change from the traditional care of these individuals. Patient who presented with clinical jaundice and was diagnosed with ICP and previously undiagnosed Hepatitis C. Evaluation of hepatic synthetic function is important in patients with severe intrahepatic cholestasis of pregnancy. The case presented supports for the role of repeat serum bile acid testing in patients with Intrahepatic Cholestasis of Pregnancy.
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Affiliation(s)
- Courtney Birchall
- Obstetrics and Gynecology Penn State Health Milton S. Hershey Medical Center, USA
| | - Danielle Prentice
- Maternal Fetal Medicine Penn State Health Milton S. Hershey Medical Center, USA
| | - Jaimey Pauli
- Maternal Fetal Medicine Penn State Health Milton S. Hershey Medical Center, USA
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240
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Coates D, Makris A, Catling C, Henry A, Scarf V, Watts N, Fox D, Thirukumar P, Wong V, Russell H, Homer C. A systematic scoping review of clinical indications for induction of labour. PLoS One 2020; 15:e0228196. [PMID: 31995603 PMCID: PMC6988952 DOI: 10.1371/journal.pone.0228196] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist. METHODS A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool. RESULTS 68 studies were included which related to post-term pregnancy (15), hypertension/pre-eclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42 weeks), and for women with hypertension/preeclampsia in terms of improved maternal outcomes. For women with preterm premature rupture of membranes (24-37 weeks), high-quality evidence supports expectant management rather than IOL/early birth. Evidence is weakly supportive for IOL in women with term rupture of membranes. For all other indications, there were conflicting findings and/or insufficient power to provide definitive evidence. CONCLUSIONS While for some indications, IOL is clearly recommended, a number of common indications for IOL do not have strong supporting evidence. Overall, few RCTs have evaluated the various indications for IOL. For conditions where clinical equipoise regarding timing of birth may still exist, such as suspected macrosomia and elevated BMI, researchers and funding agencies should prioritise studies of sufficient power that can provide quality evidence to guide care in these situations.
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Affiliation(s)
- Dominiek Coates
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Angela Makris
- Department of Medicine, Western Sydney University, Sydney, Australia
- Women’s Health Initiative Translational Unit (WHITU), Liverpool Hospital, Liverpool, Australia
| | - Christine Catling
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Amanda Henry
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
- Department of Women’s and Children’s Health, St George Hospital, Sydney, Australia
- The George Institute for Global Health, UNSW Medicine, Sydney, Australia
| | - Vanessa Scarf
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Nicole Watts
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Deborah Fox
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Purshaiyna Thirukumar
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Vincent Wong
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute of Applied Research Science, University of New South Wales, Liverpool, Australia
| | - Hamish Russell
- South Western Sydney Local Health District, Sydney, Australia
| | - Caroline Homer
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
- Maternal and Child Health Program, Burnet Institute, Victoria, Australia
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241
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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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242
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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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243
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Juusela AL, Cordero L, Gimovsky M, Nazir M. Correlation of bile acids and aspartate-aminotransferase with outcomes in cholestasis of pregnancy. J Neonatal Perinatal Med 2020; 13:513-519. [PMID: 31796691 DOI: 10.3233/npm-190276] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To identify laboratory data that correlates with poor perinatal outcomes. METHODS A retrospective chart review of women with intrahepatic cholestasis of pregnancy (ICP), admitted for delivery between January 1, 2013 and December 31, 2017, was performed. Chi-square, student's t-test, and ANOVA statistical analysis was performed. The receiver-operator characteristic curves were plotted for the prediction of each category of perinatal outcome and the areas under the curves were determined. All p-values were two-sided, and p < 0.05 was considered statistically significant. RESULTS Analysis of the 61 ICP cases showed no occurrence of the intrauterine fetal demise (IUFD), stillbirth, abruption, or neonatal demise. ROC curve analysis revealed a statistically significant correlation between bile acid and AST levels and perinatal outcomes. A bile acid (BA) level equal to or greater than 37μmol/L strongly predicted spontaneous preterm labor in women affected by ICP with a sensitivity of 100% and specificity of 60.70% (p = 0.002). A BA level equal to or greater than 42μmol/L strongly predicted meconium-stained amniotic fluid with a sensitivity of 85.70% and specificity of 66.70% (p = 0.006). AST levels equal to or greater than 62 IU/L strongly predicted NICU admission with a sensitivity of 81.30% and specificity of 62.20% (p = 0.002). AST levels equal to or greater than 75 IU/L strongly predicted hyperbilirubinemia in the neonates with a sensitivity of 87.50% and specificity of 69.80% (p = 0.001). CONCLUSIONS There is a statistically significant correlation between elevated BA and elevated AST levels and adverse perinatal outcomes.
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Affiliation(s)
- A L Juusela
- Newark Beth Israel Medical Center, Newark, NJ, USA
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Gao X, Duan X, Cai H, Hu Y, Liu M, Kang K, Zhou M, Fu D, Yi W. Pregnancy Outcome of Women with Chronic Hepatitis B who Discontinued Antiviral Treatment before or in the Early Pregnancy. Int J Med Sci 2020; 17:170-175. [PMID: 32038100 PMCID: PMC6990883 DOI: 10.7150/ijms.38410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 12/12/2019] [Indexed: 01/15/2023] Open
Abstract
Background: The aim of this study was to describe biochemical, virological features and Mother-to child-transmission (MTCT) rate in chronic hepatitis B (CHB) women who stopped antiviral therapy before or in the early pregnancy. Methods: This was a single-center, retrospective study. Forty-three CHB women who stopped treatment before or in the early pregnancy and 103 CHB women with tenofovir disoproxil fumarate (TDF) treatment throughout pregnancy were enrolled. The virological and biochemical flares during pregnancy and postpartum period were studied. MTCT rates were also compared. Results: During pregnancy, ALT flares (43.9% vs 1.0%) and viral rebound (31.7% vs 0) were more common in women who stopped treatment (P<0.001). Postpartum ALT flares were less frequent in women with treatment than those stopped treatment (0 vs 6/35, P = 0.001). The birth defect rate in the mothers who stopped treatment did not statistically differ from that of mothers treated throughout pregnancy (4.9 % vs 3.9 %, P = 1.000). There were no significant differences of gestational complications between the two groups, except intrahepatic cholestasis of pregnancy (12.2% vs 0, P = 0.002). The rate of MTCT in mothers who discontinued treatment was higher (2.4% vs 0, P = 0.285), although there was no statistically significant. Conclusion: ALT flares were common in mothers who discontinued antiviral therapy. Thus, these pregnant women should be monitored closely. Cessation of treatment was not recommended although no hepatic failure was observed. Larger studies are needed to evaluate the safety of discontinuation before pregnancy.
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Affiliation(s)
- Xuesong Gao
- Department of General Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xuefei Duan
- Department of General Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Haodong Cai
- Hepatology clinic, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yuhong Hu
- Department of Obstetrics and Gynecology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Min Liu
- Department of Obstetrics and Gynecology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Kai Kang
- Department of Obstetrics and Gynecology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Mingfang Zhou
- Department of Obstetrics and Gynecology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Dong Fu
- Department of Obstetrics and Gynecology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Wei Yi
- Department of Obstetrics and Gynecology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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245
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de Vries E, Beuers U. Ursodeoxycholic acid in pregnancy? J Hepatol 2019; 71:1237-1245. [PMID: 31479696 DOI: 10.1016/j.jhep.2019.08.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/19/2019] [Accepted: 08/26/2019] [Indexed: 02/08/2023]
Abstract
The case of a 34-year-old woman with primary biliary cholangitis (PBC) before, during and after pregnancy is described. The use of ursodeoxycholic acid (UDCA) during and after pregnancy is discussed. UDCA has not been approved by the drug regulatory authorities as a pregnancy-safe drug; therefore, the reluctance of clinicians to prescribe UDCA during pregnancy is understandable. This Grand Round aims to provide a detailed analysis of the current evidence, safety data and clinical experience with UDCA (and alternative drugs) during pregnancy and lactation. Based on this analysis, advice for clinicians regarding the use of UDCA during pregnancy and lactation is given.
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Affiliation(s)
- Elsemieke de Vries
- Department of Gastroenterology and Hepatology and Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology and Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.
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246
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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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247
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Yin G, Zhang C, Yang Z. Biostatistics pitfalls: Lessons learned from analysis of medical data. Contemp Clin Trials 2019; 87:105875. [PMID: 31676313 DOI: 10.1016/j.cct.2019.105875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/18/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022]
Abstract
In several recent issues of The Lancet, we identified a few common pitfalls in the analysis of clinical trial and medical data in the published articles (Mok et al., 2019; Herrlinger et al., 2019; Reindl-Schwaighofer et al., 2019; He et al., 2019). Without careful validation of model assumptions, even the primary endpoint of the trial might be analyzed using improper statistical methods. We carried out an in-depth analysis of the statistical issues in four real clinical trials, which highlights the importance of statistics in the medical field. With every effort, biostatisticians need to work with clinicians closely to take the most appropriate statistical approaches to data analysis; otherwise the conclusions drawn from the data might be problematic or misleading.
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Affiliation(s)
- Guosheng Yin
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong; Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, USA.
| | - Chenyang Zhang
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong
| | - Zhao Yang
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong
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248
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Manna LB, Ovadia C, Lövgren-Sandblom A, Chambers J, Begum S, Seed P, Walker I, Chappell LC, Marschall HU, Williamson C. Enzymatic quantification of total serum bile acids as a monitoring strategy for women with intrahepatic cholestasis of pregnancy receiving ursodeoxycholic acid treatment: a cohort study. BJOG 2019; 126:1633-1640. [PMID: 31483939 PMCID: PMC6899621 DOI: 10.1111/1471-0528.15926] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate enzymatic total serum bile acid quantification as a monitoring strategy for women with intrahepatic cholestasis of pregnancy (ICP) treated with ursodeoxycholic acid (UDCA). DESIGN Cohort. SETTING One UK university hospital. POPULATION 29 ICP cases treated with UDCA. METHODS Serial samples were collected prospectively throughout gestation. Total serum bile acids were measured enzymatically and individual bile acids by high-performance liquid chromatography-tandem mass spectrometry. Data were log-transformed and analysed with random effects generalised least square regression. MAIN OUTCOME MEASURES The relationship between enzymatic total bile acid measurements and individual bile acid concentrations after UDCA treatment. RESULTS In untreated women, cholic acid was the principal bile acid (51%) and UDCA concentrations were <0.5%, whereas UDCA constituted 60% (IQR 43-69) of serum bile acids following treatment and cholic acid fell to <20%. Changes in the total bile acid measurement reflected similar alterations in the concentrations of the pathologically elevated bile acids, e.g. a two-fold increase in enzymatic total bile acids is accompanied by approximately a two-fold increase in cholic acid and chenodeoxycholic acid at most UDCA doses (P < 0.001). Most of the effects of UDCA on cholic acid occur in the first week of treatment (60% relative reduction, P = 0.025, 95% CI 0.2-0.9, from 10 micromol/l (4.7-17.6) to 3.5 micromol/l (1.4-7.5). CONCLUSION Ursodeoxycholic acid becomes the main component of the bile acid measurement after treatment. Enzymatic total bile acid assays are good predictors of both cholic acid and chenodeoxycholic acid, the primary bile acids that are raised prior to treatment. TWEETABLE ABSTRACT Ursodeoxycholic acid constitutes approximately 60% of the bile acid measurement and reduces pathological cholic acid in treated women.
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Affiliation(s)
- L B Manna
- Division of Women and Children's Health, King's College London, London, UK
| | - C Ovadia
- Division of Women and Children's Health, King's College London, London, UK
| | - A Lövgren-Sandblom
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
| | - J Chambers
- Division of Women and Children's Health, King's College London, London, UK.,Women's Health Research Centre, Imperial College Healthcare NHS Trust, London, UK
| | - S Begum
- Division of Women and Children's Health, King's College London, London, UK
| | - P Seed
- Division of Women and Children's Health, King's College London, London, UK
| | - I Walker
- Clinical Biochemistry, Frimley Health NHS trust, Wexham Park Hospital, Slough, UK
| | - L C Chappell
- Division of Women and Children's Health, King's College London, London, UK
| | - H-U Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - C Williamson
- Division of Women and Children's Health, King's College London, London, UK
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249
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Marschall HU. Ursodeoxycholic acid for intrahepatic cholestasis in pregnancy. Lancet 2019; 394:810-812. [PMID: 31378393 DOI: 10.1016/s0140-6736(19)31607-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 06/24/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg 41345, Sweden.
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250
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Chappell LC, Bell JL, Smith A, Linsell L, Juszczak E, Dixon PH, Chambers J, Hunter R, Dorling J, Williamson C, Thornton JG. Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial. Lancet 2019; 394:849-860. [PMID: 31378395 PMCID: PMC6739598 DOI: 10.1016/s0140-6736(19)31270-x] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/10/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy, characterised by maternal pruritus and increased serum bile acid concentrations, is associated with increased rates of stillbirth, preterm birth, and neonatal unit admission. Ursodeoxycholic acid is widely used as a treatment without an adequate evidence base. We aimed to evaluate whether ursodeoxycholic acid reduces adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy. METHODS We did a double-blind, multicentre, randomised placebo-controlled trial at 33 hospital maternity units in England and Wales. We recruited women with intrahepatic cholestasis of pregnancy, who were aged 18 years or older and with a gestational age between 20 weeks and 40 weeks and 6 days, with a singleton or twin pregnancy and no known lethal fetal anomaly. Participants were randomly assigned 1:1 to ursodeoxycholic acid or placebo, given as two oral tablets a day at an equivalent dose of 500 mg twice a day. The dose could be increased or decreased at the clinician's discretion, to a maximum of four tablets and a minimum of one tablet a day. We recommended that treatment should be continued from enrolment until the infant's birth. The primary outcome was a composite of perinatal death (in-utero fetal death after randomisation or known neonatal death up to 7 days after birth), preterm delivery (<37 weeks' gestation), or neonatal unit admission for at least 4 h (from birth until hospital discharge). Each infant was counted once within this composite. All analyses were done according to the intention-to-treat principle. The trial was prospectively registered with the ISRCTN registry, number 91918806. FINDINGS Between Dec 23, 2015, and Aug 7, 2018, 605 women were enrolled and randomly allocated to receive ursodeoxycholic acid (n=305) or placebo (n=300). The primary outcome analysis included 304 women and 322 infants in the ursodeoxycholic acid group, and 300 women and 318 infants in the placebo group (consent to use data was withdrawn for 1 woman and 2 infants). The primary composite outcome occurred in 74 (23%) of 322 infants in the ursodeoxycholic acid group and 85 (27%) of 318 infants in the placebo group (adjusted risk ratio 0·85 [95% CI 0·62-1·15]). Two serious adverse events were reported in the ursodeoxycholic acid group and six serious adverse events were reported in the placebo group; no serious adverse events were regarded as being related to treatment. INTERPRETATION Treatment with ursodeoxycholic acid does not reduce adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy. Therefore, its routine use for this condition should be reconsidered. FUNDING National Institute for Health Research Efficacy and Mechanism Evaluation Programme.
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Affiliation(s)
- Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
| | - Jennifer L Bell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anne Smith
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter H Dixon
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | | | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, IWK Health Centre, Halifax, NS, Canada
| | - Catherine Williamson
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
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