Unnecessary confusion about family planning after intrahepatic cholestasis of pregnancy

[Intrahepatic cholestasis of pregnancy: French College of Obstetricians and Gynecologists guidelines for clinical practice]

OBJECTIVE

To identify strategies for reducing neonatal and maternal morbidity associated with intrahepatic cholestasis pregnancy (ICP).

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE methodology with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 14 questions (from 12 PICO questions and one definition question outside the PICO format), there was agreement between the working group and the external reviewers on 14 (100%). The level of evidence of the literature was insufficient to provide a recommendation on two questions. ICP is defined by the occurrence of suggestive pruritus (palmoplantar, nocturnal) associated with a total bile acid level>10μmol/L or an alanine transaminase level above 2N after ruling out differential diagnoses. In the absence of suggestive symptoms of a differential diagnosis, it is recommended not to carry out additional biological or ultrasound tests. In women with CIP, ursodeoxycholic acid is recommended to reduce the intensity of maternal pruritus (Strong recommendation. Quality of the evidence moderate) and to decrease the level of total bile acids and alanine transaminases. (Strong recommendation. Quality of the evidence moderate). S-adenosyl-methionine, dexamethasone, guar gum or activated charcoal should not be used to reduce the intensity of maternal pruritus (Strong recommendation. Quality of evidence low), and there is insufficient data to recommend the use of antihistamines (No recommendation. Quality of evidence low). Rifampicin (Weak recommendation. Very low quality of evidence) or plasma exchange (Strong recommendation. Very low quality of evidence) should not be used to reduce maternal pruritus and perinatal morbidity. Serum monitoring of bile acids is recommended to reduce perinatal morbidity and mortality (stillbirth, prematurity) (Low recommendation. Quality of the evidence low). The level of evidence is insufficient to determine whether fetal heart rate or fetal ultrasound monitoring are useful to reduce perinatal morbidity (No recommendation). Birth is recommended when bile acid level is above 99μmol/L from 36 weeks gestation to reduce perinatal morbidity, in particular stillbirth. When bile acid level is above 99μmol/L is below 100μmol/L, women should be informed that induction of labor could be considered 37 and 39 weeks gestation to reduce perinatal morbidity. (Strong recommendation. Quality of evidence low). In postpartum, total bile acids and alanine transaminases level should be checked and normalized before prescribing estrogen-progestin contraception, ideally with a low estrogen dose (risk of recurrence of pruritus and cytolysis) (Low recommendation. Quality of evidence very low).

CONCLUSION

Although the quality of evidence regarding ICP gestational cholestasis remains low, there is a strong consensus in France, as shown by our Delphi study, on how to manage women with ICP. The reference first-line treatment is ursodeoxycholic acid.

Contraceptive vaginal ring-induced cholestasis in a patient with a history of intrahepatic cholestasis of pregnancy

INTRODUCTION

Intrahepatic cholestasis of pregnancy (ICP) is a heterogeneous group of liver disorders with a high recurrence rate. Patients with a history of ICP are at risk of developing contraceptive-induced cholestasis, especially if they harbour a biliary transporter mutation. We report the first case of drug-induced cholestasis associated with a contraceptive vaginal ring (CVR) in a patient with a prior history of ICP.

PRESENTATION

Our patient was a women with a history of multiple pregnancies and spontaneous abortions and early and severe ICP. Two to four weeks after initiation of CVR, she developed signs and symptoms of cholestasis, which resolved after discontinuation of the CVR. A thorough investigation to exclude other plausible causes of cholestasis was performed, including a liver biopsy. Genetic testing revealed pathogenic mutations in both the ABCB11 and ABCB4 genes.

DISCUSSION

Although a history of ICP used to be an absolute contraindication for oral contraceptive pills (OCP), recent studies suggest a lower risk of cholestasis associated with low-dose oestrogen pills (20-35 mcg compared to the original 50 mcg). No previous case report could confirm the theoretical risk associated with the use of a CVR, which delivers a very low estrogen dose (15 mcg). The two biliary transporter mutations identified in our case could potentially explain the patient's susceptibility to the cholestatic effect of oestrogen.

CONCLUSION

This case illustrates that CVR can trigger drug-induced cholestasis in a susceptible patient. While such cases should not discourage the trial of low-dose hormonal contraception in women with prior ICP, an appropriate follow-up is necessary to ensure early detection and treatment of drug-induced cholestasis.

Long-term survival after intrahepatic cholestasis of pregnancy: A follow-up of 571 mothers

OBJECTIVE

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disorder during pregnancy. ICP has been associated with morbidity but little is known about women's long-term survival. Our aim was to determine whether ICP is associated with mothers' long-term survival.

STUDY DESIGN

The study population comprised 571 women with ICP in at least one pregnancy seen at Tampere University Hospital in Finland between 1969‒1988. The reference group comprised 1333 women: the previous and the following participant in the maternity ward diary. The data were obtained from Statistics Finland in March 2017 containing deaths among the study participants between 1971‒2015. The follow-up time of the cohort was 27-46 years. The Kaplan-Meier method was used.

RESULTS

Totally, 39 of the mothers with ICP (6.8%) and 111 of the reference group (8.3%) had died by the end of 2015 (p = 0.267). The mean survival time of ICP women was 77.4 years and of the reference group 79.2 years (p = 0.288). The mean survival time from labour in the ICP group was 45.0 years and in the reference group 44.8 years (p = 0.259).

CONCLUSIONS

Based on this study ICP does not seem to be associated with women's survival. There is no need to follow-up ICP mothers' health because of the nonexistent risk of premature death.

Men’s Health Is Not Affected by Their Mothers’ Intrahepatic Cholestasis of Pregnancy

Little is known about the effects of mother’s intrahepatic cholestasis of pregnancy (ICP) on the health of sons born to these mothers. The purpose of the present study was to explore the health of sons born to mothers with ICP. The study design was a retrospective study of ICP mothers’ sons. In the region of Tampere University Hospital in Finland, 365 sons of mothers with ICP during 1969 to 1988 and 617 sons of mothers without ICP were sent a questionnaire in 2010. The response rates were 37.8% ( n = 138) and 36.6% ( n = 226), respectively. Only minor differences were reported between the two groups. Self-evaluated health was similar. There were no significant differences between the groups regarding symptoms and complaints, diagnosed diseases, mental health, and use of medicines. Cough was 10.8 percentage points less common among ICP mothers’ sons than among controls ( p = .034). Urticaria was more common among ICP mothers’ sons, the difference in percentage points being 2.2 ( p = .026). In general, a mother’s ICP does not affect her son’s health.

The impact of intrahepatic cholestasis of pregnancy with hepatitis B virus infection on perinatal outcomes

Introduction

To investigate the impact of intrahepatic cholestasis of pregnancy (ICP) with hepatitis B virus (HBV) infection on perinatal outcomes.

Methods

In the study, 200 pregnant women were divided into four groups, including 50 cases with ICP and HBV infection, 50 cases with ICP, 50 cases with HBV infection, and 50 healthy pregnancies. The delivery process and perinatal outcomes were analyzed among different groups.

Results

When compared to the healthy pregnancy group, significantly increased rates of premature rupture of membranes, meconium-stained amniotic fluid, and cesarean section were observed in cases of ICP, HBV infection, or ICP patients with HBV (P<0.05). Specifically, the rates of HBV infection in the newborn, fetal distress, neonatal asphyxia, and birth defects in the newborn, and infant Apgar scores were higher in ICP pregnancies with HBV (56%, 48%, 16%, and 48%, respectively) than in the other groups (P<0.05).

Conclusion

ICP combined with HBV infection has a clear influence on perinatal infant outcomes.