Severe intrahepatic cholestasis of pregnancy is a risk factor for preeclampsia in singleton and twin pregnancies

Elevated maternal serum bile acids level, hypertensive disorders of pregnancy and adverse fetal outcomes: a cohort study of 117,789 pregnant women in China

BACKGROUND

Elevated maternal serum total bile acids (sTBA) level during pregnancy was associated with adverse fetal outcomes. Women with elevated sTBA could complicate with hepatic dysfunction or vascular disorders (hypertensive disorders of pregnancy, HDP), which aggravated adverse fetal outcomes. However, the relationships among sTBA level, hepatic dysfunction, HDP and adverse fetal outcomes were still illusive.

OBJECTIVE

We aimed to explore whether hepatic dysfunction or vascular disorders (HDP) mediated the associations between elevated sTBA level and adverse fetal outcomes.

METHODS

A large retrospective cohort study encompassing 117,789 Chinese pregnant women with singleton delivery between Jan 2014 and Dec 2022 was conducted. Causal mediation analysis was applied to assess the mediating role of hepatic dysfunction (alanine transaminase > 40 U/L) or HDP in explaining the relationship between high maternal sTBA level (≥10 μmol/L) and adverse fetal outcomes, including low birth weight (LBW), small for gestational age (SGA), and preterm birth (PTB).

RESULTS

sTBA level were positively associated with LBW (adjusted odds ratio (aOR) = 1.40; [95 % confidence interval (CI): 1.24-1.59]), SGA (aOR=1.31; [95 % CI: 1.18-1.46]), and PTB (aOR=1.27; [95 % CI: 1.15-1.41]), respectively. The estimated proportions of the total associations mediated by HDP were 47 % [95 % CI: 31 %-63 %] for LBW, 24 % [95 % CI: 13 %-35 %] for SGA, and 34 % [95 % CI: 19 %-49 %] for PTB, excepting the direct effects of high sTBA level. The contribution of hepatic dysfunction as a mediator was weaker on the association between high sTBA level on fetal outcomes, as the proportions mediated and 95 % CI were 16 % [4 %-29 %], 4 % [-6%-14 %], 32 % [15 %-50 %] for LBW, SGA, and PTB, respectively. Moreover, the mediating effect of hepatic dysfunction was nearly eliminated after excluding cases of HDP in the sensitivity analysis.

CONCLUSIONS

The substantial mediating effects through HDP highlighted its significant role in adverse fetal outcomes associated with elevated sTBA level. The findings also provoked new insights into understanding the mechanism and developing clinical management strategies (i.e. vascular protection) for adverse fetal outcomes associated with elevated sTBA level.

Guideline No. 452: Diagnosis and Management of Intrahepatic Cholestasis of Pregnancy

OBJECTIVE

To summarize the current evidence and to make recommendations for the diagnosis and management of intrahepatic cholestasis of pregnancy.

TARGET POPULATION

Pregnant people with intrahepatic cholestasis of pregnancy.

OPTIONS

Diagnosing the condition using fasting or non-fasting bile acids, classifying disease severity, determining what treatment to offer, establishing how to monitor for antenatal fetal wellbeing, identifying when to perform elective birth.

BENEFITS, HARMS, AND COSTS

Individuals with intrahepatic cholestasis of pregnancy are at increased risk of adverse perinatal outcomes including preterm birth, neonatal respiratory distress and admission to a neonatal intensive care unit, with an increased risk of stillbirth when bile acid levels are ≥100 μmol/L. There is inequity in bile acid testing availability and timely access to results, along with uncertainly of how to treat, monitor. and ultimately deliver these pregnancies. Optimization of diagnostic and management protocols can improve maternal and fetal postnatal outcomes.

EVIDENCE

Medline, PubMed, Embase, and the Cochrane Library were searched from inception to March 2023, using medical subject headings (MeSH) and keywords related to pregnancy, intrahepatic cholestasis of pregnancy, bile acids, pruritis, ursodeoxycholic acid, and stillbirth. This document presents an abstraction of the evidence rather than a methodological review.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations).

INTENDED AUDIENCE

Obstetric care providers, including obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, and radiologists.

SOCIAL MEDIA ABSTRACT

Intrahepatic cholestasis of pregnancy requires adequate diagnosis with non-fasting bile acid levels which guide optimal management and delivery timing.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Intrahepatic cholestasis of pregnancy and its association with preeclampsia and gestational diabetes: a retrospective analysis

PURPOSE

To evaluate maternal and neonatal outcomes in patients with intrahepatic cholestasis of pregnancy (ICP).

METHODS

Patients who gave birth in our hospital between January 2018 and March 2022 were retrospectively reviewed from the hospital database and patient file records. The study comprised 1686 patients, 54 in the ICP group and 1632 controls. Patients who had ICP after 20 weeks of gestation and were monitored and delivered at our facility were enrolled. Maternal demographic and obstetric characteristics data were examined. Perinatal outcomes were also assessed. Logistic regression analysis was used to determine adverse maternal outcomes.

RESULTS

The mean age was 29 years. ART, GDM, and preeclampsia were significantly higher in the ICP group. The mean serum bile acid level was 19.3 ± 3 μmol/L in the ICP group. There was a higher risk of GDM and pre-eclampsia in women with ICP compared with those without and a significant association between ICP and adverse perinatal outcomes. There was a statistically significant relation between the presence of ICP and spontaneous preterm delivery, iatrogenic preterm delivery, 5th-minute Apgar scores < 7, and NICU requirement. No significant relationship was found between the presence of ICP and SGA and meconium. There was a significant relationship between the presence of ICP, mode of delivery, and PPH (p < 0.05). Those with ICP had a lower gestational week and birth weight, and higher rates of cesarean delivery and PPH.

CONCLUSION

ICP should prompt close monitoring and management to mitigate the potential exacerbation of adverse outcomes, including preeclampsia, GDM, and preterm birth.

Predictors of Adverse Fetal Outcomes in Intrahepatic Cholestasis of Pregnancy (ICP): a Narrative Review

Intrahepatic cholestasis of pregnancy (ICP) is a hepatic disorder in pregnancy linked with adverse fetal outcomes, which primarily manifests in the late second and third trimesters of pregnancy. This review aims to recapitulate the existing evidence on factors that can predict detrimental perinatal outcomes in pregnant women diagnosed with intrahepatic cholestasis of pregnancy. We searched PubMed, Web of Science, Cochrane Library, Scopus, Medline, and Embase databases and selected studies related to predictors of fetal outcome in intrahepatic cholestasis of pregnancy. Studies of the articles showed that predictors of an adverse fetal outcome include in vitro fertilization (IVF) pregnancy, multifetal pregnancy, biochemical markers, gestational age of ICP onset, presence of comorbidities (preeclampsia and gestational diabetes mellitus), maternal history of ICP, and hepatobiliary disease.Intrahepatic cholestasis of pregnancy (ICP) complicates the pregnancy. Hence, early assessment of low-risk and high-risk groups will help to administer definite management protocols and strategies to prevent adverse neonatal outcomes. Further research should concentrate on the number of conditions/factors and the predictive power of different factors to determine the most reliable predictors and biomarkers that can predict adverse fetal outcomes and improve the assessment of risk in pregnancy complicated with ICP.

A nomogram for predicting the risk of preeclampsia in women with intrahepatic cholestasis of pregnancy based on prenatal monitoring time: a multicenter retrospective cohort study

BACKGROUND AND AIMS

Intrahepatic cholestasis of pregnancy (ICP) is a special liver disease during pregnancy, characterized by abnormal bile acid metabolism. However, there is no consensus on how to group women with ICP based on the time of diagnosis worldwide. This study aimed to adopt a new grouping model of women with ICP, and the time from diagnosis to delivery was defined as the monitoring period.

METHODS

This retrospective real-world data study was conducted across multiple centers and included 3172 women with ICP. The study first evaluated the significant difference in medication and nonmedication during different monitoring times. The least absolute shrinkage and selection operator (LASSO) model was then used to screen nine risk factors based on the predictors. The model's discrimination, clinical usefulness, and calibration were assessed using the area under the receiver operating characteristic (ROC) curve, decision curve, and calibration analysis.

RESULTS

The incidence of preeclampsia risk in ICP patients without drug intervention increased with the extension of the monitoring period. However, the risk of preeclampsia decreased in ICP patients treated with ursodeoxycholic acid. A predictive nomogram and risk score model was developed based on nine risk factors. The area under the ROC curve of the nomogram was 0.765 [95% confidence interval (CI): 0.724-0.807] and 0.812 (95% CI: 0.736-0.889) for the validation cohort.

CONCLUSIONS

This study found that a longer ICP monitoring period could lead to adverse pregnancy outcomes in the absence of drug intervention, especially preeclampsia. A predictive nomogram and risk score model was developed to better manage ICP patients, maintain pregnancy to term delivery, and minimize the risk of severe adverse maternal and fetal outcomes.

Pregnancy outcomes following antenatal screening for intrahepatic cholestasis of pregnancy (ICP)

OBJECTIVE

To evaluate the maternal and perinatal outcomes following antenatal screening for ICP using a retrospective approach.

MATERIALS AND METHODS

A retrospective study was conducted at the second affiliated hospital of Chongqing Medical University, Chongqing, China, from 2012 to 2017. Pregnant women registered for antenatal in our hospital were screened for ICP. The pregnant women with detailed delivery record and presenting with the diagnosis of ICP based on TBA level ≥10 mmol/L and abnormal liver enzymes were included in the study.

METHOD

The pregnant women with detailed delivery records presenting with the diagnosis of ICP based on TBA level ≥10 mmol/L and abnormal liver enzymes were included in the study. 1410 pregnant women were enrolled in this study. We selected 940 pregnant women without the diagnosis of ICP as our control and 470 pregnant women diagnosed with ICP as our case study. Data collection and sampling in the control group was done using microsoft excel (version 16.61) random number generator.

RESULTS

The mean age of the pregnant women and the gestational age at the time of diagnosis of ICP were 29.01 ± 4.3 years and 31.90 ± 8.83 weeks, respectively. It was found that a significant number of patients with ICP had a preterm birth and low birth weight (LBW), n = 151 (32.5%) P < 0.001 and n = 70 (14.9%) P < 0.001, respectively. A significant number of patients in the case group had a history of liver disease and gall bladder disease, p < 0.001 and p = 0.005, respectively, and a higher rate of GDM p < 0.001. Despite treatment, high TBA titer among ICP patients was associated with preterm delivery.

CONCLUSION

ICP in pregnancy leads to complications and poor perinatal outcomes. Fetal outcomes depend on the TBA levels; therefore, early diagnosis of ICP through routine screening followed by treatment is recommended in high-risk persons/areas.

Cholelithiasis is an additional pre-pregnancy clinical risk factor for preeclampsia

PURPOSE

To investigate additional potential clinical risk factors for preeclampsia.

METHODS

This is a nested case-control study of preeclampsia and unaffected pregnancies. Cases were either from a prenatal screening database or from a national network of clinicians, and controls were from the same prenatal source. Preeclampsia was defined by international criteria which were endorsed by the Ukraine Ministry of Health. Questionnaires were used to record a range of pregnancy related factors, personal history of health conditions and family history, followed by a telephone interview to collect more details.

RESULTS

There were 103 cases, 56 from the prenatal database and 47 from the clinicians, and 480 controls from the database. The two types of case did not differ in terms of age, weight, BMI or parity. Known risk factors were more common in cases than controls. In addition there was a 17-fold higher prevalence of cholelithiasis in cases compared with controls (29.1% versus 1.7%), a highly statistically significant difference (P < 0.0001). There was also an 8.8-fold increase among the mothers of cases and controls (P < 0.0001), and if either the patient or her mother had the disease the increase was 6.4-fold (P < 0.0001). Including the father or sibling did not increase the relative risk.

CONCLUSION

Cholelithiasis is a clinical risk factor for preeclampsia which has not previously been reported. If confirmed by additional studies it may have utility in routine prenatal screening and provide insight into the pathogenesis of preeclampsia.

Per- and Poly-fluoroalkyl Substances and Bile Acid Profiles in Pregnant Women

Alterations in bile acid (BA) profiles are closely associated with adverse outcomes in pregnant women and their offspring and may be one potential pathway underlying the related metabolic effects of per- and poly-fluoroalkyl substances (PFAS) exposure. However, evidence of associations between PFAS exposure and BA profiles in pregnant women is scarce. This study examined the associations of individual PFAS and PFAS mixture with BA profiles of pregnant women. We obtained quantitative data on the plasma concentrations of 13 PFAS and 15 BAs in 645 pregnant women from the Jiashan birth cohort. In Bayesian kernel machine regression models, the PFAS mixture was associated with increased plasma CA, TCA, TCDCA, and GLCA levels but with decreased GCA and LCA concentrations. Furthermore, the PFAS mixture was associated with increased concentrations of total BAs and the secondary/primary BA ratio but with decreased conjugated/unconjugated and glycine/taurine-conjugated BA ratios. PFHxS, PFUdA, PFOS, PFNA, and PFDA were the dominant contributors. The results of the linear regression analysis of individual PFAS were generally similar. Our findings provide the first epidemiological evidence for the associations of a PFAS mixture with BA profiles in pregnant women and may provide explanatory insights into the biological pathways underlying the related metabolic effects of PFAS exposure.

Risk factors associated with cesarean section and adverse fetal outcomes in intrahepatic cholestasis of pregnancy

Background

To determine the risk factors for cesarean section (CS) and adverse fetal outcomes (AFOs) in patients with intrahepatic cholestasis of pregnancy (ICP) based on the severity of maternal hypercholanemia.

Methods

A hospital-based retrospective cohort study was performed between January 1, 2015, and December 31, 2019. A total of 227 nulliparous women with a singleton fetus complicated by ICP were included. The patients were divided into two groups according to the levels of total bile acids, that is, mild (10 μmol/L < total bile acids < 40 μmol/L) and severe (≥40 μmol/L). The patients' clinical characteristics and fetal outcomes were assessed.

Results

Among the 227 eligible women, 177 (78.0%) were allocated to the mild group and 50 (22.0%) were in the severe group. Women with severe ICP also had a significantly higher incidence of planned and unplanned CS compared with mild ICP subjects (52.0% vs. 23.7% and 22.0% vs. 6.8%, respectively; p < 0.001). The indications for CS showed that fetal intolerance (65.4% vs. 14.3%) was higher in severe ICP compared with mild ICP (p < 0.001). Severe ICP was associated with an increased risk of preterm delivery (p < 0.001), low birthweight (p = 0.001), and neonatal intensive care unit (NICU) admission (p < 0.001). Women with severe ICP (OR 6.397, 95%CI 3.041-13.455, p < 0.001) or preeclampsia (OR 12.434, 95%CI 5.166-29.928, p < 0.001) had increased risks of AFOs compared to controls.

Conclusions

Severe ICP and preeclampsia are associated with a higher incidence of AFOs.

Labetalol and soluble endoglin aggravate bile acid retention in mice with ethinylestradiol-induced cholestasis

Labetalol is used for the therapy of hypertension in preeclampsia. Preeclampsia is characterized by high soluble endoglin (sEng) concentration in plasma and coincides with intrahepatic cholestasis during pregnancy (ICP), which threatens the fetus with the toxicity of cumulating bile acids (BA). Therefore, we hypothesized that both labetalol and increased sEng levels worsen BA cumulation in estrogen-induced cholestasis. C57BL/6J, transgenic mice overexpressing human sEng, and their wild-type littermates were administrated with ethinylestradiol (EE, 10 mg/kg s.c., the mice model of ICP) and labetalol (10 mg/kg s.c.) for 5 days with sample collection and analysis. Plasma was also taken from healthy pregnant women and patients with ICP. Administration of labetalol to mice with EE cholestasis aggravated the increase in BA plasma concentrations by induction of hepatic Mrp4 efflux transporter. Labetalol potentiated the increment of sEng plasma levels induced by estrogen. Increased plasma levels of sEng were also observed in patients with ICP. Moreover, increased plasma levels of human sEng in transgenic mice aggravated estrogen-induced cholestasis in labetalol-treated mice and increased BA concentration in plasma via enhanced reabsorption of BAs in the ileum due to the upregulation of the Asbt transporter. In conclusion, we demonstrated that labetalol increases plasma concentrations of BAs in estrogen-induced cholestasis, and sEng aggravates this retention. Importantly, increased sEng levels in experimental and clinical forms of ICPs might present a novel mechanism explaining the coincidence of ICP with preeclampsia. Our data encourage BA monitoring in the plasma of pregnant women with preeclampsia and labetalol therapy.

Elevated GABRP expression is correlated to the excessive autophagy in intrahepatic cholestasis of pregnancy

In intrahepatic cholestasis of pregnancy (ICP) patients, high concentrations of bile acids altered the normal maternal-fetal-unit physiological condition and could bring negative influence on placenta functionality. GABRP is the pi subunit of the gamma-aminobutyric acid type A receptor (GABA_A) and plays pivotal role in regulating GABA_A receptor's physiological function. Here we presented evidence that increased expression of GABRP in parallel with autophagic biomarkers, LC3 and ATG14, in patients with ICP.

METHODS

A total of 27 participants, including 18 ICP patients and 9 healthy pregnancies were recruited according to strict inclusion criteria. Placentas of ICP patients and controls were collected immediately after cesarean section before labor onset. GABRP and autophagic markers expression in placenta were investigated by immunohistochemistry (IHC), RT-qPCR, and Western blot.

RESULTS

The neonatal birthweight and gestational weeks were significantly lower in severe ICP group, while the hepatic enzymes were elevated in ICP group. Semiquantitative analysis of IHC revealed the AOD of GABRP in severe ICP patients was higher than that in mild ICP patients and control pregnancies. Western blot and RT-qPCR analysis both indicated that the expression of GABRP and ATG14 were significantly elevated in severe ICP patients. Moreover, GABRP was correlated with TBA (r = 0.64, p < 0.05), ATG14 (r = 0.87, p < 0.05), direct bilirubin (r = 0.54, p < 0.05), ALT (r = 0.72, p < 0.05), and AST (r = 0.67, p < 0.05).

CONCLUSION

There were elevated expression of GABRP, ATG14 and LC3 in ICP placentas compared with uncomplicated pregnancies. The expression of GABRP was associated with autophagy and was correlated with the TBA levels.

The impact of intrahepatic cholestasis on pregnancy outcomes: a retrospective cohort study

BACKGROUND

This study analyzed the pregnancy outcomes of patients with intrahepatic cholestasis of pregnancy (ICP) in Hangzhou, China.

METHODS

Cases of pregnant women monitored by antepartum testing at Hangzhou Women's Hospital from January 2018 to December 2020 were reviewed. Subjects were classified into two groups according to whether they had ICP: 688 cases of ICP were assigned to an exposure group while 38,556 cases of non-ICP were assigned to a non-exposed group. Univariate analysis was performed on qualitative or quantitative data using the Chi-Squared test or Mann-Whitney U test, and the adjusted odds ratio (aOR) and 95% confidence interval (CI) of the two groups of related variables were calculated by multivariate binary logistic regression analysis.

RESULTS

The incidence rate of ICP was 1.75%. Pregnant women with hepatitis B virus were correlated with ICP. Hepatitis B carriers (aOR = 3.873), preeclampsia (PE, aOR = 3.712), thrombocytopenia (aOR = 1.992), gestational hypertension (GH, aOR = 1.627), hyperlipidemia (aOR = 1.602) and gestational diabetes mellitus (GDM, aOR = 1.265) were all risk factors for ICP. In contrast, Body Mass Index (BMI) ≥ 30 kg/m² (aOR = 0.446), 25 m² < maternal BMI < 29.9 kg/m² (aOR = 0.699) and parity ≥ 1 (aOR = 0.722) were protective factors for ICP. Pregnant women in the ICP group had an increased risk of gestation days < 259 days (aOR = 4.574) and cesarean delivery (aOR = 1.930) after ICP, and a decreased risk of longer gestational days (aOR = 0.105), premature rupture of membranes (aOR = 0.384) and fetal macrosomia (aOR = 0.551).

CONCLUSIONS

By analyzing a Chinese population with ICP, we identified that pregnant women who are hepatitis B carriers or with PE, thrombocytopenia, GH, hyperlipidemia, and GDM are at higher risk of ICP. Moreover, ICP is associated with adverse pregnancy outcomes; in particular, ICP may increase the incidence of shorter gestational days and non-vaginal delivery methods such as cesarean section but reduce the incidence of premature rupture of membranes and fetal macrosomia.

Severe Intrahepatic Cholestasis of Pregnancy-Potential Mechanism by Which Fetuses Are Protected from the Hazardous Effect of Bile Acids

Intrahepatic cholestasis of pregnancy (ICP) is characterized by elevated total bile acids (TBA). Although elevated maternal TBA is a major risk factors for fetal morbidity and mortality, it is unclear why some fetuses are more prone to the hazardous effect of bile acids (BA) over the others. It is unclear whether fetuses are protected by placental BA uptake, or it is the fetal BA metabolism that reduces fetal BA as compared to maternal levels. Therefore, we aimed to compared TBA levels in the umbilical vein and artery to maternal TBA in women with ICP. The study included 18 women who had TBA > 40 μmol/L and their 23 fetuses. We found that the TBA level in umbilical vein was significantly lower compared to maternal TBA level. The TBA levels in umbilical vein and umbilical artery were similar. No fetus had a serious neonatal complication. Importantly, since TBA level remains low even though maternal TBA level is high the fetuses are protected from the hazardous effects of maternal BA. Our findings suggest that there is no effective metabolism of BA in the fetus and the main decrease in TBA in the fetus is related to placental BA uptake.

Trends in gestational age at delivery for intrahepatic cholestasis of pregnancy and adoption of society guidelines

BACKGROUND

Intrahepatic cholestasis of pregnancy is associated with a significant risk of stillbirth, which contributes to variation in clinical management. Recent Society for Maternal-Fetal Medicine guidance recommends delivery at 36 weeks of gestation for patients with serum bile acid levels of >100 μmol/L, consideration for delivery between 36 and 39 weeks of gestation stratified by bile acid level, and against preterm delivery for those with clinical features of cholestasis without bile acid elevation.

OBJECTIVE

This study aimed to investigate institutional practices before the publication of the new delivery timing recommendations to establish the maternal and neonatal effects of late preterm, early-term, and term deliveries in the setting of cholestasis.

STUDY DESIGN

This study examined maternal and neonatal outcomes of 441 patients affected by cholestasis delivering 484 neonates in a 4-hospital system over a 30-month period. Logistic and linear regression analyses were performed to assess neonatal outcomes concerning peak serum bile acid levels at various gestational ages controlling for maternal comorbidities, multiple pregnancies, and neonatal birthweight.

RESULTS

With the clinical flexibility afforded by the new guidelines, pregnancy prolongation to term may have been achieved in 91 patients (21%), and 286 patients (74%) with bile acid elevation could have delivered at a later gestational age. Preterm deliveries of patients with bile acid levels of >10 μmol/L were associated with higher rates of neonatal intensive care unit admission and adverse neonatal outcomes than early-term deliveries.

CONCLUSION

Study data suggested an opportunity for education and practice change to reflect current Society for Maternal-Fetal Medicine guidelines in efforts to reduce potential neonatal morbidities associated with late preterm deliveries among pregnancies affected by cholestasis.

Intrahepatic cholestasis of pregnancy can increase the risk of metabolic disorders: A meta-analysis

BACKGROUND

Gestational diabetes mellitus (GDM) and preeclampsia (PE) are common complications during pregnancy. Studies indicated that abnormal bile acid metabolism is related to its pathogenesis. Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-specific liver disease, which classic symptoms include generalized pruritus that commonly and biochemical evidence of elevated bile acids. Our study aimed to explore the correlation between the ICP presence and risk of GDM, PE incident in pregnant women.

METHODS

A meta-analysis, which included 10 eligible studies including 17,688 ICP cases and 1,386,771 controls, was performed to assess the correlation of ICP with preeclampsia (PE) and gestational diabetes mellitus (GDM). There were 7 studies investigating the relationship between ICP and PE, and 9 studies that evaluated the relationship between ICP and GDM. All eligible studies were screened from Pubmed, Web of Science and EBSCO databases.

RESULTS

The results of this meta-analysis indicate that ICP significantly increase the risk for both PE (pooled odds ratio OR: 2.56 95%CI: 2.27 2.88, I2 heterogeneity = 35%, p heterogeneity = 0.16) and GDM (pooled OR: 2.28 95%CI: 1.69 3.07, I2 heterogeneity = 81%, p heterogeneity < 0.001). In the sensitivity analysis of GDM, excluding the largest heterogeneity study cannot change the result (pooled OR: 2.86 95%CI: 2.59 3.16, I2 heterogeneity = 0%, p heterogeneity = 0.56).

CONCLUSIONS

This meta-analysis shows that ICP is closely associated with ICP increased risk of PE and GDM) during pregnancy.

Metabolomic Markers for Predicting Preeclampsia in the First Trimester of Pregnancy: A Retrospective Study

We sought to identify the characteristic metabolite profile of blood plasma samples obtained from patients with preeclampsia. Direct high-resolution mass spectrometry was used to analyze samples from 79 pregnant women, 34 of whom had preeclampsia. We performed a comparative analysis of the metabolite profiles and found that they differed between pregnant women with and without preeclampsia. Lipids and sugars were identified as components of the metabolite profile that are likely to be associated with the development of preeclampsia. While PE was established only in the third trimester, a set of metabolites specific for the third trimester, including 2-(acetylamino)-1,5-anhydro-2-deoxy-4-O-b-D-galactopyranosyl-D-arabino-Hex-1-enitol, N-Acetyl-D-glucosaminyldiphosphodolichol, Cer(d18:0/20:0), and allolithocholic acid, was already traced in the first trimester. These components are also likely involved in lipid metabolism disorders and the development of oxidative stress.

Per- and polyfluoroalkyl substance (PFAS) exposure, maternal metabolomic perturbation, and fetal growth in African American women: A meet-in-the-middle approach

BACKGROUND

Prenatal exposures to per- and polyfluoroalkyl substances (PFAS) have been linked to reduced fetal growth. However, the detailed molecular mechanisms remain largely unknown. This study aims to investigate biological pathways and intermediate biomarkers underlying the association between serum PFAS and fetal growth using high-resolution metabolomics in a cohort of pregnant African American women in the Atlanta area, Georgia.

METHODS

Serum perfluorohexane sulfonic acid (PFHxS), perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and perfluorononanoic acid (PFNA) measurements and untargeted serum metabolomics profiling were conducted in 313 pregnant African American women at 8-14 weeks gestation. Multiple linear regression models were applied to assess the associations of PFAS with birth weight and small-for-gestational age (SGA) birth. A high-resolution metabolomics workflow including metabolome-wide association study, pathway enrichment analysis, and chemical annotation and confirmation with a meet-in-the-middle approach was performed to characterize the biological pathways and intermediate biomarkers of the PFAS-fetal growth relationship.

RESULTS

Each log2-unit increase in serum PFNA concentration was significantly associated with higher odds of SGA birth (OR = 1.32, 95% CI 1.07, 1.63); similar but borderline significant associations were found in PFOA (OR = 1.20, 95% CI 0.94, 1.49) with SGA. Among 25,516 metabolic features extracted from the serum samples, we successfully annotated and confirmed 10 overlapping metabolites associated with both PFAS and fetal growth endpoints, including glycine, taurine, uric acid, ferulic acid, 2-hexyl-3-phenyl-2-propenal, unsaturated fatty acid C18:1, androgenic hormone conjugate, parent bile acid, and bile acid-glycine conjugate. Also, we identified 21 overlapping metabolic pathways from pathway enrichment analyses. These overlapping metabolites and pathways were closely related to amino acid, lipid and fatty acid, bile acid, and androgenic hormone metabolism perturbations.

CONCLUSION

In this cohort of pregnant African American women, higher serum concentrations of PFOA and PFNA were associated with reduced fetal growth. Perturbations of biological pathways involved in amino acid, lipid and fatty acid, bile acid, and androgenic hormone metabolism were associated with PFAS exposures and reduced fetal growth, and uric acid was shown to be a potential intermediate biomarker. Our results provide opportunities for future studies to develop early detection and intervention for PFAS-induced fetal growth restriction.

Navigating Uncertainty: A Case Study of Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (ICP), the most common liver disorder of pregnancy, is associated with complications for both a pregnant person and their fetus. The underlying cause is not well understood. The pruritus associated with ICP is uncomfortable for pregnant people; however, the primary concern is the fetal risk. Fetal risks include preterm labor and birth and intrauterine fetal demise. This is particularly significant for certain populations because of the disparities in incidence of ICP; in the United States, it disproportionately affects Latinx people, the largest and fastest‐growing minority population. Diagnosis, monitoring, and treatment of ICP are vital to reduce discomfort from pruritis and avoid potential fetal demise. However, diagnosis and treatment are complicated by the lack of definitive diagnostic criteria, the frequent delay in laboratory analysis, and the cost of treatment. This case report aims to improve midwives’ familiarity with ICP and discusses the epidemiology, risk factors, presentation, diagnostic criteria, and available management strategies for this disease as well as the importance of anticipatory guidance regarding increased lifetime risk of ICP in future pregnancies and hepatobiliary disease. Additionally, it discusses the challenges involved in diagnosis and access to treatment. Prompt diagnosis and initiation of treatment may reduce fetal morbidity and mortality.

Perinatal outcomes of twin pregnancies with preterm premature rupture of the membranes at 24-34 weeks' gestation

To describe the perinatal outcomes of twin pregnancies with preterm premature rupture of membranes (PPROM) before 34 weeks’ gestation and identify factors associated with discharge without severe or moderate-severe neonatal morbidity. This study was conducted as a retrospective analysis of twin pregnancies with PPROM occurring at 24 0/7 to 33 6/7 weeks’ gestation. Perinatal outcomes were assessed by gestational age (GA) at PPROM and compared between PPROM and non PPROM twins. Factors associated with discharge without severe or moderate-severe neonatal morbidity were identified using logistic regression analysis. Of the 180 pregnancies (360 foetuses), only 17 (9.4%) women remained pregnant 7 days after PPROM. There were 10 (2.8%) cases of prenatal or neonatal death; 303 (84.2%) and 177 (49.2%) neonates were discharged without severe or moderate-severe morbidity, respectively. As GA at PPROM increased, the adverse obstetric and neonatal outcomes decreased, especially after 32 weeks. There was no significant difference in general neonatal outcomes between PPROM and non PPROM twins. The GA at PPROM and latency period were both significantly associated with discharge without severe or moderate-severe neonatal morbidity. Pregnancy complications and 5-min Apgar score < 7 increased severe neonatal morbidity. As GA at PPROM increased, the risk of adverse perinatal outcomes decreased. GA at PPROM and latency period were significantly associated with discharge without severe or moderate-severe neonatal morbidity.

Intrahepatic cholestasis of pregnancy: risk factors for severe disease

INTRODUCTION

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-associated hepatic disorder characterized by pruritus in the setting of elevated serum bile acids (BA). Risk factors for the disease include preexisting hepatobiliary disease, personal or family history of ICP, and advanced maternal age. Recent data suggests that patients with severe ICP (BA ≥100 μmol/L) have a higher risk of adverse pregnancy outcomes including stillbirth.

MATERIAL AND METHODS

This was a retrospective cohort study of patients diagnosed with ICP between 2012 and 2019 at a tertiary referral center. ICP was defined as symptomatic pruritus combined with serum BA >10 μmol/L. Maternal characteristics and outcomes were abstracted from electronic medical records. Baseline characteristics were compared between patients with mild (BA <40 μmol/L), moderate (BA 40-99 μmol/L) and severe (BA ≥100 μmol/L) ICP. Obstetrics and neonatal outcomes for patients in each category were then analyzed. Shapiro-Wilk test was used to test for normality for continuous variables, and ANOVA, Kruskal-Wallis, Chi-squared or Fisher's exact tests were used as appropriate. A p-value <.05 was considered statistically significant.

RESULTS

438 patients were included in the analysis. Individuals with pregestational diabetes (p < .01), history of ICP (p < .01), prior cholecystectomy (p < .01), and tobacco use (p < .05) were more likely to have severe disease. When compared to individuals with moderate and mild disease, individuals with severe disease were more likely to be diagnosed earlier (29w1d vs 34w1d vs 34w1d, p < .05), have gestational diabetes (50% vs 6% vs 13%, p < .01), hypertensive disorders of pregnancy (42% vs 10% vs 15%, p = .02), and abnormal aspartate aminotransferase (91% vs 65% vs 27%, p < .01) and alanine aminotransferase levels (91% vs 60% vs 26%, p < .01). There were no differences in preterm labor, meconium-stained amniotic fluid, or neonatal respiratory distress syndrome and no stillbirths in this cohort.

CONCLUSIONS

In patients with ICP, those with pregestational diabetes, history of ICP, prior cholecystectomy, and tobacco use are more likely to develop severe disease. Given the adverse outcomes associated with severe disease, serial BA measurements to monitor for development of severe disease may be warranted in this population.

Changes in serum total bile acid concentrations are associated with the risk of developing adverse maternal and perinatal outcomes in pregnant Chinese women

BACKGROUND AND AIMS

We aimed to investigate the association between total bile acid (TBA) concentrations changes during the second and third trimesters and the risk of developing adverse maternal and perinatal outcomes (AMPO).

METHODS

A total of 1569 pregnant Chinese women were enrolled. Serum TBA concentrations were measured during the 16-18^th and 29-34^th weeks of gestation. Logistic regression models were performed.

RESULTS

After multivariable adjustment, each standard deviation increase in the TBA concentrations in the second trimester was associated with a 30% (odds ratio [OR] = 1.30, 95% confidence interval [CI]: 1.13, 1.50) increased risk of gestational diabetes mellitus (GDM) and a 22% (OR = 1.22, 95% CI: 1.07, 1.63) increased risk of premature rupture of membranes (PROM). When we compared the highest and lowest quartiles of changes in the TBA Z-scores across the second and third trimesters, the adjusted ORs were 1.84 (95% CI: 1.28, 2.65) for PROM and 1.47 (95% CI: 1.07, 2.28) for macrosomia.

CONCLUSION

Elevated serum TBA concentrations during pregnancy were positively associated with increased risks of GDM and PROM. Women with more drastic changes in TBA concentrations across the second and third trimesters were at a higher risk of developing PROM and macrosomia.

Intrahepatic Cholestasis of Pregnancy

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.

Management of Intrahepatic Cholestasis of Pregnancy: Recommendations of the Working Group on Obstetrics and Prenatal Medicine - Section on Maternal Disorders

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease specific to pregnancy. The cardinal symptom of pruritus and a concomitant elevated level of bile acids in the serum and/or alanine aminotransferase (ALT) are suggestive for the diagnosis. Overall, the maternal prognosis is good. The fetal outcome depends on the bile acid level. ICP is associated with increased risks for adverse perinatal outcomes, including preterm delivery, meconium-stained amniotic fluid, and stillbirth. Acute fetal asphyxia and not chronic uteroplacental dysfunction leads to stillbirth. Therefore, predictive fetal monitoring is not possible. While medication with ursodeoxycholic acid (UDCA) improves pruritus, it has not been shown to affect fetal outcome. The indication for induction of labour depends on bile acid levels and gestational age. There is a high risk of recurrence in subsequent pregnancies.

Association of Elevated Maternal Serum Total Bile Acids With Low Birth Weight and Intrauterine Fetal Growth Restriction

IMPORTANCE

Bile acids play essential roles in metabolic modulation. Excessive serum total bile acid (sTBA) levels during pregnancy are associated with adverse perinatal outcomes; however, their association with the risk of intrauterine growth restriction (IUGR) remains unclear.

OBJECTIVE

To investigate the association between maternal sTBA concentration during pregnancy and the risk of IUGR.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included pregnant individuals who delivered live singleton neonates and had regular antenatal examination records available at a hospital-based center in Shanghai, China, from 2014 to 2018. Data were analyzed from July to November 2020.

EXPOSURES

Maternal sTBA concentration during pregnancy.

MAIN OUTCOMES AND MEASURES

Fetal birth weight and probability of low birth weight (LBW) and IUGR.

RESULTS

This study included 68 245 singleton pregnancies with live births for analysis. The mean (SD) age of the pregnant individuals was 30.5 (3.8) years, 67 168 patients (98.4%) were Han, and 50 155 (73.5%) were nulliparous. Nonlinear regression models suggested that there was an inverted J-shaped association between maternal sTBA level during pregnancy and fetal birth weight, with a steep decrease in birth weight at high sTBA levels (estimated mean [SE] birth weight for sTBA of 40.8 ug/mL, 2879 [39.9] g) and greater birth weights at lower sTBA levels (estimated mean [SE] birth weight for sTBA 0.4 μg/mL, 3290 [3.9] g; and for 4.1 μg/mL, 3334 [1.6] g). Lower birth weight and a higher incidence of IUGR were observed in patients with gestational hypercholanemia (sTBA ≥4.08 μg/mL) compared with those without gestational hypercholanemia (birth weight: estimated adjusted mean [SE], 3309 [3.32] vs 3338 [0.80] g; P = .005; incidence of IUGR: 62 of 4467 [1.4%] vs 312 of 63 778 [0.5%]; P < .001). Moreover, compared with patients with sTBA concentrations of less than 4.08 μg/mL, those with gestational hypercholanemia had an increased risk of LBW (adjusted odds ratio [aOR], 1.29; 95% CI, 1.09-1.53) and IUGR (aOR, 2.18; 95% CI, 1.62-2.91). In addition, there was an additive interaction between hypertensive disorders in pregnancy (HDP) and hypercholanemia on LBW and IUGR risk. The highest risks of LBW and IUGR were found in pregnant individuals with both HDP and hypercholanemia compared with those with normotensive pregnancies with sTBA concentrations less than 4.08 μg/mL (LBW: aOR, 9.13; 95% CI, 6.88-12.12; IUGR: aOR, 19.14; 95% CI, 12.09-30.28).

CONCLUSIONS AND RELEVANCE

This study found that gestational hypercholanemia was associated with an increased risk of LBW and IUGR, especially in pregnant individuals with HDP. Therefore, it would be meaningful to monitor sTBA concentration during the follow-up of pregnancies with potential IUGR.

Pre-eclampsia: incidence, determinants, and pregnancy outcomes from maternity hospitals in Qatar: a population-based case-control study

BACKGROUND

We aimed to study the maternal characteristics and obstetric and neonatal outcomes in pregnant mothers with pre-eclampsia (PE) compared to normotensive.

METHODS

This was a population-based retrospective data analysis. Data were obtained from the PEARL-Peristat Study perinatal registry (Perinatal Neonatal Outcomes Research Study in the Arabian Gulf) Qatar. The birth periods ranged from January to December 2017 in the main Women's Hospital (now named Women's Wellness Research Center) and March to December 2017 in other hospitals. This study examined 19762 singleton births at 24 weeks of gestation and above. This analysis included only 19,194 births with complete data in the registry database at the time of this analysis, divided into normotensive women (n = 18,735) and women with PE (n = 459) excluding women with gestational hypertension and chronic hypertension without superimposed PE(n = 568). We compared the maternal characteristics of mothers with PE with normotensive mothers and studied the obstetric and neonatal outcomes including cesarean section, stillbirths, prematurity, fetal growth restriction and postpartum hemorrhage (PPH).

RESULTS

The prevalence of hypertensive disorders among the 19,762 singleton pregnancies was 1027/19,762 (5.1%). The incidence of pre-eclampsia was 459/19,762 (2.3%) while gestational (341/19,762 (1.7%) and chronic hypertension 219/19,762 (1.1%)). A history of PE or eclampsia in past pregnancies was reported in 12.9% vs 0.9% p < .001 of PE vs normotensive women, respectively. After adjusting for significant maternal risk factors using multivariate logistic regression anlaysis, it was noted that PE was significantly associated with a higher odds for cesarean section (odds ratio (OR), 2.67 (95% CI, 2.19-3.25); p < .001), acute maternal morbidity (OR, 16.42 (95% CI, 5.58-48.30); p < .001), still births (OR, 3.27 (95% CI, 1.56-6.83); p < .001), preterm births (OR, 8.67 (95% CI, 7.05-10.65); p < .001), NICU admissions (OR, 4.41 (95% CI, 3.61-5.38); p < .001) and low birth weight (OR, 7.93 (95% CI, 6.43-9.29); p < .001).

CONCLUSION

Women with pre-eclampsia when compared to the normotensive women, they are older, nulliparous, diabetic and obese with an increased risk of preterm birth and cesarean deliveries. It was noted that PE was significantly associated with acute maternal morbidity, still births, cesarean section and preterm births. By taking preventive measures, prompt delivery and appropriate care we can reduce the risks associated with it or prolong the pregnancy to a gestational period which is considered safe for the neonatal survival. Therefore it's imperative to be aware of the population-based risk factors and its mode of presentation in order to give a timely appropriate care and to prevent severe maternal and fetal morbidities and mortalities.

[Intrahepatic cholestasis of pregnancy]

Intrahepatic cholestasis of pregnancy (ICP) is the most frequent pregnancy-specific liver disease. It is characterized by pruritus and an accompanying elevation of serum bile acid concentrations and/or alanine aminotransferase (ALT), which are the key parameters in the diagnosis. Despite good maternal prognosis, elevated bile acid concentration in maternal blood is an influencing factor to advers fetal outcome. The ICP is associated with increased rates of preterm birth, neonatal unit admission and stillbirth. This is the result of acute fetal asphyxia as opposed to a chronic uteroplacental insufficiency. Reliable monitoring or predictive tools (e.g. cardiotocography (CTG) or ultrasound) that help to prevent advers events are yet to be explored. Medicinal treatment with ursodeoxycholic acid (UDCA) does not demonstrably reduce adverse perinatal outcomes but does improve pruritus and liver function test results. Bile acid concentrations and gestational age should be used as indications to determine delivery. There is a high risk of recurrence in subsequent pregnancies.

Role of ursodeoxycholic acid on maternal serum bile acids and perinatal outcomes in intrahepatic cholestasis of pregnancy

AIM

Intrahepatic cholestasis of pregnancy (ICP) is associated with safe maternal outcomes but perinatal outcomes have been variable. We assessed clinical factors and impact of bile acid levels on maternal and neonatal outcomes in ICP.

METHODS

Patients with ICP (defined as pruritus with serum bile acids ≥ 10 mmol/l) were included prospectively with an assessment of risk factors, modes of delivery as well as maternal and neonatal outcomes. Mild and severe ICP were diagnosed when serum bile acid was always <40 mmol/l and ≥40 mmol/l, respectively. Patients with gestational pruritus served as controls.

RESULTS

Out of 643 patients, 375 patients (mean age 29 ± 7.6 years, 45.8% primigravida) met inclusion criteria. Pregnancy-induced hypertension [PIH: 10.5%; odds ratio (OR): 4.8; 95% confidence interval (CI): 2.4-8.5; P = 0.0014], gestational diabetes (GDM: 12.5%; OR: 2.6; 95% CI: 2.3-4.1; P = 0.045) and spontaneous preterm labor (15.1%; OR: 2.5; 95% CI: 1.2-3.5; P = 0.040) were higher in patients with ICP. Ursodeoxycholic acid (UDCA) (median dose 900 mg; 600-1800 mg) ameliorated symptoms of cholestasis, bile acid levels and liver aminotransferases in 79% cases. When compared with patients with mild ICP, patients with severe ICP presented at a lower gestational period (26 vs. 32 weeks, P = 0.036), required frequent induction (12.5%; OR: 3.2; 95% CI: 2.1-5.6; P = 0.045) and had increased fetal distress (15%; OR: 1.9; 95% CI: 1.3-4.9; P = 0.048).Overall eight stillbirths were recorded.

CONCLUSION

Severe ICP is associated with a higher incidence of GDM and PIH, risk of pre-term labor, elective induction and stillbirths. UDCA remains a first-line agent in treating ICP.

Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy: Replaces Consult #13, April 2011

Intrahepatic cholestasis of pregnancy is a hepatic disorder characterized by pruritus and an elevation in serum bile acid levels. Although intrahepatic cholestasis of pregnancy poses little risk for women, this condition carries a significant risk for the fetus, including complications such as preterm delivery, meconium-stained amniotic fluid, and stillbirth. The purpose of this Consult is to review the current literature on intrahepatic cholestasis of pregnancy and provide recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend measurement of serum bile acid and liver transaminase levels in patients with suspected intrahepatic cholestasis of pregnancy (GRADE 1B); (2) we recommend that ursodeoxycholic acid be used as the first-line agent for the treatment of maternal symptoms of intrahepatic cholestasis of pregnancy (GRADE 1A); (3) we suggest that patients with a diagnosis of intrahepatic cholestasis of pregnancy begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal fetal testing results or at the time of diagnosis if the diagnosis is made later in gestation (GRADE 2C); (4) we recommend that patients with total bile acid levels of ≥100 μmol/L be offered delivery at 36 0/7 weeks of gestation, given that the risk of stillbirth increases substantially around this gestational age (GRADE 1B); (5) we recommend delivery between 36 0/7 and 39 0/7 weeks of gestation for patients with intrahepatic cholestasis of pregnancy and total bile acid levels of <100 μmol/L (GRADE 1C); (6) we recommend administration of antenatal corticosteroids for fetal lung maturity for patients delivering before 37 0/7 weeks of gestation if not previously administered (GRADE 1A); (7) we recommend against preterm delivery at <37 weeks of gestation in patients with a clinical diagnosis of intrahepatic cholestasis of pregnancy without laboratory confirmation of elevated bile acid levels (GRADE 1B).

Intrahepatic cholestasis of pregnancy is associated with an increased risk of gestational diabetes and preeclampsia

Background

Previous studies have shown that intrahepatic cholestasis of pregnancy (ICP) is associated with an increased incidence of adverse perinatal outcomes, and this supports the contention that ICP is associated with increased risk for both gestational diabetes mellitus (GDM) and preeclampsia. The purpose of this study was to review adverse maternal and perinatal outcomes of ICP in the Chinese population, and to investigate the association between ICP and GDM, as well as between ICP and preeclampsia.

Methods

We conducted a retrospective cohort study in which we compared pregnancies affected by ICP with all other deliveries during the study period. Data from women with singleton pregnancies who delivered in 14 representative hospitals in China between October 1, 2016 and September 30, 2017 were collected from our database system. We then performed logistic regression analysis to determine the odds ratios (OR) and 95%CIs of the adverse pregnancy outcomes among women with or without ICP.

Results

A total of 95,728 singleton births were included in the study, and among these, 911 pregnancies were diagnosed as having ICP, resulting in an incidence of 0.95%. Women with ICP were more likely to have GDM [adjusted odds ratio (aOR), 1.406; 95% CI, 1.179-1.677; P<0.001] and preeclampsia (aOR, 2.241; 95% CI, 1.678-2.992; P<0.001) compared with those who did not have ICP. Women in the ICP group exhibited higher rates of scheduled cesarean deliveries (aOR, 3.527; 95% CI, 2.981-4.173; P<0.001) and cesarean deliveries during labor (aOR, 4.388; 95% CI, 1.815-10.612; P=0.027). Women with ICP were also more likely to have iatrogenic preterm delivery (aOR, 2.449; 95% CI, 1.92-3.122; P<0.001) and admission to the neonatal intensive care unit (aOR, 1.572; 95% CI, 1.318-1.874; P<0.001). There was no increased risk of stillbirth in the cohort of ICP cases (aOR, 0.430; 95% CI, 0.049-3.767; P=0.259).

Conclusions

ICP was associated with an increased risk of GDM and preeclampsia in singleton pregnancies. Pregnancies with ICP therefore have significantly increased risks of adverse perinatal outcomes.

Prevalence and risk factors of intrahepatic cholestasis of pregnancy in a Chinese population

Studies on the risk factors for intrahepatic cholestasis of pregnancy (ICP) in a population-based cohort are lacking. We assess the prevalence and risk factors of ICP in a Chinese population. In this study, a cohort study was conducted that included 12,200 eligible pregnant women. The overall incidence of ICP in this cohort was 6.06%. With increasing maternal age, the incidence of ICP decreased in women younger than 30 years of age but increased in those older than 30. With increasing pre-pregnancy BMI, the incidence of ICP decreased if the pre-pregnancy BMI was less than 23 kg/m² but increased if it was 23 kg/m² or higher. Further analysis showed that the risk of ICP increased when maternal age was < 25 years (Adjusted RR  2.01; 95% CI 1.64–2.47) or ≥ 35 years (Adjusted RR  1.34; 95% CI 1.02–1.76). Furthermore, an increased risk of ICP was associated with pre-pregnancy underweight (adjusted RR  1.27; 95% CI 1.04–1.56), inadequate gestational weight gain (GWG) (adjusted RR  1.58; 95% CI 1.28–1.96), lower maternal education (adjusted RR  2.96; 95% CI 2.35–3.74), multiparity (adjusted RR  1.54; 95% CI 1.23–1.93), and twin/multiple pregnancies (adjusted RR  2.12; 95% CI 1.25–3.58). Maternal age (< 25 or ≥ 35 years), underweight, inadequate GWG, lower maternal education, multiparity, and twin/multiple pregnancies were identified as risk factors of ICP.

Risk of pre-eclampsia in patients with a maternal genetic predisposition to common medical conditions: a case-control study

OBJECTIVE

To assess whether women with a genetic predisposition to medical conditions known to increase pre-eclampsia risk have an increased risk of pre-eclampsia in pregnancy.

DESIGN

Case-control study.

SETTING AND POPULATION

Pre-eclampsia cases (n = 498) and controls (n = 1864) in women of European ancestry from five US sites genotyped on a cardiovascular gene-centric array.

METHODS

Significant single-nucleotide polymorphisms (SNPs) from 21 traits in seven disease categories (cardiovascular, inflammatory/autoimmune, insulin resistance, liver, obesity, renal and thrombophilia) with published genome-wide association studies (GWAS) were used to create a genetic instrument for each trait. Multivariable logistic regression was used to test the association of each continuous scaled genetic instrument with pre-eclampsia. Odds of pre-eclampsia were compared across quartiles of the genetic instrument and evaluated for significance.

MAIN OUTCOME MEASURES

Genetic predisposition to medical conditions and relationship with pre-eclampsia.

RESULTS

An increasing burden of risk alleles for elevated diastolic blood pressure (DBP) and increased body mass index (BMI) were associated with an increased risk of pre-eclampsia (DBP, overall OR 1.11, 95% CI 1.01-1.21, P = 0.025; BMI, OR 1.10, 95% CI 1.00-1.20, P = 0.042), whereas alleles associated with elevated alkaline phosphatase (ALP) were protective (OR 0.89, 95% CI 0.82-0.97, P = 0.008), driven primarily by pleiotropic effects of variants in the FADS gene region. The effect of DBP genetic loci was even greater in early-onset pre-eclampsia cases (at <34 weeks of gestation, OR 1.30, 95% CI 1.08-1.56, P = 0.005). For other traits, there was no evidence of an association.

CONCLUSIONS

These results suggest that the underlying genetic architecture of pre-eclampsia may be shared with other disorders, specifically hypertension and obesity.

TWEETABLE ABSTRACT

A genetic predisposition to increased diastolic blood pressure and obesity increases the risk of pre-eclampsia.

Continuous association of total bile acid levels with the risk of small for gestational age infants

The association between maternal serum total bile acid (TBA) levels and small-for-gestational-age (SGA) infants is unclear. We investigated the association between various degrees of serum TBA levels and the risk of SGA infants in a Chinese population. The current study performed a cohort study among 11811 mothers with singleton pregnancy. Subjects were divided into seven categories according to maternal serum TBA levels. Interestingly, birth sizes were reduced, whereas the rate of SGA infants was increased across increasing categories of serum TBA. Compared to category 1, adjusted ORs (95%CI) for SGA infants were 0.99 (0.82-1.21) in category 2, 1.22 (0.97-1.53) in category 3, 1.99 (1.53-2.58) in category 4, 2.91 (2.16-3.93) in category 5, 4.29 (3.33-5.54) in category 6, and 9.01 (5.99-13.53) in category 7, respectively. Furthermore, adjusted ORs (95%CI) for SGA infants for each 1-SD increase in serum TBA levels were 1.36 (1.29-1.43) among all subjects, 2.40 (1.82-3.45) among subjects without cholestasis, and 1.13 (1.06-1.22) among subjects with cholestasis, respectively. These results suggest that gestational cholestasis increases the risk of SGA infants. Additionally, our results indicate strong, continuous associations of serum TBA levels below those diagnostic of cholestasis with a decreased birth sizes and an increased risk of SGA infants.

Pregnancy-specific liver diseases

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.

Intrahepatic cholestasis of pregnancy as a risk factor for preeclampsia

PURPOSE

Intrahepatic cholestasis of pregnancy and preeclampsia are two major pregnancy complications. We aimed to investigate the association between intrahepatic cholestasis of pregnancy (ICP) and preeclampsia.

METHODS

Single-center retrospective study. Study group included 180 women (162 singletons and 18 twin gestations) who were diagnosed with ICP based on clinical presentation, elevated liver enzymes and bile acids. The reference group included 1618 women (1507 singletons and 111 twin gestations) who delivered during the study period, and were matched according to age, gravidity, parity and singleton or twin gestation.

RESULTS

The incidence of ICP was 0.36%. The incidence of preeclampsia was higher in women with ICP compared to reference group (7.78% vs 2.41%, aOR, 3.74 95% CI 12.0-7.02, p < 0.0001), for either without-(3.89% vs 1.61%, aOR 2.83, 95% CI 1.23-6.5, p = 0.145) or with severe features (3.89% vs 0.80%, aOR 5.17 95% CI 2.14-12.50, p = 0.0003). For both singleton and twin pregnancies, overall preeclampsia rates were higher in the ICP group (5.56% vs 2.19%, aOR 2.91 95% CI 1.39-6.07 p = 0.0045; and 27.78% vs 5.41%, aOR 10.9 95% CI 2.16-47.19, p = 0.0033, respectively). Earlier diagnosis of ICP was associated with higher incidence of preeclampsia (31.1 ± 3.8 vs 34.86 ± 6.2 gestational weeks, p = 0.0259). The average time between ICP diagnosis and to the onset of preeclampsia was 29.7 ± 24 days.

CONCLUSION

ICP is associated with an increased risk for preeclampsia. We suggest intensified follow-up for preeclampsia in women with ICP, especially among those with early ICP presentation and twins' gestations.

The maternal and perinatal implications of hypertensive disorders of pregnancy in a multiple pregnancy cohort

INTRODUCTION

Hypertensive disorders of pregnancy are common and may result in increased maternal and neonatal morbidity and mortality. Multiple pregnancies confer an increased risk of development of a hypertensive disorder of pregnancy. The purpose of this study was to examine a large cohort of women delivering a multiple pregnancy in a single large tertiary unit, and to evaluate the implications of hypertensive disorders of pregnancy on both maternal and perinatal outcomes.

MATERIAL AND METHODS

Retrospective study of all twin pregnancies delivered at Cork University Maternity Hospital, Ireland over a 9-year period (2009-2017). The twin pregnancies were divided according to the presence or absence of hypertensive disorder of pregnancy and the two groups were compared.

RESULTS

Maternal age >40 years, nulliparity, conception through use of a donor oocyte, and presence of obstetric cholestasis are all risk factors for the development of hypertensive disorders of pregnancy in women with a multiple pregnancy. When a hypertensive disorder complicates a twin pregnancy, it increases the incidence of iatrogenic late prematurity and neonatal hypoglycemia.

CONCLUSIONS

This study is informative for clinicians caring for women with a multiple pregnancy with its relevant data on perinatal outcomes following a diagnosis of hypertensive disorder in pregnancy.

Obeticholic Acid Protects against Gestational Cholestasis-Induced Fetal Intrauterine Growth Restriction in Mice

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.

Outpatient versus inpatient follow-up for intrahepatic cholestasis of pregnancy

Aim of the study

The optimum management method and the best time of delivery still remain unclear for intrahepatic cholestasis of pregnancy (ICP). We aimed to ascertain whether there is a benefit of close monitoring at hospital.

Material and methods

We evaluated the maternal and neonatal records of ICPs over a recent five-year period. A total of 35 women and their 38 newborns were analyzed. The impact of hospitalization was evaluated in terms of delivery type, labor induction, preterm delivery, Apgar scores, and neonatal intensive care unit admission.

Results

The median maternal age was 30.7 years, and median gestation at diagnosis was 34 weeks. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were normal in three patients; 32 (91.4%) women had at least one increased hepatic enzyme level. The median AST level was elevated to 66 U/l (almost two-fold), and the median ALT level was 91 U/l (about three-fold). The median gestation time at delivery was 37 weeks. The preterm delivery rate was 45.7%. The median birth weight was 3020 g, and median Apgar scores were 9 and 10 at the 1^st and 5^th minutes, respectively. Neonatal intensive care unit admission occurred in 21 neonates (55.3%). During pregnancy follow-up, 22 women (62.8%) were hospitalized during their pregnancies. There was no statistically significant difference between groups in terms of obstetric and perinatal outcomes (p > 0.05). However, the hospitalized pregnant women were found to have higher levels of serum transaminases (p = 0.15 and p = 0.01 for ALT and AST, respectively).

Conclusions

Hospitalization may be helpful in some ICP cases, especially when enzyme levels are elevated.

Perinatal outcomes of intrahepatic cholestasis of pregnancy in twin versus singleton pregnancies: is plurality associated with adverse outcomes?

PURPOSE

To determine the rate of obstetric and neonatal complications associated with intrahepatic cholestasis of pregnancy in twin versus singleton gestations.

METHODS

A retrospective cohort study including patients diagnosed with intrahepatic cholestasis of pregnancy at a single tertiary center between 2011 and 2016. Women were allocated into two groups: twin pregnancies (n = 56) and singleton pregnancies (n = 186). Obstetric and neonatal outcomes were compared between the two groups.

RESULTS

Intrahepatic cholestasis of pregnancy was diagnosed earlier in gestation in twin compared to singleton pregnancies (33.1 ± 2.8 vs. 35.1 ± 3.0 weeks, respectively; adjusted P < 0.001). Maternal serum levels of fasting total bile acids were significantly higher in twin pregnancies compared to singletons [27 (IQR 16-44) vs. 16 (IQR 10-26) µmol/L, respectively; P = 0.01]. None of the pregnancies in our cohort was complicated by fetal death. Apgar score at 5 min and umbilical artery and vein PH at delivery were comparable between the two groups.

CONCLUSIONS

Intrahepatic cholestasis of pregnancy in twin pregnancies appears to be more severe compared to singletons, as reflected by an earlier presentation and higher levels of maternal serum total bile acids. Large prospective studies are required to customize a management strategy specific for women with twin pregnancies and intrahepatic cholestasis of pregnancy.

Women successfully treated for severe intrahepatic cholestasis of pregnancy do not have increased risks for adverse perinatal outcomes

Intrahepatic cholestasis of pregnancy (ICP) increases adverse perinatal outcome (APO) incidence. Whether successful treatment of severe ICP reduces APO risk is unclear.This retrospective, single-center study in China enrolled consecutive women with ICP who had term delivery (≥37 weeks, singleton) between August 2013 and June 2016. Patients were divided into the mild ICP (serum bile acids (SBA) ≤40 μmol/L throughout pregnancy) and severe ICP (SBA >40 μmol/L during pregnancy but fell after ursodeoxycholate therapy) groups. Baseline characteristics, laboratory investigations, and maternal and neonatal outcomes were assessed. Logistic regression was used to identify factors associated with meconium staining of amniotic fluid (MSAF) and APOs.Seventy-three patients were included (mild ICP group, n=47; severe ICP group, n=26). Pruritus was more common in the severe ICP group (65.4% vs 40.4%; P <.05), but other baseline characteristics were similar. Compared with the mild ICP group, the severe ICP group had higher SBA at first visit and peak value, higher direct bilirubin before delivery and 4 days postpartum, and lower gamma-glutamyltransferase at peak value, before delivery and 4 days postpartum (P <.05). Other laboratory parameters, type of delivery, hemorrhage, and liver function abnormality were similar between groups, although the severe ICP group had longer duration of hepatic dysfunction (P <.05). Birth weight was lower in the mild ICP group (P <.05), but other fetal outcomes were similar between groups. Logistic regression identified no factors (including SBA group) associated with APOs or MSAF.Women successfully treated for severe ICP do not have increased risks for APOs.

Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses

BACKGROUND

Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcomes, but the association with the concentration of specific biochemical markers is unclear. We aimed to quantify the adverse perinatal effects of intrahepatic cholestasis of pregnancy in women with increased serum bile acid concentrations and determine whether elevated bile acid concentrations were associated with the risk of stillbirth and preterm birth.

METHODS

We did a systematic review by searching PubMed, Web of Science, and Embase databases for studies published from database inception to June 1, 2018, reporting perinatal outcomes for women with intrahepatic cholestasis of pregnancy when serum bile acid concentrations were available. Inclusion criteria were studies defining intrahepatic cholestasis of pregnancy based upon pruritus and elevated serum bile acid concentrations, with or without raised liver aminotransferase concentrations. Eligible studies were case-control, cohort, and population-based studies, and randomised controlled trials, with at least 30 participants, and that reported bile acid concentrations and perinatal outcomes. Studies at potential higher risk of reporter bias were excluded, including case reports, studies not comprising cohorts, or successive cases seen in a unit; we also excluded studies with high risk of bias from groups selected (eg, a subgroup of babies with poor outcomes were explicitly excluded), conference abstracts, and Letters to the Editor without clear peer review. We also included unpublished data from two UK hospitals. We did a random effects meta-analysis to determine risk of adverse perinatal outcomes. Aggregate data for maternal and perinatal outcomes were extracted from case-control studies, and individual patient data (IPD) were requested from study authors for all types of study (as no control group was required for the IPD analysis) to assess associations between biochemical markers and adverse outcomes using logistic and stepwise logistic regression. This study is registered with PROSPERO, number CRD42017069134.

FINDINGS

We assessed 109 full-text articles, of which 23 studies were eligible for the aggregate data meta-analysis (5557 intrahepatic cholestasis of pregnancy cases and 165 136 controls), and 27 provided IPD (5269 intrahepatic cholestasis of pregnancy cases). Stillbirth occurred in 45 (0·83%) of 4936 intrahepatic cholestasis of pregnancy cases and 519 (0·32%) of 163 947 control pregnancies (odds ratio [OR] 1·46 [95% CI 0·73-2·89]; I2=59·8%). In singleton pregnancies, stillbirth was associated with maximum total bile acid concentration (area under the receiver operating characteristic curve [ROC AUC]) 0·83 [95% CI 0·74-0·92]), but not alanine aminotransferase (ROC AUC 0·46 [0·35-0·57]). For singleton pregnancies, the prevalence of stillbirth was three (0·13%; 95% CI 0·02-0·38) of 2310 intrahepatic cholestasis of pregnancy cases in women with serum total bile acids of less than 40 μmol/L versus four (0·28%; 0·08-0·72) of 1412 cases with total bile acids of 40-99 μmol/L (hazard ratio [HR] 2·35 [95% CI 0·52-10·50]; p=0·26), and versus 18 (3·44%; 2·05-5·37) of 524 cases for bile acids of 100 μmol/L or more (HR 30·50 [8·83-105·30]; p<0·0001).

INTERPRETATION

The risk of stillbirth is increased in women with intrahepatic cholestasis of pregnancy and singleton pregnancies when serum bile acids concentrations are of 100 μmol/L or more. Because most women with intrahepatic cholestasis of pregnancy have bile acids below this concentration, they can probably be reassured that the risk of stillbirth is similar to that of pregnant women in the general population, provided repeat bile acid testing is done until delivery.

FUNDING

Tommy's, ICP Support, UK National Institute of Health Research, Wellcome Trust, and Genesis Research Trust.

Intrahepatic Cholestasis of Pregnancy in Women With Twin Pregnancy

The aim of the present work was to determine maternal and fetal outcomes of intrahepatic cholestasis of pregnancy (ICP) in twin pregnancies. All twin pregnancies delivered above 28 gestational weeks in West China Second University Hospital from January 2013 to May 2015 were included. Data on maternal demographics and obstetric complications together with fetal outcomes were collected. The risk of adverse maternal and fetal outcomes were determined in relation to ICP by crude odds ratios (OR) and adjusted ORs (aOR) with 95% confidence intervals (CI). Subgroup analysis concentrated on the effect of assisted reproductive technology (ART), ICP severity, and onset time. A total of 1,472 twin pregnancies were included, of which 362 were cholestasis patients and 677 were conceived by ART. Higher rates of preeclampsia (aOR 1.96; 95% CI 1.35, 2.85), meconium-stained amniotic fluid (aOR 3.10; 95% CI 2.10, 4.61), and preterm deliveries (aOR 3.20; 95% CI 2.35, 4.37) were observed in ICP patients. Subgroup analysis revealed higher incidences of adverse outcomes in severe and early onset ICP groups. In conclusion, adverse maternal and fetal outcomes were strongly associated with ICP in twin patients. Active management and close antenatal monitoring are needed, especially in the early onset and severe groups.

Intrahepatic cholestasis of pregnancy: Recent advances

Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a pruritic condition of pregnancy characterized by an underlying elevation in circulating bile acids and liver derangement, and associated with adverse fetal outcomes, such as preterm labor and stillbirth. Limited understanding of the underlying pathophysiology and mechanisms involved in adverse outcomes has previously restricted treatment options and pregnancy management. Recent advances in these research fields provide tantalizing targets to improve the care of pregnant women affected by this condition.

Intrahepatic Cholestasis of Pregnancy with Severe Elevation of Bile Acids in the Setting of Acute Hepatitis C Infection

Intrahepatic cholestasis of pregnancy (ICP) is a complication of pregnancy resulting in elevation of serum bile acid levels. ICP is often associated with underlying liver disease, including hepatitis C. Bile acids in relationship to the acute infection of hepatitis C virus have not yet been delineated in the literature. A 26-year-old gravida 4 para 2103 with dichorionic, diamniotic twin gestation and history of intravenous drug abuse developed ICP in the setting of acute hepatitis C infection. In addition to clinical symptoms of pruritus and right upper quadrant pain, she developed severe elevation in bile acids, 239 micromol/L, and transaminitis aspartate aminotransferase 1033 U/L, and alanine aminotransferase 448 U/L. She received ursodeoxycholic acid and antenatal testing was performed. Patient delivered vaginally at 33-week gestation following preterm rupture of membranes. Neonates were admitted to NICU and had uncomplicated neonatal courses. In the setting of ICP with significant transaminitis and severe elevation of bile acids, consideration of acute viral hepatitis is important, especially considering the worsening opioid epidemic and concurrent increase in intravenous drug use in the United States. Further study is needed regarding the acute form of HCV infection and its effect on ICP and associated bile acids.