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Mechanisms of pruritus in cholestasis: understanding and treating the itch. Nat Rev Gastroenterol Hepatol 2023; 20:26-36. [PMID: 36307649 DOI: 10.1038/s41575-022-00687-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 02/01/2023]
Abstract
Pruritus in cholestatic liver diseases can be a major burden and dramatically impair the quality of life of those affected. Here, we provide an update on the latest insights into the molecular pathogenesis of and novel therapeutic approaches for cholestasis-associated itch. Endogenous and exogenous small-molecule pruritogen candidates bind to their receptors on unmyelinated itch C-fibres in the skin. Candidate pruritogens in cholestasis include certain lysophospholipids and sulfated progesterone metabolites, among others, whereas total bile acid or bilirubin conjugates seem unlikely to have a dominant role in the pathogenesis of cholestasis-associated pruritus. Transmission of itch signals via primary, secondary and tertiary itch neurons to the postcentral gyrus and activation of scratch responses offer various targets for therapeutic intervention. At present, evidence-based treatment options for pruritus in fibrosing cholangiopathies, such as primary biliary cholangitis and primary sclerosing cholangitis, are the peroxisome proliferator-associated receptor (PPAR) agonist bezafibrate and the pregnane X receptor (PXR) agonist rifampicin. In pruritus of intrahepatic cholestasis of pregnancy, ursodeoxycholic acid is recommended and might be supported in the third trimester by rifampicin if needed. Alternatively, non-absorbable anion exchange resins, such as cholestyramine, can be administered, albeit with poor trial evidence. Liver transplantation for intolerable refractory pruritus has become an extremely rare therapeutic strategy.
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Jurk SM, Kremer AE, Schleussner E. Intrahepatic Cholestasis of Pregnancy. Geburtshilfe Frauenheilkd 2021; 81:940-947. [PMID: 34393257 PMCID: PMC8354350 DOI: 10.1055/a-1522-5178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/02/2021] [Indexed: 12/29/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a rare but potentially serious complication of pregnancy, the main symptom of which is intense pruritus with elevated serum levels of bile acids. The elevated serum bile acid concentration is regarded as a predictor for poor perinatal outcome including intrauterine death. Ursodeoxycholic acid (UDCA) has become established as the treatment of choice in clinical management to achieve a significant improvement in symptoms and reduce the cholestasis. Pregnant women with severe intrahepatic cholestasis should always be managed in a perinatal centre with close interdisciplinary monitoring and treatment involving perinatologists and hepatologists to minimise the markedly increased perinatal morbidity and mortality as well as maternal symptoms.
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Affiliation(s)
| | - Andreas E Kremer
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Erlangen, Germany.,Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Switzerland
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Ovadia C, Sajous J, Seed PT, Patel K, Williamson NJ, Attilakos G, Azzaroli F, Bacq Y, Batsry L, Broom K, Brun-Furrer R, Bull L, Chambers J, Cui Y, Ding M, Dixon PH, Estiú MC, Gardiner FW, Geenes V, Grymowicz M, Günaydin B, Hague WM, Haslinger C, Hu Y, Indraccolo U, Juusela A, Kane SC, Kebapcilar A, Kebapcilar L, Kohari K, Kondrackienė J, Koster MPH, Lee RH, Liu X, Locatelli A, Macias RIR, Madazli R, Majewska A, Maksym K, Marathe JA, Morton A, Oudijk MA, Öztekin D, Peek MJ, Shennan AH, Tribe RM, Tripodi V, Türk Özterlemez N, Vasavan T, Wong LFA, Yinon Y, Zhang Q, Zloto K, Marschall HU, Thornton J, Chappell LC, Williamson C. Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:547-558. [PMID: 33915090 PMCID: PMC8192305 DOI: 10.1016/s2468-1253(21)00074-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ursodeoxycholic acid is commonly used to treat intrahepatic cholestasis of pregnancy, yet its largest trial detected minimal benefit for a composite outcome (stillbirth, preterm birth, and neonatal unit admission). We aimed to examine whether ursodeoxycholic acid affects specific adverse perinatal outcomes. METHODS In this systematic review and individual participant data meta-analysis, we searched PubMed, Web of Science, Embase, MEDLINE, CINAHL, Global Health, MIDIRS, and Cochrane without language restrictions for relevant articles published between database inception, and Jan 1, 2020, using search terms referencing intrahepatic cholestasis of pregnancy, ursodeoxycholic acid, and perinatal outcomes. Eligible studies had 30 or more study participants and reported on at least one individual with intrahepatic cholestasis of pregnancy and bile acid concentrations of 40 μmol/L or more. We also included two unpublished cohort studies. Individual participant data were collected from the authors of selected studies. The primary outcome was the prevalence of stillbirth, for which we anticipated there would be insufficient data to achieve statistical power. Therefore, we included a composite of stillbirth and preterm birth as a main secondary outcome. A mixed-effects meta-analysis was done using multi-level modelling and adjusting for bile acid concentration, parity, and multifetal pregnancy. Individual participant data analyses were done for all studies and in different subgroups, which were produced by limiting analyses to randomised controlled trials only, singleton pregnancies only, or two-arm studies only. This study is registered with PROSPERO, CRD42019131495. FINDINGS The authors of the 85 studies fulfilling our inclusion criteria were contacted. Individual participant data from 6974 women in 34 studies were included in the meta-analysis, of whom 4726 (67·8%) took ursodeoxycholic acid. Stillbirth occurred in 35 (0·7%) of 5097 fetuses among women with intrahepatic cholestasis of pregnancy treated with ursodeoxycholic acid and in 12 (0·6%) of 2038 fetuses among women with intrahepatic cholestasis of pregnancy not treated with ursodeoxycholic acid (adjusted odds ratio [aOR] 1·04, 95% CI 0·35-3·07; p=0·95). Ursodeoxycholic acid treatment also had no effect on the prevalence of stillbirth when considering only randomised controlled trials (aOR 0·29, 95% CI 0·04-2·42; p=0·25). Ursodeoxycholic acid treatment had no effect on the prevalence of the composite outcome in all studies (aOR 1·28, 95% CI 0·86-1·91; p=0·22), but was associated with a reduced composite outcome when considering only randomised controlled trials (0·60, 0·39-0·91; p=0·016). INTERPRETATION Ursodeoxycholic acid treatment had no significant effect on the prevalence of stillbirth in women with intrahepatic cholestasis of pregnancy, but our analysis was probably limited by the low overall event rate. However, when considering only randomised controlled trials, ursodeoxycholic acid was associated with a reduction in stillbirth in combination with preterm birth, providing evidence for the clinical benefit of antenatal ursodeoxycholic acid treatment. FUNDING Tommy's, the Wellcome Trust, ICP Support, and the National Institute for Health Research.
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Affiliation(s)
- Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, UK
| | - Jenna Sajous
- Department of Women and Children's Health, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, King's College London, London, UK
| | - Kajol Patel
- Department of Women and Children's Health, King's College London, London, UK
| | | | - George Attilakos
- Department of Obstetrics and Gynaecology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Francesco Azzaroli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Yannick Bacq
- Department of Hepatology and Gastroenterology, University Hospital of Tours, Tours, France
| | - Linoy Batsry
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Kelsey Broom
- Bendigo Healthcare Group, Bendigo, VIC, Australia
| | - Romana Brun-Furrer
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Laura Bull
- Department of Medicine and Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Jenny Chambers
- Women's Health Research Centre, Imperial College London, London, UK
| | - Yue Cui
- School of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Min Ding
- School of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Peter H Dixon
- Department of Women and Children's Health, King's College London, London, UK
| | - Maria C Estiú
- Ramón Sardá Mother's and Children's Hospital, Buenos Aires, Argentina
| | | | - Victoria Geenes
- Department of Women and Children's Health, King's College London, London, UK
| | - Monika Grymowicz
- Department of Gynecological Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Berrin Günaydin
- Department of Anesthesiology and Reanimation, Gazi University School of Medicine, Ankara, Turkey
| | - William M Hague
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | | | - Yayi Hu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Ugo Indraccolo
- Maternal-Infantile Department, Complex Operative Unit of Obstetrics and Gynecology Alto Tevere Hospital of Città di Castello, Città di Castello, Italy
| | | | - Stefan C Kane
- Department of Maternal-Fetal Medicine, Royal Women's Hospital, Parkville, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Ayse Kebapcilar
- Department of Gynecology and Obstetrics, Selcuk University, Konya, Turkey
| | | | - Katherine Kohari
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Jūratė Kondrackienė
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Maria P H Koster
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | - Richard H Lee
- Department of Obstetrics and Gynecology, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - Xiaohua Liu
- Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Anna Locatelli
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, Monza, Italy
| | - Rocio I R Macias
- Department of Physiology and Pharmacology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institute of Biomedical Research of Salamanca, University of Salamanca, Salamanca, Spain
| | - Riza Madazli
- Department of Obstetrics and Gynecology, Istanbul University, Cerrahpaşa, Istanbul, Turkey
| | - Agata Majewska
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Kasia Maksym
- Department of Obstetrics and Gynaecology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jessica A Marathe
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Adam Morton
- Department of Obstetric Medicine, Mater Health Services Public Hospital, Brisbane, QLD, Australia
| | - Martijn A Oudijk
- Department of Obstetrics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Deniz Öztekin
- Department of Obstetrics and Gynecology, İzmir Bakircay University, İzmir, Turkey
| | - Michael J Peek
- ANU Medical School, College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
| | - Andrew H Shennan
- Department of Women and Children's Health, King's College London, London, UK
| | - Rachel M Tribe
- Department of Women and Children's Health, King's College London, London, UK
| | - Valeria Tripodi
- Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Naciye Türk Özterlemez
- Department of Anesthesiology and Reanimation, Gazi University School of Medicine, Ankara, Turkey
| | - Tharni Vasavan
- Department of Women and Children's Health, King's College London, London, UK
| | - L F Audris Wong
- Department of Women's and Newborn, Gold Coast University Hospital, Southport, QLD, Australia
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Qianwen Zhang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Keren Zloto
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Jim Thornton
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
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Abstract
Intrahepatic cholestasis of pregnancy is a common disorder of pregnancy manifested by pruritus and elevated bile acids. The etiology of cholestasis is poorly understood and management is difficult due to the paucity of data regarding its diagnosis, treatment, and related adverse outcomes. In this article, we review the epidemiology, pathophysiology, risk factors, laboratory findings, complications, treatment, management, and current evidence surrounding intrahepatic cholestasis of pregnancy.
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Hagenbeck C, Pecks U, Lammert F, Hütten MC, Borgmeier F, Fehm T, Schleußner E, Maul H, Kehl S, Hamza A, Keitel V. [Intrahepatic cholestasis of pregnancy]. GYNAKOLOGE 2021; 54:341-356. [PMID: 33896963 PMCID: PMC8056200 DOI: 10.1007/s00129-021-04787-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 12/19/2022]
Abstract
Die Schwangerschaftscholestase („intrahepatic cholestasis of pregnancy“, ICP) ist die häufigste schwangerschaftsspezifische Lebererkrankung. Das Leitsymptom Juckreiz sowie eine begleitende Serumkonzentrationserhöhung von Gallensäuren und/oder der Alaninaminotransferase (ALT) sind wegweisend in der Diagnosestellung. Die mütterliche Prognose ist gut. Das fetale Outcome ist abhängig von der Gallensäurenkonzentration. Die ICP ist dabei sowohl mit Frühgeburt als auch mit intrauterinem Fruchttod (IUFT) assoziiert. Dieser ist Folge einer akuten fetalen Asphyxie, nicht einer chronischen uteroplazentaren Dysfunktion. Ein prädiktives Monitoring, z. B. durch Kardiotokographie (CTG) oder Ultraschall gibt es nicht. Eine medikamentöse Therapie mit Ursodeoxycholsäure (UDCA) bessert den Juckreiz, aber beeinflusst das fetale Outcome nicht nachweislich. Eine Entbindungsindikation ist in Abhängigkeit von Gallensäurenkonzentration und Gestationsalter gegeben. In Folgeschwangerschaften besteht ein hohes Wiederholungsrisiko.
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Affiliation(s)
- Carsten Hagenbeck
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Deutschland
| | - Ulrich Pecks
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Frank Lammert
- Klinik für Innere Medizin II, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg, Deutschland
| | - Matthias C. Hütten
- Neonatologie, Maastricht Universitair Medisch Centrum+, Maastricht, Niederlande
| | - Felix Borgmeier
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Deutschland
| | - Tanja Fehm
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Deutschland
| | | | - Holger Maul
- Frauenklinik, Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Deutschland
| | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Amr Hamza
- Kantonsspital Baden, Baden, Schweiz
- Klinikum für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universität des Saarlandes, Homburg, Deutschland
| | - Verena Keitel
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universität Düsseldorf, Düsseldorf, Deutschland
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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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7
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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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Wang R, Cheng N, Peng R, Yu Z, Nan M, Cao H. Oral herbal medicine for women with intrahepatic cholestasis in pregnancy: a systematic review of randomized controlled trials. BMC Complement Med Ther 2020; 20:303. [PMID: 33028282 PMCID: PMC7542867 DOI: 10.1186/s12906-020-03097-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/28/2020] [Indexed: 01/17/2023] Open
Abstract
Background Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy complication whose range has been calculated to be between 0.01 and 15.6% all around the world. We wanted to systematically evaluate the effect and safety of oral herbal medicine on treatment for ICP. Methods Details of the methods could be found in the registered protocol on PROSPERO (CRD42018096013). Trials assessing the effectiveness of herbal medicine for ICP were searched from seven electronic databases from inception to 28th February 2020. RevMan 5.3 software was used to perform all statistical analysis. Meta-analysis, additional analysis, Trial Sequential Analysis (TSA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were conducted if data permitted. Results Totally 43 randomized controlled trials with 3556 patients were included. Meta-analysis showed potential good adjunctive effect of herbal medicine on decreasing the pruritus scores (MD -0.58, 95% CI − 0.79 to − 0.36), the serum TBA scores (MD − 3.99 μmol/L, 95% CI − 4.24 to − 3.74) on the basis with Ursodesoxycholic acid. Compared to the medicine alone, significantly lower incidence of fetal distress (RR 0.41, 95% CI 0.32 to 0.51), asphyxia neonatorum (RR 0.35, 95%CI 0.25 to 0.49), cesarean section (RR 0.73, 95% CI 0.63 to 0.85), postpartum hemorrhage (RR 0.45, 95% CI 0.28 to 0.72) were observed in the combination group. But the comparison between herbal medicine and medicine showed inconsistent results among trials. Insufficient information could be used to evaluate the safety of herbal medicine for ICP. Conclusion This review found the current evidence may support the effectiveness of combination of herbal medicine and conventional medicine for decreasing the maternal pruritus scores, the serum TBA, and the number of fetal distress, or asphyxia neonatorum events related to this condition (which was supported by TSA results). Since there were obvious statistical and clinical heterogeneity among trials, and the methodological quality of the included studies was poor, the level of the evidence could only be defined as “very low” according to the GRADE criteria. Further high quality studies are still needed to testify the effectiveness and safety of herbal medicine for ICP.
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Affiliation(s)
- Ruiting Wang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Nuo Cheng
- Beijing University of Chinese Medicine, Beijing, China
| | - Rongyan Peng
- Beijing University of Chinese Medicine, Beijing, China
| | - Zeyu Yu
- Centre for Evidence Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Mengdie Nan
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Huijuan Cao
- Centre for Evidence Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China.
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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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10
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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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11
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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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Obeticholic Acid Protects against Gestational Cholestasis-Induced Fetal Intrauterine Growth Restriction in Mice. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:7419249. [PMID: 31827696 PMCID: PMC6885290 DOI: 10.1155/2019/7419249] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/25/2019] [Accepted: 09/23/2019] [Indexed: 12/18/2022]
Abstract
Gestational cholestasis is a common disease and is associated with adverse pregnancy outcomes. However, there are still no effective treatments. We investigated the effects of obeticholic acid (OCA) on fetal intrauterine growth restriction (IUGR) during 17α-ethynylestradiol- (E2-) induced gestational cholestasis in mice. All pregnant mice except controls were subcutaneously injected with E2 (0.625 mg/kg) daily from gestational day (GD) 13 to GD17. Some pregnant mice were orally administered with OCA (5 mg/kg) daily from GD12 to GD17. As expected, OCA activated placental, maternal, and fetal hepatic FXR signaling. Additionally, exposure with E2 during late pregnancy induced cholestasis, whereas OCA alleviated E2-induced cholestasis. Gestational cholestasis caused reduction of fetal weight and crown-rump length and elevated the incidence of IUGR. OCA decreased the incidence of IUGR during cholestasis. Interestingly, OCA attenuated reduction of blood sinusoid area in placental labyrinth layer and inhibited downregulation of placental sodium-coupled neutral amino acid transporter- (SNAT-) 2 during cholestasis. Additional experiment found that OCA attenuated glutathione depletion and lipid peroxidation in placenta and fetal liver and placental protein nitration during cholestasis. Moreover, OCA inhibited the upregulation of placental NADPH oxidase-4 and antioxidant genes during cholestasis. OCA activated antioxidant Nrf2 signaling during cholestasis. Overall, we demonstrated that OCA treatment protected against gestational cholestasis-induced placental dysfunction and IUGR through suppressing placental oxidative stress and maintaining bile acid homeostasis.
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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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Manzotti C, Casazza G, Stimac T, Nikolova D, Gluud C. Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy. Cochrane Database Syst Rev 2019; 7:CD012546. [PMID: 31283001 PMCID: PMC6613619 DOI: 10.1002/14651858.cd012546.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy is a pregnancy-specific liver disorder, possibly associated with an increased risk of severe fetal adverse events. Total serum bile acids (TSBA) concentration, alone or in combination with serum aminotransferases, have been the most often used biomarkers for the diagnosis of intrahepatic cholestasis of pregnancy in clinical practice. Serum bile acid profile, composed of primary or secondary, conjugated or non-conjugated bile acids, may provide more specific disease information. OBJECTIVES To assess and compare, independently or in combination, the diagnostic accuracy of total serum bile acids or serum bile acids profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women, presenting with pruritus. To define the optimal cut-off values for components of serum bile acid profile; to investigate possible sources of heterogeneity. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register, the Cochrane Library, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, BIOSIS, CINAHL, two Chinese databases (CKNI, VIP), Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Evidence Search: Health and Social Care by the National Institute for Health and Care Excellence (NICE), the World Health Organization (WHO) Reproductive Health Library (RHL), and the Turning Research into Practice database (TRIP). The most recent date of search was 6 May 2019. We identified additional references by handsearching the references of articles, meta-analyses, and evidence-based guidelines retrieved from the computerised databases, on-line trial registries, and grey literature through OpenSIGLE, National Technical Information Service (NTIS), ProQuest Dissertations & Thesis Database, and Index to Theses in Great Britain and Ireland. SELECTION CRITERIA Prospective or retrospective diagnostic case-control or cross-sectional studies, irrespective of publication date, format, and language, which evaluated the diagnostic accuracy of total serum bile acids (TSBA) or components of serum bile acid profile for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women of any age or ethnicity, in any clinical setting, symptomatic for pruritus. DATA COLLECTION AND ANALYSIS We selected studies by reading titles, abstracts, or full texts, and assessing their fulfilment of our inclusion criteria. We emailed primary authors to request missing data or individual participant data. Having extracted data from each included study, we built the two-by-two tables for each primary study and for all the index tests considered. We estimated sensitivity and specificity with their 95% confidence intervals (CI). We presented data in coupled forest plots, showing sensitivities and specificities of each study, and we plotted the studies in the Receiver Operating Characteristic (ROC) space. We performed meta-analyses adopting the hierarchical summary ROC model (HSROC) or the bivariate model to meta-analyse the data. We made indirect comparisons of the considered index tests by adding the index tests as covariates to the bivariate or HSROC models. We performed heterogeneity analysis and sensitivity analysis on studies assessing TSBA accuracy. We used Review Manager 5 (RevMan 5) and SAS statistical software, release 9.4 (SAS Institute Inc., Cary, NC, USA), to perform all statistical analyses. We used QUADAS-2 domains to assess the risk of bias of the included studies. MAIN RESULTS Our search yielded 5073 references, but at the end of our selection process, only 16 studies fulfilled the review inclusion criteria. Nine of these provided individual participant data. We analysed only data concerning TSBA, cholic acid (CA), glycocholic acid (GCA), chenodeoxycholic acid (CDCA), and CA/CDCA because the remaining planned index tests were assessed in few studies. Only one study had low risk of bias in all four QUADAS-2 domains. The most biased domains were the patient sampling and the reference standard domains. When considering all studies with a cut-off of 10 μmol/L, TSBA overall sensitivity ranged from 0.72 to 0.98 and specificity ranged from 0.81 to 0.97. After a sensitivity analysis excluding case-control studies, TSBA sensitivity ranged from 0.48 to 0.66 and specificity from 0.52 to 0.99. After a sensitivity analysis excluding studies in which TSBA was part of the reference standard, TSBA sensitivity ranged from 0.49 to 0.65 and specificity from 0.53 to 0.99. We found the estimates of the overall accuracy for some serum bile acid components (CA, GCA, CDCA, and CA/CDCA) to be imprecise, with the CI for sensitivity and specificity very wide or impossible to calculate. Indirect comparisons between serum bile acid profile components and TSBA were not statistically significant. None of the heterogeneity analysis performed was statistically significant, except for the timing of assessment of TSBA (onset of symptoms, peak value among multiple assessments, delivery) but without clinically relevant results. We could not analyse the diagnostic accuracy of combinations of index tests because none of the included studies carried them out, and because of the small number of included studies. AUTHORS' CONCLUSIONS The overall high risk of bias, the existing concern regarding applicability of the results in clinical practice, and the great heterogeneity of the results in the included studies prevents us from making recommendations and reaching definitive conclusions at the present time. Thus, we do not find any compelling evidence to recommend or refute the routine use of any of these tests in clinical practice. So far, the diagnostic accuracy of TSBA for intrahepatic cholestasis of pregnancy might have been overestimated. There were too few studies to permit a precise estimate of the accuracy of serum bile acid profile components. Further primary clinical research is mandatory. We need both further phase II and phase III diagnostic studies.
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Affiliation(s)
- Cristina Manzotti
- Fondazione IRCCS Ca' Granda ‐ Ospedale Maggiore Policlinico, Università degli Studi di MilanoObstetrics and Gynecology DepartmentVia Commenda 12 ‐ Clinica Mangiagalli, piano terraMilanMilanItaly20122
- Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
- Fondazione IRCCS Ca' Granda ‐ Ospedale Maggiore Policlinico, Università degli Studi di MilanoGastro‐Intestinal UnitVia Commenda 12 ‐ Clinica Mangiagalli, 1° piano, scala AMilanMilanItaly20122
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
| | - Tea Stimac
- Clinical Hospital Centre RijekaObstetrics and GynecologyCambierieva 17RijekaCroatia51000
| | - Dimitrinka Nikolova
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Mohan M, Antonios A, Konje J, Lindow S, Ahmed Syed M, Akobeng A. Stillbirth and associated perinatal outcomes in obstetric cholestasis: a systematic review and meta-analysis of observational studies. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100026. [PMID: 31403117 PMCID: PMC6687374 DOI: 10.1016/j.eurox.2019.100026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/06/2019] [Accepted: 04/16/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Obstetric cholestasis is a condition occurring in pregnancy with suspected adverse perinatal outcomes. Stillbirth is a significant adverse event associated with obstetric cholestasis and considered for intervention in pregnancy. OBJECTIVES There are multiple studies with epidemiological data with regards to the outcomes of obstetric cholestasis. Our hypothesis is to the test the association of stillbirth and related outcomes in obstetric cholestasis. SEARCH STRATEGY & SELECTION CRITERIA Two independent reviewers did independent searches and selection with a standardized design as outlined in the PRISMA statement. ANALYSIS The retrieved relevant literature was subjected to a rigorous quality assessment and followed by standardized interpretable results. RESULTS The pooled estimate in this study showed that there was no significant difference in the stillbirth rates in the obstetric (OC) population when compared to the non-obstetric cholestasis (reference) population. However, there was an increased risk of preterm birth in the OC population compared to the reference population; however, the cesarean section and induction of labor results were directly related. DISCUSSION This study provides an epidemiological data related to the perinatal outcomes associated with obstetric cholestasis, specifically stillbirth. This result is likely to produce a benchmark for current evidence-based practice and to assist future research in understanding the implication of associated stillbirth risk and related outcomes with OC.
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Affiliation(s)
- Manoj Mohan
- Women’s Clinical Management Group (WCMG), Sidra Medicine, Doha, Qatar
| | | | | | | | | | - Anthony Akobeng
- Gastro intestinal Hepatology & Nutritional Unit, Sidra Medicine, Doha, Qatar
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Shen Y, Zhou J, Zhang S, Wang XL, Jia YL, He S, Wang YY, Li WC, Shao JG, Zhuang X, Liu YL, Qin G. Is It Necessary to Perform the Pharmacological Interventions for Intrahepatic Cholestasis of Pregnancy? A Bayesian Network Meta-Analysis. Clin Drug Investig 2019; 39:15-26. [PMID: 30357607 DOI: 10.1007/s40261-018-0717-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Although many meta-analyses have evaluated the pharmacotherapy of intrahepatic cholestasis of pregnancy (ICP) and recommended ursodeoxycholic acid (UDCA) as an effective treatment, the defect of the pair-wise analyses and the mixture of the control group made the outcome uncertain and unclear. We aimed to employ Bayesian network meta-analysis (NMA) to compare the maternal and fetal outcomes after UDCA, S-adenosylmethionine (SAMe) mono-therapy or the combination treatment of these two drugs for ICP patients. METHODS Multiple electronic database searches were conducted for articles published up to 1 September 2018. The relevant information was extracted from the published reports with a predefined data extraction sheet, and the risk of bias was assessed with the Cochrane risk-of-bias tool. Poisson Bayesian network meta-analysis was employed to identify the synthesized evidence from the relevant trials, with reporting hazard risks (HRs) and 95% credible intervals (CrIs). RESULTS The pooled outcomes of the 13 randomized controlled trials (RCTs) with 625 participants indicated that none of the three regimens can significantly improve maternal and fetal outcomes. CONCLUSION This NMA of the RCTs clarified that the current intervention has no favorable effect on pruritus and other symptoms in ICP patients.
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Affiliation(s)
- Yi Shen
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, China
| | - Jie Zhou
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, China
| | - Sheng Zhang
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, China
| | - Xu-Lin Wang
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, China
| | - Yu-Long Jia
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, China
| | - Shu He
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, China
| | - Yuan-Yuan Wang
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, China
| | - Wen-Chao Li
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, China
| | - Jian-Guo Shao
- Center for Liver Diseases, Nantong Third People's Hospital, Nantong University, 60 Mid-Youth Road, Nantong, 226006, Jiangsu, China
| | - Xun Zhuang
- Department of Epidemiology and Medical Statistics, School of Public Health, Nantong University, Nantong, China
| | - Yuan-Lin Liu
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Nantong, China
| | - Gang Qin
- Center for Liver Diseases, Nantong Third People's Hospital, Nantong University, 60 Mid-Youth Road, Nantong, 226006, Jiangsu, China.
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Yeap SP, Harley H, Thompson R, Williamson KD, Bate J, Sethna F, Farrell G, Hague WB. Biliary transporter gene mutations in severe intrahepatic cholestasis of pregnancy: Diagnostic and management implications. J Gastroenterol Hepatol 2019; 34:425-435. [PMID: 29992621 DOI: 10.1111/jgh.14376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Clinical syndromes associated with biallelic mutations of bile acid (BA) transporters usually present in childhood. Subtle mutations may underlie intrahepatic cholestasis of pregnancy (ICP) and oral contraceptive steroid (OCS) induced cholestasis. In five women with identified genetic mutations of such transporters, with eight observed pregnancies complicated by ICP, we examined relationships between transporter mutations, clinical phenotypes, and treatment outcomes. METHODS Gene mutation analysis for BA transporter deficiencies was performed using Next Generation/Sanger sequencing, with analysis for gene deletions/duplications. RESULTS Intrahepatic cholestasis of pregnancy was early-onset (9-32 weeks gestation) and severe (peak BA 74-370 μmol/L), with premature delivery (28+1 -370 weeks gestation) in 7/8 pregnancies, in utero passage of meconium in 4/8, but overall good perinatal outcomes, with no stillbirths. There was generally no response to ursodeoxycholic acid and variable responses to rifampicin and chelation therapies; naso-biliary drainage appeared effective in 2/2 episodes persisting post-partum in each of the two sisters. Episodic jaundice occurring spontaneously or provoked by non-specific infections, and OCS-induced cholestasis, had previously occurred in 3/5 women. Two cases showed biallelic heterozygosity for several ABCB11 mutations, one was homozygous for an ABCB4 mutation and a fourth case was heterozygous for another ABCB4 mutation. CONCLUSIONS Early-onset or recurrent ICP, especially with previous spontaneous or OCS-induced episodes of cholestasis and/or familial cholestasis, may be attributable to transporter mutations, including biallelic mutations of one or more transporters. Response to standard therapies for ICP is often incomplete; BA sequestering therapy or naso-biliary drainage may be effective. Optimized management can produce good outcomes despite premature birth and evidence of fetal compromise.
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Affiliation(s)
- Sze Pheh Yeap
- Liver Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hugh Harley
- Liver Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | | | | | - John Bate
- Liver Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Farah Sethna
- Department of Obstetrics and Gynaecology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Geoffrey Farrell
- Liver Research Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia.,The Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - William Bill Hague
- Obstetric Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia
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18
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Chappell LC, Chambers J, Dixon PH, Dorling J, Hunter R, Bell JL, Bowler U, Hardy P, Juszczak E, Linsell L, Rounding C, Smith A, Williamson C, Thornton JG. Ursodeoxycholic acid versus placebo in the treatment of women with intrahepatic cholestasis of pregnancy (ICP) to improve perinatal outcomes: protocol for a randomised controlled trial (PITCHES). Trials 2018; 19:657. [PMID: 30482254 PMCID: PMC6260710 DOI: 10.1186/s13063-018-3018-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 10/24/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disorder specific to pregnancy and presents with maternal pruritus, raised concentrations of serum bile acids and abnormal liver function tests. ICP is associated with increased rates of spontaneous and iatrogenic preterm labour, fetal hypoxia, meconium-stained amniotic fluid and intrauterine death. Some clinicians treat ICP with ursodeoxycholic acid (UDCA) to improve maternal pruritus and biochemical abnormalities. However, there are currently no data to support the use of UDCA to improve pregnancy outcome as none of the trials performed to date have been powered to address this question. METHODS The PITCHES trial is a triple-masked, placebo-controlled randomised trial, to evaluate UDCA versus placebo in women with ICP between 20 + 0 to 40 + 6 weeks' gestation. The primary objective of the trial is to determine if UDCA treatment of women with ICP between 20 + 0 and 40 + 6 weeks' gestation reduces the primary perinatal outcome: a composite of perinatal death (as defined by in utero fetal death after randomisation or known neonatal death up to 7 days) or preterm delivery (less than 37 weeks' gestation) or neonatal unit admission for at least 4 h (from infant delivery until hospital discharge). The secondary objectives of the trial are (1) to investigate the effect of UDCA on other short-term outcomes for both mother and infant and (2) to assess the impact of UDCA on health care resource use, in terms of the total number of nights for mother and infant, together with level of care. DISCUSSION Current practice in the UK at the time of trial commencement for the treatment of ICP is inconsistent, with some units routinely prescribing UDCA, others prescribing very little and the remainder offering it variably. Our previous pilot trial of UDCA in women with ICP demonstrated that the trial would be feasible, and the research question remains active and unanswered. Results are highly likely to influence clinical practice, through direct management and impact on national and international guidelines. TRIAL REGISTRATION ISRCTN registry, ID: ISRCTN91918806 . Prospectively registered on 27 August 2015.
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Affiliation(s)
| | | | | | | | | | - Jennifer L Bell
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Ursula Bowler
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Pollyanna Hardy
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Catherine Rounding
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Anne Smith
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, UK
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19
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Kolberg ES, Tranung M, Aasarød KM. Increased prescribing of ursodeoxycholic acid in Norway. Int J Clin Pharm 2018; 40:1454-1457. [PMID: 30267256 DOI: 10.1007/s11096-018-0729-2] [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: 04/30/2018] [Accepted: 09/25/2018] [Indexed: 11/30/2022]
Abstract
Background Ursodeoxycholic acid is a hydrophilic bile acid prescribed for a variety of cholestatic liver disorders, although with variable clinical evidence with regards to efficacy. Objective The aim of this study was to investigate the prescription pattern of ursodeoxycholic acid in Norway over the last 13 years. Method Information on the prescribing of ursodeoxycholic acid was extracted from the Norwegian Prescription Database. Data was obtained on the number of individuals who had at least one prescription of ursodeoxycholic acid for any indication dispensed per year in the period 2004-2017. Results The period 2004-2017 witnessed an overall rise in the prevalence of ursodeoxycholic acid prescribing of 237%. With regards to development in prescribing across different age cohorts there is an increase in prescribing in all age groups, although the trend seems to be levelling off in some cohorts. Conclusion Considering the variable clinical evidence of the efficacy of ursodeoxycholic acid, the increase in prescribing is interesting and should prompt vigilance and further research with regards to its long term effects on clinical outcomes.
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Affiliation(s)
- Espen Skarstein Kolberg
- Department of Clinical Pharmacy, Trondheim Hospital Pharmacy, Olav Kyrres Gate 10, PB 8905, 7491, Trondheim, Norway. .,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Morten Tranung
- Department of Clinical Pharmacy, Trondheim Hospital Pharmacy, Olav Kyrres Gate 10, PB 8905, 7491, Trondheim, Norway
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20
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Han F, Xu L, Huang Y, Chen T, Zhou T, Yang L. Magnesium sulphate can alleviate oxidative stress and reduce inflammatory cytokines in rat placenta of intrahepatic cholestasis of pregnancy model. Arch Gynecol Obstet 2018; 298:631-638. [PMID: 30039470 DOI: 10.1007/s00404-018-4850-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/07/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE In our study, we try to investigate whether magnesium sulphate (MgSO4) could provide protection against oxidative damage and inflammatory response in rat placenta of intrahepatic cholestasis of pregnancy (ICP) model. METHODS The rat model of ICP was established by injecting s.c. 17α-ethinyl estradiol (EE) daily for 5 days. MgSO4, as an therapeutic drug for ICP, was injected i.p. daily for 3 days. Age-matched pregnant rats served as controls. The level of serum total bile acid (TBA) was measured. The data including the number and weight of offsprings on day 20 of pregnancy were collected. We observed ultrastructural changes of mitochondria and endoplasmic reticulum (ER) in placenta by transmission electron microscope. The antioxidant proteins peroxiredoxin-6 (Prdx6) and nuclear factor erythroid 2-related factor-2 (Nrf2) were analyzed by Western Blot. The inflammatory cytokines including IL-1β, TNF-α and IFN-γ were investigated by real-time PCR (RT-PCR) and enzyme-linked immune-sorbent assay (ELISA). RESULTS The weight of offsprings on day 20 of pregnancy increased in ICP rats treated with MgSO4 (ICP + MG group) compared with that in ICP rats (ICP group). However, the level of TBA was not reduced. The damage of mitochondria and ER was observed in placenta, which was much more slighter in ICP + MgSO4 group as compared with that in ICP group. Prdx6 and Nrf2 were increased, while the inflammatory cytokines including IL-1β, TNF-α and IFN-γ were decreased in ICP + MgSO4 group compared with that in ICP group. CONCLUSIONS MgSO4 had beneficial effect on improving growth of offsprings in rat model of ICP. The protective effect of MgSO4 on alleviating oxidative damage and inflammatory response in placenta may play an important role in the process. MgSO4 may improve the function of placenta.
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Affiliation(s)
- Fei Han
- Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Linhao Xu
- Hangzhou Medical College, Hangzhou, 310053, China
| | - Yaqing Huang
- Zhejiang Provincial People's Hospital, Hangzhou, 310014, China
| | - Tianqi Chen
- People's Hospital of Shaoxing City, Shaoxing, 312000, China
| | - Tiancheng Zhou
- Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Liwei Yang
- Zhejiang Provincial People's Hospital, Hangzhou, 310014, China.
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21
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Bolukbas FF, Bolukbas C, Y Balaban H, Aygun C, Ignak S, Ergul E, Yazicioglu M, S Ersahin S. Intrahepatic Cholestasis of Pregnancy: Spontaneous vs in vitro Fertilization. Euroasian J Hepatogastroenterol 2017; 7:126-129. [PMID: 29201793 PMCID: PMC5670254 DOI: 10.5005/jp-journals-10018-1232] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/06/2017] [Indexed: 12/27/2022] Open
Abstract
Aim: Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease in pregnancy. Although it was shown that multiple pregnancy and hormone therapies increase the risk of ICP, there is limited information that compared spontaneous fertilization and in vitro fertilization (IVF) from the aspect of developing ICP. In our study, we investigated the potential relationship between ICP and IVF/ spontaneous pregnancy. Materials and methods: We reviewed the records (between June 2007 and December 2014) of pregnancies with ICP who were referred to gastroenterology clinics in three different hospitals. Fifty-nine pregnancies (43 spontaneous fertilization, 16 IVF) with ICP were analyzed from the aspect of age, fertilization type, multiple/singleton pregnancy, delivery week, and biochemical results. Results: We found that serum bile acid levels were higher in the IVF group than the spontaneous fertilization group (32.8 ± 20 vs 19.6 ± 19 μmol/L; p < 0.05). There was a significant inverse correlation between serum bile acid levels and gestational age (r = -0.42, p < 0.01) in the whole group. There was no difference between IVF and spontaneous fertilization groups in term of age, onset time of symptoms, serum alanine aminotransferase (ALT), alkaline phosphatase (ALP), total and direct bilirubin levels, prothrombin time (PT), international normalized ratio (INR), and platelet count. Conclusion: Our results suggest that the serum bile acid levels are higher in IVF than in spontaneous pregnancies with ICP, but its clinical implications are not clear. Further prospective studies with large number of ICP cases are needed to clarify the effect of IVF on ICP. How to cite this article: Bolukbas FF, Bolukbas C, Balaban HY, Aygun C, Ignak S, Ergul E, Yazicioglu M, Ersahin SS. Intrahepatic Cholestasis of Pregnancy: Spontaneous vs in vitro Fertilization. Euroasian J Hepato-Gastroenterol 2017;7(2):126-129.
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Affiliation(s)
- Filiz F Bolukbas
- Department of Gastroenterology, Bahcesehir University School of Medicine, Medicalpark Goztepe Hospital, Istanbul, Turkey
| | - Cengiz Bolukbas
- Department of Gastroenterology, Bahcesehir University School of Medicine, Medicalpark Goztepe Hospital, Istanbul, Turkey
| | - Hatice Y Balaban
- Department of Gastroenterology, Istanbul Medipol University School of Medicine, Istanbul, Turkey
| | - Cem Aygun
- Department of Gastroenterology, Istanbul Medipol University School of Medicine, Istanbul, Turkey
| | - Seyda Ignak
- Department of Medical Biology, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Emine Ergul
- Department of Gynecology and Obstetrics, Istanbul Bahcelievler Medicalpark, Istanbul Turkey
| | - Mehtap Yazicioglu
- Department of Gynecology and Obstetrics, Medicalpark Goztepe Hospital, Istanbul, Turkey
| | - Suat S Ersahin
- Department of Gynecology and Obstetrics, Istanbul Bahcelievler Medicalpark, Istanbul Turkey
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22
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Ma H, Sales VM, Wolf AR, Subramanian S, Matthews TJ, Chen M, Sharma A, Gall W, Kulik W, Cohen DE, Adachi Y, Griffin NW, Gordon JI, Patti ME, Isganaitis E. Attenuated Effects of Bile Acids on Glucose Metabolism and Insulin Sensitivity in a Male Mouse Model of Prenatal Undernutrition. Endocrinology 2017; 158. [PMID: 28637315 PMCID: PMC5551557 DOI: 10.1210/en.2017-00288] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Prenatal undernutrition and low birth weight are associated with risk of type 2 diabetes and obesity. Prenatal caloric restriction results in low birth weight, glucose intolerance, obesity, and reduced plasma bile acids (BAs) in offspring mice. Because BAs can regulate systemic metabolism and glucose homeostasis, we hypothesized that BA supplementation could prevent diet-induced obesity and glucose intolerance in this model of developmental programming. Pregnant dams were food restricted by 50% from gestational days 12.5 to 18.5. Offspring of both undernourished (UN) and control (C) dams given unrestricted diets were weaned to high-fat diets with or without supplementation with 0.25% w/w ursodeoxycholic acid (UDCA), yielding four experimental groups: C, UN, C + UDCA, and UN + UDCA. Glucose homeostasis, BA composition, liver and intestinal gene expression, and microbiota composition were analyzed in the four groups. Although UDCA supplementation ameliorated diet-induced obesity in C mice, there was no effect in UN mice. UDCA similarly lowered fasting insulin, and improved glucose tolerance, pyruvate tolerance, and liver steatosis in C, but not UN, animals. BA composition differed significantly, and liver and ileal expression of genes involved in BA metabolism (Cyp7b1, Shp) were differentially induced by UDCA in C vs UN animals. Bacterial taxa in fecal microbiota correlated with treatment groups and metabolic parameters. In conclusion, prenatal undernutrition alters responsiveness to the metabolic benefits of BA supplementation, with resistance to the weight-lowering and insulin-sensitizing effects of UDCA supplementation. Our findings suggest that BA metabolism may be a previously unrecognized contributor to developmentally programmed diabetes risk.
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Affiliation(s)
- Huijuan Ma
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts 02115
- Department of Endocrinology and Metabolism, Hebei General Hospital, Shijiazhuang, Hebei, 050051, China
| | - Vicencia M Sales
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts 02115
| | - Ashley R Wolf
- Center for Genome Sciences and Systems Biology, and Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Sathish Subramanian
- Center for Genome Sciences and Systems Biology, and Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Tucker J Matthews
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts 02115
| | - Michael Chen
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts 02115
| | - Aparna Sharma
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts 02115
| | - Walt Gall
- Metabolon, Durham, North Carolina 27713
| | - Wim Kulik
- Laboratory of Genetic Metabolic Diseases, Departments of Pediatrics and Clinical Chemistry, University of Amsterdam, 1105 AZ Amsterdam-Zuidoost, The Netherlands
| | - David E Cohen
- Division of Gastroenterology and Hepatology, Joan & Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York, New York 10021
| | - Yusuke Adachi
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts 02115
| | - Nicholas W Griffin
- Center for Genome Sciences and Systems Biology, and Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Jeffrey I Gordon
- Center for Genome Sciences and Systems Biology, and Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Mary-Elizabeth Patti
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts 02115
| | - Elvira Isganaitis
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts 02115
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23
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Pataia V, Dixon PH, Williamson C. Pregnancy and bile acid disorders. Am J Physiol Gastrointest Liver Physiol 2017; 313:G1-G6. [PMID: 28450276 DOI: 10.1152/ajpgi.00028.2017] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/20/2017] [Accepted: 04/20/2017] [Indexed: 01/31/2023]
Abstract
During pregnancy, extensive adaptations in maternal metabolic and immunological physiology occur. Consequently, preexisting disease may be exacerbated or attenuated, and new disease susceptibility may be unmasked. Cholestatic diseases, characterized by a supraphysiological raise in bile acid levels, require careful monitoring during pregnancy. This review describes the latest advances in the knowledge of intrahepatic cholestasis of pregnancy (ICP), the most common bile acid disorder specific to pregnancy, with a focus on the disease etiology and potential mechanisms of ICP-associated adverse pregnancy outcomes, including fetal demise. The course of preexisting cholestatic conditions in pregnancy is considered, including primary sclerosing cholangitis, primary biliary cholangitis, biliary atresia, and Alagille syndrome. The currently accepted treatments for cholestasis in pregnancy and promising new therapeutics for the condition are described.
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Affiliation(s)
- Vanessa Pataia
- Division of Women's Health, King's College London, London, United Kingdom
| | - Peter H Dixon
- Division of Women's Health, King's College London, London, United Kingdom
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24
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Lombardi R, Onali S, Thorburn D, Davidson BR, Gurusamy KS, Tsochatzis E. Pharmacological interventions for non-alcohol related fatty liver disease (NAFLD): an attempted network meta-analysis. Cochrane Database Syst Rev 2017; 3:CD011640. [PMID: 28358980 PMCID: PMC6464620 DOI: 10.1002/14651858.cd011640.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-alcohol related fatty liver disease (commonly called non-alcoholic fatty liver disease (NAFLD)) is liver steatosis in the absence of significant alcohol consumption, use of hepatotoxic medication, or other disorders affecting the liver such as hepatitis C virus infection, Wilson's disease, and starvation. NAFLD embraces the full spectrum of disease from pure steatosis (i.e. uncomplicated fatty liver) to non-alcoholic steatohepatitis (NASH), via NASH-cirrhosis to cirrhosis. The optimal pharmacological treatment for people with NAFLD remains uncertain. OBJECTIVES To assess the comparative benefits and harms of different pharmacological interventions in the treatment of NAFLD through a network meta-analysis and to generate rankings of the available pharmacological treatments according to their safety and efficacy. However, it was not possible to assess whether the potential effect modifiers were similar across different comparisons. Therefore, we did not perform the network meta-analysis, and instead, assessed the comparative benefits and harms of different interventions using standard Cochrane methodology. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.com to August 2016. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or publication status) in participants with NAFLD. We excluded trials which included participants who had previously undergone liver transplantation. We considered any of the various pharmacological interventions compared with each other or with placebo or no intervention. DATA COLLECTION AND ANALYSIS We calculated the odds ratio (OR) and rate ratio with 95% confidence intervals (CI) using both fixed-effect and random-effects models based on an available participant analysis with Review Manager. We assessed risk of bias according to the Cochrane risk of bias tool, controlled risk of random errors with Trial Sequential Analysis, and assessed the quality of the evidence using GRADE. MAIN RESULTS We identified 77 trials including 6287 participants that met the inclusion criteria of this review. Forty-one trials (3829 participants) provided information for one or more outcomes. Only one trial was at low risk of bias in all domains. All other trials were at high risk of bias in one or more domains. Overall, all the evidence was very low quality. Thirty-five trials included only participants with non-alcohol related steatohepatitis (NASH) (based on biopsy confirmation). Five trials included only participants with diabetes mellitus; 14 trials included only participants without diabetes mellitus. The follow-up in the trials ranged from one month to 24 months.We present here only the comparisons of active intervention versus no intervention in which two or more trials reported at least one of the following outcomes: mortality at maximal follow-up, serious adverse events, and health-related quality of life, the outcomes that determine whether a treatment should be used. Antioxidants versus no interventionThere was no mortality in either group (87 participants; 1 trial; very low quality evidence). None of the participants developed serious adverse events in the trial which reported the proportion of people with serious adverse events (87 participants; 1 trial; very low quality evidence). There was no evidence of difference in the number of serious adverse events between antioxidants and no intervention (rate ratio 0.89, 95% CI 0.36 to 2.19; 254 participants; 2 trials; very low quality evidence). None of the trials reported health-related quality of life. Bile acids versus no interventionThere was no evidence of difference in mortality at maximal follow-up (OR 5.11, 95% CI 0.24 to 107.34; 659 participants; 4 trials; very low quality evidence), proportion of people with serious adverse events (OR 1.56, 95% CI 0.84 to 2.88; 404 participants; 3 trials; very low quality evidence), or the number of serious adverse events (rate ratio 1.01, 95% CI 0.66 to 1.54; 404 participants; 3 trials; very low quality evidence) between bile acids and no intervention. None of the trials reported health-related quality of life. Thiazolidinediones versus no interventionThere was no mortality in either group (74 participants; 1 trial; very low quality evidence). None of the participants developed serious adverse events in the two trials which reported the proportion of people with serious adverse events (194 participants; 2 trials; very low quality evidence). There was no evidence of difference in the number of serious adverse events between thiazolidinediones and no intervention (rate ratio 0.25, 95% CI 0.06 to 1.05; 357 participants; 3 trials; very low quality evidence). None of the trials reported health-related quality of life. Source of fundingTwenty-six trials were partially- or fully-funded by pharmaceutical companies that would benefit, based on the results of the trial. Twelve trials did not receive any additional funding or were funded by parties with no vested interest in the results. The source of funding was not provided in 39 trials. AUTHORS' CONCLUSIONS Due to the very low quality evidence, we are very uncertain about the effectiveness of pharmacological treatments for people with NAFLD including those with steatohepatitis. Further well-designed randomised clinical trials with sufficiently large sample sizes are necessary.
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Affiliation(s)
- Rosa Lombardi
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUKNW3 2QG
| | - Simona Onali
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUKNW3 2QG
| | - Douglas Thorburn
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUKNW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
| | | | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUKNW3 2QG
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Manzotti C, Casazza G, Stimac T, Nikolova D, Gluud C. Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2017. [DOI: 10.1002/14651858.cd012546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Cristina Manzotti
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano; Obstetrics and Gynecology Department; Via Commenda 12 - Clinica Mangiagalli, piano terra Milan Milan Italy 20122
- Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano; Gastro-Intestinal Unit; Via Commenda 12 - Clinica Mangiagalli, 1° piano, scala A Milan Milan Italy 20122
| | - Giovanni Casazza
- Università degli Studi di Milano; Dipartimento di Scienze Biomediche e Cliniche "L. Sacco"; via GB Grassi 74 Milan Italy 20157
| | - Tea Stimac
- Clinical Hospital Centre Rijeka; Obstetrics and Gynecology; Cambierieva 17 Rijeka Croatia 51000
| | - Dimitrinka Nikolova
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
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Feasibility and Efficacy of S-Adenosyl-L-methionine in Patients with HBV-Related HCC with Different BCLC Stages. Gastroenterol Res Pract 2016; 2016:4134053. [PMID: 28003820 PMCID: PMC5149688 DOI: 10.1155/2016/4134053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 10/26/2016] [Indexed: 02/06/2023] Open
Abstract
Aims. To understand the feasibility and efficacy of treatment with SAMe in patients with hepatitis B-related HCC with different Barcelona Clinic Liver Cancer (BCLC) stages. Methods. We retrospectively enrolled 697 patients with BCLC early-stage (stages 0-A) and advanced-stage (stages B-C) HCC who underwent SAMe therapy (354 cases) or no SAMe therapy (343 cases). The baseline characteristics, postoperative recoveries, and 24-month overall survival rates of the patients in the 2 groups were compared. Cox regression model analysis was performed to confirm the independent variables influencing the survival rate. Results. For patients in the early-stage (BCLC stages A1–A4) group, little benefit of SAMe therapy was observed. For advanced-stage (BCLC B-C) patients, SAMe therapy reduced alanine aminotransferase (ALT) and aspartate transaminase (AST) levels and effectively delayed the recurrence time and enhanced the 24-month survival rate. Cox regression model analysis in the advanced-stage group revealed that treatment with SAMe, preoperative viral load, and Child-Pugh grade were independent variables influencing survival time. Conclusion. SAMe therapy exhibited protective and therapeutic efficacy for BCLC advanced-stage HBV-related HCC patients. And the efficacy of SAMe therapy should be further explored in randomized prospective clinical trials.
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Laurberg P, Andersen SL. ENDOCRINOLOGY IN PREGNANCY: Pregnancy and the incidence, diagnosing and therapy of Graves' disease. Eur J Endocrinol 2016; 175:R219-30. [PMID: 27280373 DOI: 10.1530/eje-16-0410] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/01/2016] [Indexed: 12/27/2022]
Abstract
Thyroid hormones are essential developmental factors, and Graves' disease (GD) may severely complicate a pregnancy. This review describes how pregnancy changes the risk of developing GD, how early pregnancy by several mechanisms leads to considerable changes in the results of the thyroid function tests used to diagnose hyperthyroidism, and how these changes may complicate the diagnosing of GD. Standard therapy of GD in pregnancy is anti-thyroid drugs. However, new studies have shown considerable risk of birth defects if these drugs are used in specific weeks of early pregnancy, and this should be taken into consideration when planning therapy and control of women who may in the future become pregnant. Early pregnancy is a period of major focus in GD, where pregnancy should be diagnosed as soon as possible, and where important and instant change in therapy may be warranted. Such change may be an immediate stop of anti-thyroid drug therapy in patients with a low risk of rapid relapse of hyperthyroidism, or it may be an immediate shift from methimazole/carbimazole (with risk of severe birth defects) to propylthiouracil (with less risk), or maybe to other types of therapy where no risk of birth defects have been observed. In the second half of pregnancy, an important concern is that not only the mother with GD but also her foetus should have normal thyroid function.
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Affiliation(s)
- Peter Laurberg
- Department of Endocrinology Department of Clinical MedicineAalborg University, Aalborg, Denmark
| | - Stine Linding Andersen
- Department of Endocrinology Department of Clinical BiochemistryAalborg University Hospital, Aalborg, Denmark,
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Kong X, Kong Y, Zhang F, Wang T, Yan J. Evaluating the effectiveness and safety of ursodeoxycholic acid in treatment of intrahepatic cholestasis of pregnancy: A meta-analysis (a prisma-compliant study). Medicine (Baltimore) 2016; 95:e4949. [PMID: 27749550 PMCID: PMC5059052 DOI: 10.1097/md.0000000000004949] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is a specific pregnancy-related disorder without standard medical therapies. Ursodeoxycholic acid (UDCA) is the most used medicine, but the efficacy and safety of UDCA remain uncertain. Several meta-analyses had been made to assess the effects of UDCA in ICP. However, the samples were not large enough to convince obstetricians to use UDCA. We conducted a meta-analysis to evaluate the effects and safety of UDCA in patients with ICP, which included only randomized controlled trials (RCTs). METHODS Six databases were searched. The search terms were "ursodeoxycholicacid," "therapy," "management," "treatment," "intrahepatic cholestasis of pregnancy," "obstetric cholestasis," "recurrent jaundice of pregnancy," "pruritus gravidarum," "idiopathic jaundice of pregnancy," "intrahepatic jaundice of pregnancy," and "icterus gravidarum."Randomized controlled trials of UDCA versus control groups (included using other medicines) among patients with ICP were included. The primary outcomes were improved pruritus scores and liver function. Secondary outcomes were the maternal and fetal outcomes in patients with ICP.Data were extracted from included RCTs. The Mantel-Haenzel random-effects model or fixed-effects model was used for meta-analysis. RESULTS A total of 12 RCTs involving 662 patients were included in the meta-analysis. In pooled analyses that compared UDCA with all controls, UDCA was associated with resolution of pruritus (risk ratio [RR], 1.68; 95% confidence interval [CI],1.12-2.52; P = 0.01),decrease of serum levels of alanine aminotransferase (ALT) (standardized mean difference (SMD), -1.36; 95% CI, -2.08 to -0.63; P <0.001), reduced serum levels of bile acid (SMD, -0.68; 95% CI, -1.15 to -0.20; P <0.001), fewer premature births (RR, 0.56; 95% CI, 0.43-0.72; P <0.001),reduced fetal distress (RR, 0.68; 95% CI, 0.49-0.94; P = 0.02), high Apgar scores at 5 minutes (RR, 0.44; 95% CI, 0.24-0.82; P = 0.009), less frequent respiratory distress syndrome (RDS) (RR, 0.33; 95% CI, 0.13-0.86; P = 0.02), and fewer neonates in the intensive care unit (NICU) (RR, 0.55; 95% CI, 0.35-0.87; P <0.05), increased gestational age (SMD,0.44; 95% CI, 0.26-0.63; P <0.001), and birth weight (SMD, 0.21; 95% CI, 0.02-0.40; P = 0.03). There were no differences in meconium staining and intrauterine growth retardation (IUGR) between the groups (P >0.05). No trials reported adverse effects on mothers and fetuses except nausea and emesis. CONCLUSION UDCA is effective and safe to improve pruritus and liver function in ICP. UDCA also reduced adverse maternal and fetal outcomes in pregnant women with ICP.
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Affiliation(s)
- Xiang Kong
- Department of Obstetrics and Gynecology, Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu, China
- Correspondence: Xiang Kong, No. 98, West Nantong Road, Yangzhou, 225001, Jiangsu Province, China (e-mail: )
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Rungsiprakarn P, Laopaiboon M, Sangkomkamhang US, Lumbiganon P. Pharmacological interventions for generalised itching (not caused by systemic disease or skin lesions) in pregnancy. Cochrane Database Syst Rev 2016; 2:CD011351. [PMID: 26891962 PMCID: PMC8665832 DOI: 10.1002/14651858.cd011351.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Generalised itching is one of the most common dermatological symptoms in pregnant women. Having itchy skin during pregnancy may be very frustrating and can lead to poor sleep, exhaustion and impaired quality of life. There is a need for a systematic review to evaluate the effectiveness and safety of pharmacological interventions for treating itching in pregnancy. OBJECTIVES To assess the effectiveness and safety of pharmacological interventions for treating generalised itching (not caused by systemic diseases or skin lesions) in pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2016) and the reference list of the one identified study. SELECTION CRITERIA All published, unpublished and ongoing randomised controlled trials (RCTs) evaluating interventions for itching in pregnancy.Quasi-RCTs, cluster-RCTs, RCTs using a cross-over design, and studies reported in abstract form (without full text) were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the one trial report that was identified from the search strategy and this was subsequently excluded. MAIN RESULTS There are no included studies as we did not identify any relevant trials. AUTHORS' CONCLUSIONS Generalised itching (not caused by systemic disease or skin lesions) is quite a common symptom in pregnancy. However, there is no evidence from randomised controlled trials to guide practice in terms of the effectiveness and safety of pharmacological interventions for treating this condition.Well-designed randomised controlled trials are needed in order to evaluate the effectiveness of topical and systemic pharmacological interventions as well as any adverse effects of the interventions. Such studies should consider important outcomes such as relief of itching, women's satisfaction, sleep disturbance, and adverse effects.
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Affiliation(s)
| | - Malinee Laopaiboon
- Khon Kaen UniversityDepartment of Biostatistics and Demography, Faculty of Public Health123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Ussanee S Sangkomkamhang
- Khon Kaen HospitalDepartment of Obstetrics and GynaecologySrichan RoadMaungKhon KaenThailand40000
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
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Abstract
Intrahepatic cholestasis of pregnancy (ICP) is characterized by maternal pruritus, and elevated serum transaminases and bile acids. Genetic defects in at least 6 canalicular transporters have been found. Association studies stress the variability of genotypes, different penetrance, and influence of environmental factors. Serum autotaxin is a sensitive, specific, and robust diagnostic marker. Elevated maternal bile acids correlate with fetal complications. Long-term sequelae for mothers include the gallstone risk and chronic liver disease. There is an association between ICP and hepatitis C. Current treatment is ursodeoxycholic acid, owing to benefits on pruritus, liver function, safety, and decreased rates of adverse effects.
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Affiliation(s)
- Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani, 2, Padova 35128, Italy.
| | - Maria Teresa Gervasi
- Department of Obstetrics and Gynecology, Azienda Ospedaliera, Via Giustiniani, 2, Padova 35128, Italy
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Sepúlveda Marín S, Contreras Maragaño V, Vera C. Is ursodeoxycholic acid effective for intrahepatic cholestasis of pregnancy? Medwave 2016; 16 Suppl 1:e6361. [PMID: 26817509 DOI: 10.5867/medwave.2015.6361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy is a condition associated with fetal morbidity and mortality. Ursodeoxycholic acid has been proposed as a treatment alternative, but its use remains controversial. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified three systematic reviews including eight randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded ursodeoxycholic acid reduces prematurity risk and need for admission in neonatal intensive care units. It might also reduce maternal pruritus.
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Affiliation(s)
- Sebastián Sepúlveda Marín
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile. Address: Facultad de Medicina, Pontificia Universidad Católica de Chile, Lira 63, Santiago Centro, Chile.
| | - Valeria Contreras Maragaño
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Proyecto Epistemonikos, Santiago, Chile
| | - Claudio Vera
- Proyecto Epistemonikos, Santiago, Chile; Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Departamento de obstetricia y ginecología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Larson SP, Kovilam O, Agrawal DK. Immunological basis in the pathogenesis of intrahepatic cholestasis of pregnancy. Expert Rev Clin Immunol 2015; 12:39-48. [PMID: 26469633 DOI: 10.1586/1744666x.2016.1101344] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intrahepatic cholestasis of pregnancy poses a great risk to both maternal and fetal health. Despite extensive research, much of the pathogenesis of this disorder is unknown. The increase in bile acids observed in patients with intrahepatic cholestasis of pregnancy has been noted to cause a change in the immune system from the normally mediated TH2 response to one that is more oriented towards TH1. In this literature review, we have critically reviewed the current literature regarding the changes in the immune system and the potential effects of immunological changes in the management of the patient. The current treatment, ursodeoxycholic acid, is also discussed along with potential combination therapies and future directions for research.
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Affiliation(s)
- Spencer P Larson
- a Center for Clinical & Translational Science , Creighton University School of Medicine , Omaha , NE , USA.,b Department of Obstetrics and Gynecology , Creighton University School of Medicine , Omaha , NE , USA
| | - Oormila Kovilam
- b Department of Obstetrics and Gynecology , Creighton University School of Medicine , Omaha , NE , USA
| | - Devendra K Agrawal
- a Center for Clinical & Translational Science , Creighton University School of Medicine , Omaha , NE , USA
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Kawakita T, Parikh LI, Ramsey PS, Huang CC, Zeymo A, Fernandez M, Smith S, Iqbal SN. Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol 2015; 213:570.e1-8. [PMID: 26071912 PMCID: PMC5199141 DOI: 10.1016/j.ajog.2015.06.021] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/26/2015] [Accepted: 06/03/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We sought to determine predictors of adverse neonatal outcomes in women with intrahepatic cholestasis of pregnancy (ICP). STUDY DESIGN This study was a multicenter retrospective cohort study of all women diagnosed with ICP across 5 hospital facilities from January 2009 through December 2014. Obstetric and neonatal complications were evaluated according to total bile acid (TBA) level. Multivariable logistic regression models were developed to evaluate predictors of composite neonatal outcome (neonatal intensive care unit admission, hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, transient tachypnea of the newborn, mechanical ventilation use, oxygen by nasal cannula, pneumonia, and stillbirth). Predictors including TBA level, hepatic transaminase level, gestational age at diagnosis, underlying liver disease, and use of ursodeoxycholic acid were evaluated. RESULTS Of 233 women with ICP, 152 women had TBA levels 10-39.9 μmol/L, 55 had TBA 40-99.9 μmol/L, and 26 had TBA ≥100 μmol/L. There was no difference in maternal age, ethnicity, or prepregnancy body mass index according to TBA level. Increasing TBA level was associated with higher hepatic transaminase and total bilirubin level (P < .05). TBA levels ≥100 μmol/L were associated with increased risk of stillbirth (P < .01). Increasing TBA level was also associated with earlier gestational age at diagnosis (P < .01) and ursodeoxycholic acid use (P = .02). After adjusting for confounders, no predictors were associated with composite neonatal morbidity. TBA 40-99.9 μmol/L and TBA ≥100 μmol/L were associated with increased risk of meconium-stained amniotic fluid (adjusted odds ratio, 3.55; 95% confidence interval, 1.45-8.68 and adjusted odds ratio, 4.55; 95% confidence interval, 1.47-14.08, respectively). CONCLUSION In women with ICP, TBA level ≥100 μmol/L was associated with increased risk of stillbirth. TBA ≥40 μmol/L was associated with increased risk of meconium-stained amniotic fluid.
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Affiliation(s)
- Tetsuya Kawakita
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC.
| | - Laura I Parikh
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC
| | - Patrick S Ramsey
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Chun-Chih Huang
- Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, MD
| | - Alexander Zeymo
- Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, MD
| | - Miguel Fernandez
- Department of Obstetrics and Gynecology, Virginia Hospital Center, Arlington, VA
| | - Samuel Smith
- Department of Obstetrics and Gynecology, MedStar Franklin Square Medical Center, Baltimore, MD
| | - Sara N Iqbal
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC
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Excessive bile acid activated NF-kappa B and promoted the development of alcoholic steatohepatitis in farnesoid X receptor deficient mice. Biochimie 2015; 115:86-92. [DOI: 10.1016/j.biochi.2015.05.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 05/13/2015] [Indexed: 02/06/2023]
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Joutsiniemi T, Timonen S, Linden M, Suvitie P, Ekblad U. Intrahepatic cholestasis of pregnancy: observational study of the treatment with low-dose ursodeoxycholic acid. BMC Gastroenterol 2015; 15:92. [PMID: 26215400 PMCID: PMC4517361 DOI: 10.1186/s12876-015-0324-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 07/20/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To exam the biochemical, obstetric management and pregnancy outcome in women with intrahepatic cholestasis of pregnancy (ICP) and treatment with ursodeoxycholic acid (UDCA). METHODS Pregnancy outcome in patients with ICP (N = 307) was studied and patients treated with UDCA (N = 208) vs. no UDCA were compared. The data of the antenatal visits, deliveries and neonatal outcome of 307 pregnancies with ICP was collected from the hospital computerized delivery room log book. UDCA was used in 208 pregnancies. The diagnosis was made by maternal pruritus and elevation of total fasting bile acid (BA) (>6 μmol/l) and elevation of serum alanine aminotransferases (ALT) (>45 U/l). Maternal and neonatal data was analysed and data of the patients who used UDCA during pregnancy was analysed separately and compared with the data from patients without medication. RESULTS UDCA was well tolerated. Mothers receiving UDCA had ICP diagnosed five weeks earlier than mothers without medication. At the diagnosis, levels of total BA and ALT were higher in the group using UDCA compared to the group without medication. Most deliveries were induced and perinatal outcome was good. Apgar scores at 5 min were significantly lower in UDCA group (p < 0.05), but fetal umbilical artery pH values were similar in both groups (p > 0.05). There were 30 patients with total BA > 40 μmol/l at diagnosis, 24 with UDCA and 6 without medication and those deliveries were induced soon after diagnosis. The preterm labour was also more common in these patents (p < 0.05). Women with preterm babies had significantly early onset pruritus and ICP was diagnosed earlier. Serum ALT and total BA levels were significantly higher in those pregnancies at diagnosis and also at first control. CONCLUSIONS Preterm labour was associated in severe ICP (total BA > 40 μmol/l), ALT levels were also significantly higher and ICP was diagnosed earlier (p < 0.05). Apgar scores were lower in preterm babies (p < 0.05), but umbilical artery pHvalues were not significantly lower. UDCA was well tolerated by pregnant women. With low-dose UDCA treatment the obstetric outcome was good. We still recommend careful obstetrical follow-up.
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Affiliation(s)
- Titta Joutsiniemi
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Susanna Timonen
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Maria Linden
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Pia Suvitie
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Ulla Ekblad
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
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Noureddin M, Mato JM, Lu SC. Nonalcoholic fatty liver disease: update on pathogenesis, diagnosis, treatment and the role of S-adenosylmethionine. Exp Biol Med (Maywood) 2015; 240:809-20. [PMID: 25873078 PMCID: PMC4818965 DOI: 10.1177/1535370215579161] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is currently the most common liver disease worldwide affecting over one-third of the population in the U.S. It has been associated with obesity, type 2 diabetes, hyperlipidemia, and insulin resistance and is initiated by the accumulation of triglycerides in hepatocytes. Isolated hepatic steatosis (IHS) remains a benign process, while a subset develops superimposed inflammatory activity and progression to nonalcoholic steatohepatitis (NASH) with or without fibrosis. However, the molecular mechanisms underlying NAFLD progression are not completely understood. Liver biopsy is still required to differentiate IHS from NASH as easily accessible noninvasive biomarkers are lacking. In terms of treatments for NASH, pioglitazone, vitamin E, and obeticholic acid have shown some benefit. All of these agents have potential complications associated with long-term use. Nowadays, a complex hypothesis suggests that multiple parallel hits are involved in NASH development. However, the 'key switch' between IHS and NASH remains to be discovered. We have recently shown that knocking out enzymes involved in S-adenosylmethionine (SAMe) metabolism, the main biological methyl donor in humans that is abundant in the liver, will lead to NASH development in mice. This could be due to the fact that a normal SAMe level is required to establish the proper ratio of phosphatidylethanolamine to phosphatidylcholine that has been found to be important in NAFLD progression. New data from humans have also suggested that these enzymes play a role in the pathogenesis of NAFLD and that some of SAMe cycle metabolites may serve as noninvasive biomarkers of NASH. In this review, we discuss the evidence of the role of SAMe in animal models and humans with NAFLD and how studying this area may lead to the discovery of new noninvasive biomarkers and possibly personalized treatment for NASH.
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Affiliation(s)
| | - José M Mato
- Ibaizabal Kalea, 101, 48170 Zamudio, Bizkaia, Spain
| | - Shelly C Lu
- Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Guo T, Chang L, Xiao Y, Liu Q. S-adenosyl-L-methionine for the treatment of chronic liver disease: a systematic review and meta-analysis. PLoS One 2015; 10:e0122124. [PMID: 25774783 PMCID: PMC4361566 DOI: 10.1371/journal.pone.0122124] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/07/2015] [Indexed: 12/13/2022] Open
Abstract
It has been well established that S-adenosyl-L-methionine (SAMe) is the principal methyl donor in methyltransferase reactions and that SAMe supplementation restores hepatic glutathione (GSH) deposits and attenuates liver injury. However, the effectiveness of SAMe therapy in chronic liver disease has not been adequately addressed. We searched globally recognized electronic databases, including PubMed, the Cochrane Database and EMBASE, to retrieve relevant randomized controlled trials (RCTs) of chronic liver disease published in the past 20 years. We then performed a systematic review and meta-analysis of the enrolled trials that met the inclusion criteria.The results showed that twelve RCTs from 11 studies, which examined 705 patients, were included in this research. For liver function, certain results obtained from data synthesis and independent comparisons demonstrated significant differences between the levels of total bilirubin (TBIL) and aspartate transaminase (AST). However, no studies identified significant differences regarding alanine transaminase (ALT) levels. An analysis of the adverse events and long-term prognosis also indicated no significant differences between the SAMe and the placebo groups. In a subgroup analysis of gravidas and children, several of the included data indicated that there was a significant difference in the pruritus score. Furthermore, the results regarding ursodeoxycholic acid (UDCA) and stronger neo-minophagen C (SNMC) indicated that both treatments were more effective than SAMe was in certain chronic liver diseases. These findings suggest that SAMe could be used as the basis of a medication regimen for liver function improvement because of its safety. However, SAMe also demonstrated limited clinical value in the treatment of certain chronic liver diseases.
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Affiliation(s)
- Tao Guo
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital, Wuhan University, Wuhan 430071, P.R. China
| | - Lei Chang
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital, Wuhan University, Wuhan 430071, P.R. China
| | - Yusha Xiao
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital, Wuhan University, Wuhan 430071, P.R. China
| | - Quanyan Liu
- Department of General Surgery, Research Center of Digestive Diseases, Zhongnan Hospital, Wuhan University, Wuhan 430071, P.R. China
- * E-mail:
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Garcia-Flores J, Cañamares M, Cruceyra M, Garicano A, Espada M, Lopez A, Tamarit I. Clinical value of maternal bile Acid quantification in intrahepatic cholestasis of pregnancy as an adverse perinatal outcome predictor. Gynecol Obstet Invest 2015; 79:222-8. [PMID: 25720981 DOI: 10.1159/000370003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 11/18/2014] [Indexed: 11/19/2022]
Abstract
AIMS To evaluate the correlation between perinatal outcome and bile acid levels in intrahepatic cholestasis of pregnancy (ICP), and to evaluate variations in the mean bile acid level when stratifying by maternal and perinatal factors. A comparison between mild and severe ICP was made. METHODS A prospective observational study was performed in pregnant patients who underwent blood tests for bile acids due to persistent pruritus. Based on bile acid levels, maternal and neonatal data were obtained and were compared between patients presenting with ICP and gestational pruritus (normal bile acid level). RESULTS A total of 145 patients were included, 47 of whom were diagnosed as ICP (52 newborns) and 98 as gestational pruritus (102 newborns). The ICP group had a higher rate of NICU admission (14/42 vs. 6/98, p < 0.001) and global neonatal morbidity (13/42 vs. 9/98, p = 0.002), but these differences were no longer seen after adjusting for gestational age, singleton pregnancies and induction of labour. Patients presenting with severe ICP (maximum bile acids levels above 40 µmol/l) showed a higher rate of meconium-stained amniotic fluid (0/28 vs. 4/14, p = 0.009), NICU admission (9/34 vs. 11/17, p = 0.01) and neonatal global morbidity (5/32 vs. 8/17, p = 0.02). CONCLUSIONS ICP patients have higher rates of adverse neonatal outcomes when compared to those with gestational pruritus. Some of this neonatal morbidity may be secondary to late spontaneous preterm deliveries, multiple gestation and a policy of elective induction of labour after 37 weeks of gestation. A comparison of outcomes among patients with mild and severe ICP shows that the severely affected group has higher rates of meconium-stained amniotic fluid and neonatal morbidity.
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Affiliation(s)
- Jose Garcia-Flores
- Obstetrics and Gynecology Department, Hospital Universitario Quiron Madrid, Madrid, Spain
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Marchioni Beery RM, Vaziri H, Forouhar F. Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis: a Review Featuring a Women's Health Perspective. J Clin Transl Hepatol 2014; 2:266-84. [PMID: 26357630 PMCID: PMC4521232 DOI: 10.14218/jcth.2014.00024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 10/15/2014] [Accepted: 10/19/2014] [Indexed: 12/12/2022] Open
Abstract
Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are two major types of chronic cholestatic liver disease. Each disorder has distinguishing features and variable progression, but both may ultimately result in cirrhosis and hepatic failure. The following offers a review of PBC and PSC, beginning with a general overview of disease etiology, pathogenesis, diagnosis, clinical features, natural course, and treatment. In addition to commonly associated manifestations of fatigue, pruritus, and fat-soluble vitamin deficiency, select disease-related topics pertaining to women's health are discussed including metabolic bone disease, hyperlipidemia and cardiovascular risk, and pregnancy-related issues influencing maternal disease course and birth outcomes. This comprehensive review of PBC and PSC highlights some unique clinical considerations in the care of female patients with cholestatic liver disease.
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Affiliation(s)
- Renée M. Marchioni Beery
- Division of Internal Medicine, Department of Gastroenterology and Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- Correspondence to: Renée M. Marchioni Beery, DO, Division of Internal Medicine, Department of Gastroenterology and Hepatology, 263 Farmington Avenue, Farmington, CT 06030-1845, USA. Tel: +01-860-679-3158, Fax: +01-860-679-3159. E-mail:
| | - Haleh Vaziri
- Division of Internal Medicine, Department of Gastroenterology and Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - Faripour Forouhar
- Department of Pathology and Lab Medicine, University of Connecticut Health Center, Farmington, CT, USA
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Arthur C, Mahomed K. Intrahepatic cholestasis of pregnancy: diagnosis and management; a survey of Royal Australian and New Zealand College of Obstetrics and Gynaecology fellows. Aust N Z J Obstet Gynaecol 2014; 54:263-7. [PMID: 24506294 DOI: 10.1111/ajo.12178] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/16/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is an uncommon obstetric condition characterised by intense maternal pruritis and biochemical abnormality. There is a degree of contention regarding the diagnosis and management of ICP, and currently, there are no nationally accepted guidelines. AIMS To conduct a survey of Fellows and Members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) regarding their diagnosis and management ICP. METHODS An online survey of currently practising RANZCOG Fellows and Members, utilising Survey Monkey. RESULTS Thirty percent of those sent the survey responded, comprising approximately 40% of practising obstetricians. Fasting bile acid and serum transaminase elevation in association with the characteristic itch define the disease process for the majority of respondents and also inform management decisions. There was no critical level of bile acid elevation that mandated treatment for the majority of respondents. Nearly 90% of respondents induce women with ICP at 37-38 completed weeks of pregnancy, due to concerns regarding possible fetal demise. About one-third of respondents refer to the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline to advise their decision-making process, and a similar proportion use local or hospital-based guidelines. CONCLUSIONS Elevated fasting bile acids and abnormal liver function tests define the diagnosis and inform management of ICP by Australian obstetricians. Routine induction of labour for patients with ICP at 37-38 completed weeks of pregnancy is widely practised in Australia. An evidence-based guideline would assist clinicians who manage such cases in Australia.
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Affiliation(s)
- Chris Arthur
- Redcliffe Hospital, Redcliffe, Queensland, Australia
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