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Zhang P, Tan Z, Li C, Han Z, Zhou J, Yin Y. The correlation between serum total bile acid and adverse perinatal outcomes in pregnant women with intrahepatic cholestasis of pregnancy (ICP) and non-ICP hypercholanemia of pregnancy. Ann Med 2024; 56:2331059. [PMID: 38515230 PMCID: PMC10962286 DOI: 10.1080/07853890.2024.2331059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 02/23/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The association between excessive serum total bile acid (TBA) and adverse perinatal outcomes in individuals with non-intrahepatic cholestasis of pregnancy (non-ICP) hypercholanemia has not been determined, and it is unclear if this link is similar to that observed in patients with ICP. OBJECTIVE To examine the adverse perinatal outcomes in two specific subcategories: those with ICP and those with non-ICP, including individuals with liver disease and asymptomatic hypercholanemia of pregnancy (AHP), at different levels of TBA. Investigate the correlation between TBA levels and adverse perinatal outcomes of ICP, liver disease, and AHP. METHODS From 2013 to 2021, pregnant women with excessive TBA levels were taken from the electronic medical record database of our hospital and categorized into three groups: ICP (n = 160), liver disease (n = 164), and AHP (n = 650). This was done as part of a retrospective cohort research project. Multivariable regression and subgroup analyses were performed to examine the association between TBA levels and adverse perinatal outcomes in each group. RESULTS The study found no significant differences in adverse perinatal outcomes between the ICP and liver disease groups at different TBA levels. However, at moderate TBA levels, both groups had a higher risk of adverse perinatal outcomes than the AHP group (p < 0.017). Among liver disease cases with TBA ≥ 100µmol/L, three cases of perinatal deaths (6.67%) associated with moderate-to-severe acute hepatitis occurred between 27 and 33 weeks of gestation. A 59% higher chance of perinatal death was found for every 10 µmol/L rise in TBA, even after significant variables and confounders were taken into account (adjusted odds ratio (aOR) = 1.59; 95% confidence interval (CI): 1.06-2.40; p = 0.03). CONCLUSIONS If a pregnant woman has moderate-to-severe liver disease and TBA ≥ 100µmol/L, preterm termination of pregnancy (before 34 weeks) may be considered.
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Affiliation(s)
- Peizhen Zhang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhangmin Tan
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Chuo Li
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhenyan Han
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jin Zhou
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yuzhu Yin
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Salas G, Litta AA, Medeot AC, Schuck VS, Andermatten RB, Miszczuk GS, Ciriaci N, Razori MV, Barosso IR, Sánchez Pozzi EJ, Roma MG, Basiglio CL, Crocenzi FA. NADPH oxidase-generated reactive oxygen species are involved in estradiol 17ß-d-glucuronide-induced cholestasis. Biochimie 2024; 223:41-53. [PMID: 38608750 DOI: 10.1016/j.biochi.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/14/2024]
Abstract
The endogenous metabolite of estradiol, estradiol 17β-D-glucuronide (E17G), is considered the main responsible of the intrahepatic cholestasis of pregnancy. E17G alters the activity of canalicular transporters through a signaling pathway-dependent cellular internalization, phenomenon that was attributed to oxidative stress in different cholestatic conditions. However, there are no reports involving oxidative stress in E17G-induced cholestasis, representing this the aim of our work. Using polarized hepatocyte cultures, we showed that antioxidant compounds prevented E17G-induced Mrp2 activity alteration, being this alteration equally prevented by the NADPH oxidase (NOX) inhibitor apocynin. The model antioxidant N-acetyl-cysteine prevented, in isolated and perfused rat livers, E17G-induced impairment of bile flow and Mrp2 activity, thus confirming the participation of reactive oxygen species (ROS) in this cholestasis. In primary cultured hepatocytes, pretreatment with specific inhibitors of ERK1/2 and p38MAPK impeded E17G-induced ROS production; contrarily, NOX inhibition did not affect ERK1/2 and p38MAPK phosphorylation. Both, knockdown of p47phox by siRNA and preincubation with apocynin in sandwich-cultured rat hepatocytes significantly prevented E17G-induced internalization of Mrp2, suggesting a crucial role for NOX in this phenomenon. Concluding, E17G-induced cholestasis is partially mediated by NOX-generated ROS through internalization of canalicular transporters like Mrp2, being ERK1/2 and p38MAPK necessary for NOX activation.
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Affiliation(s)
- Gimena Salas
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Alen A Litta
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Anabela C Medeot
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Virginia S Schuck
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Romina B Andermatten
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Gisel S Miszczuk
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Nadia Ciriaci
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Ma Valeria Razori
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Ismael R Barosso
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Enrique J Sánchez Pozzi
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Marcelo G Roma
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Cecilia L Basiglio
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina
| | - Fernando A Crocenzi
- Instituto de Fisiología Experimental (IFISE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Departamento de Ciencias Fisiológicas, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Argentina.
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Axelsen SM, Schmidt MC, Kampmann U, Grønbæk H, Fuglsang J. The effect of twin pregnancy in intrahepatic cholestasis of pregnancy: A case control study. Acta Obstet Gynecol Scand 2024. [PMID: 39058263 DOI: 10.1111/aogs.14928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/20/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Intrahepatic cholestasis of pregnancy (ICP) is one of the most common hepatic disorders during pregnancy, and the etiology is thought to be multifactorial including both environmental and hormonal contributions. In twin pregnancies, the fetal and placental mass is generally greater than in singleton pregnancies, and is, theoretically, likely to have a greater influence upon the maternal hepatic metabolism compared to singleton pregnancy. The aim of this study was to compare ICP in twin and singleton pregnancies according to ICP characteristics, time of diagnosis, serum bile acid levels, pharmacological treatment, and pregnancy outcomes. MATERIAL AND METHODS This case control study was undertaken at Aarhus University Hospital, Denmark, from 2012 to 2019. The study comprised 51 women with twin pregnancies and ICP. These women were matched with 153 women with twin pregnancies without ICP and 153 women with singleton pregnancies with ICP, respectively. Three controls were matched per case, and data obtained from medical records and Danish obstetrical databases were compared. RESULTS We found a significantly lower gestational age at ICP diagnosis in twin pregnancies (227 vs. 242 days for singleton pregnancies; p = 0.002). Bile acids reached significantly higher maximum blood levels in twin pregnancies (32.9 vs. 22.2 μmol/L; p = 0.012), and at a lower gestational age (gestational age maximum bile acids: 235 vs. 250 days; p < 0.001). No difference in pharmacological treatment was observed between the groups. Twin pregnancies with and without ICP had comparable pregnancy outcomes; however, ICP pregnancies had a higher incidence of gestational diabetes mellitus (15.7% vs. 5.2%; p = 0.03). In repeat pregnancies, ICP was diagnosed earlier in the twin pregnancy (p = 0.006). CONCLUSIONS Compared to singleton pregnancies, twin pregnant women with ICP have an earlier diagnosis of ICP, and levels of bile acids are higher. Compared to twin pregnancies without ICP, the pregnancy outcomes are comparable.
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Affiliation(s)
- Silja Maigaard Axelsen
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Ulla Kampmann
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Henning Grønbæk
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Fuglsang
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
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Eyisoy ÖG, Demirci O, Taşdemir Ü, Özdemir M, Öcal A, Kahramanoğlu Ö. Effect of Maternal Ursodeoxycholic Acid Treatment on Fetal Atrioventricular Conduction in Patients with Intrahepatic Cholestasis of Pregnancy. Fetal Diagn Ther 2024:1-7. [PMID: 39008965 DOI: 10.1159/000540261] [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: 11/02/2023] [Accepted: 07/02/2024] [Indexed: 07/17/2024]
Abstract
INTRODUCTION The aim of this study was, first, to investigate the difference in fetal atrioventricular conduction in patients with and without intrahepatic cholestasis of pregnancy (ICP) by measuring the fetal PR interval; second, to evaluate the altering effect of ursodeoxycholic acid (UDCA) treatment on the fetal PR interval in ICP patients. METHODS The study consisted of 42 ICP patients and 48 healthy pregnant women. Fetal echocardiography was performed to measure the mechanical PR interval. The fetal PR interval and the clinical characteristics were compared between the two groups. The effect of UDCA treatment on the fetal PR interval in ICP patients was evaluated. RESULTS In ICP patients, significantly longer fetal PR intervals were observed than in the control group (123.21 ± 8.54 vs. 115.13 ± 5.95 ms, p < 0.001). In the ICP group, there was a positive correlation between the fetal PR interval and maternal fasting total bile acid (TBA) levels (r = 0.514, p = 0.001). After 1 week of treatment with UDCA in patients with ICP, the PR interval was shorter than before, although the reduction was not statistically significant (120.98 ± 6.70 vs. 123.21 ± 8.54 ms, p = 0.095). In patients with severe ICP (TBA >40 mmol/L, n = 10), a significant reduction in the fetal PR interval was observed after treatment with UDCA (127.5 ms [IQR, 118.0-134.75] before vs. 122 ms [IQR, 109.5-126.5] after, p = 0.037). CONCLUSION Fetal PR interval increased in ICP patients in correlation with maternal serum TBA concentration. Treatment with UDCA may have limited positive effects on the fetal AV conduction system. The beneficial effects of UDCA on the fetal PR interval may be more pronounced in patients with higher bile acid levels.
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Affiliation(s)
- Ömer Gökhan Eyisoy
- Division of Perinatology, Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Zeynep Kamil Women and Children Diseases Education and Research Hospital Istanbul, Istanbul, Turkey
| | - Oya Demirci
- Division of Perinatology, Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Zeynep Kamil Women and Children Diseases Education and Research Hospital Istanbul, Istanbul, Turkey
| | - Ümit Taşdemir
- Division of Perinatology, Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Zeynep Kamil Women and Children Diseases Education and Research Hospital Istanbul, Istanbul, Turkey
| | - Mucize Özdemir
- Division of Perinatology, Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Zeynep Kamil Women and Children Diseases Education and Research Hospital Istanbul, Istanbul, Turkey
| | - Aydın Öcal
- Division of Perinatology, Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Özge Kahramanoğlu
- Division of Perinatology, Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Zeynep Kamil Women and Children Diseases Education and Research Hospital Istanbul, Istanbul, Turkey
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Boujenah J. [Intrahepatic cholestasis of pregnancy: For a holistic view of women. About ultrasound screening]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:427. [PMID: 38408607 DOI: 10.1016/j.gofs.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 02/06/2024] [Indexed: 02/28/2024]
Affiliation(s)
- Jeremy Boujenah
- Département d'obstétrique, GH Diaconesses Croix Saint-Simon, Paris, France.
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Zeng W, Hou Y, Gu W, Chen Z. Proteomic Biomarkers of Intrahepatic Cholestasis of Pregnancy. Reprod Sci 2024; 31:1573-1585. [PMID: 38177949 PMCID: PMC11111573 DOI: 10.1007/s43032-023-01437-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/14/2023] [Indexed: 01/06/2024]
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disease, which can lead to adverse fetal outcomes, including preterm labor and intrauterine death. The pathogenesis of ICP is still unclear. We hypothesized that pathological index leads to abnormal placenta changes in ICP. Investigation of these differences in protein expression in parallel profiling is essential to understand the comprehensive pathophysiological mechanism underlying ICP. The present study screened differentially expressed proteins (DEPs) as novel diagnostic markers for ICP. Proteomic profiles of placental tissues from 32 ICP patients and 24 healthy volunteers (controls) were analyzed. Our founding was valid by following western blotting and immunohistochemistry staining, respectively. The association of the key protein expression with clinicopathological features of ICP was further analyzed. A total of 178 DEPs were identified between the ICP and control groups. Functional enrichment analysis showed these proteins were significantly enriched in the PPAR singling pathway by KEGG and PPARα/RXRα activation by IPA. Apolipoprotein A2 (APOA2) was the only upregulated protein, which uniquely identified in ICP groups and related to both pathways. Validation of western blotting and immunohistochemical staining analysis showed significantly higher APOA2 expression in the ICP group than in the control group. Furthermore, the expression of APOA2 is associated with clinicopathological features in ICP groups. Receiver operating characteristic (ROC) curve analyses showed that the AUC of APOA2 was 0.8984 (95% confidence interval (CI): 0.772-1.000). This study has identified up-regulated APOA2 associated with PPAR singling pathway and PPARα/RXRα activation in ICP. Thus, APOA2 may be involved in ICP pathogenesis, serving as a novel biomarker for its diagnosis.
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Affiliation(s)
- Weijian Zeng
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Yanyan Hou
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Wei Gu
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China.
- Shanghai Key Laboratory of Embryo Original Diseases, The International Peace Maternity and Child Health Hospital, Shanghai, 200030, China.
- Shanghai Municipal Key Clinical Specialty, The International Peace Maternity and Child Health Hospital, Shanghai, 200030, China.
| | - Zheng Chen
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China.
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Sentilhes L, Sénat MV, Bouchghoul H, Delorme P, Gallot D, Garabedian C, Madar H, Sananès N, Perrotin F, Schmitz T. [Sentilhes L., Sénat M.V., Bouchghoul H., Delorme P., Gallot D., Garabedian C., Madar H., Sananès N., Perrotin F., Schmitz T., in reply to the article by Boujenah J., entitled "La cholestase gravidique : pour une vision holistique de la femme. À propos des examens complémentaires lors du diagnostic". Gynecol Obstet Fertil 2024;52(6). doi:10.1016/j.gofs.2024.02.023]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:440-441. [PMID: 38408606 DOI: 10.1016/j.gofs.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 02/28/2024]
Affiliation(s)
- Loïc Sentilhes
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France.
| | - Marie-Victoire Sénat
- Service de gynécologie-obstétrique, hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Hanane Bouchghoul
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Pierre Delorme
- Service de gynécologie-obstétrique, hôpital Trousseau, AP-HP, Paris, France
| | - Denis Gallot
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Charles Garabedian
- Service de gynécologie-obstétrique, CHU de Lille, université de Lille, ULR 2694-METRICS, 59000 Lille, France
| | - Hugo Madar
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Nicolas Sananès
- Service de gynécologie-obstétrique, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Franck Perrotin
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Tours, Tours, France
| | - Thomas Schmitz
- Service de gynécologie obstétrique, hôpital Robert-Debré, AP-HP, Paris, France
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Feng F, Li J, Liao J, Qin S, Liu Y, Che X, Zhou Y, Jiang D, Xiao H, Chen A, Shao Y. Associations of clinical subtypes and bile acid levels of intrahepatic cholestasis of pregnancy with pregnancy outcomes. Sci Rep 2024; 14:12185. [PMID: 38806569 PMCID: PMC11133304 DOI: 10.1038/s41598-024-63183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 05/27/2024] [Indexed: 05/30/2024] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) can lead to many adverse pregnancy outcomes, and the influencing factors remain unclear at present. This study retrospectively analyzed clinical data from 1815 pregnant women with ICP and evaluated the relationship between ICP subtypes, gestational age at onset, and pregnancy outcomes. The results of this study show that during pregnancy, the levels of biochemical indicators (TBA, DBIL and ALT) in the serum of pregnant women initially diagnosed with subtypes of ICP were noted to constantly change, and the subtype of ICP and its severity also changed. The incidence of adverse pregnancy outcomes [meconium-stained amniotic fluid (MSAF), NICU transfer, Apgar score ≤ 7 at 1 min, and preterm birth] in patients with ICP1 (icteric type) was significantly higher than for patients with ICP2, ICP3 or ICP4. The preterm birth rate of early-onset ICP was higher than that of late-onset ICP in ICP1 and ICP3 subtypes. In conclusion, the outcome of pregnancy in women with ICP is closely related to the serum TBA level and ICP subtype, which should be recognized in the clinic.
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Affiliation(s)
- Fan Feng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Juhong Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Department of Obstetrics and Gynecology, Yubei District Maternal and Child Health Hospital, Chongqing, China
| | - Junqun Liao
- Department of Experiment, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shiyi Qin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yaling Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Department of Obstetrics and Gynecology, Yubei District Maternal and Child Health Hospital, Chongqing, China
| | - Xian Che
- Department of Obstetrics and Gynecology, Yubei District Maternal and Child Health Hospital, Chongqing, China
| | - Yanjun Zhou
- Department of Obstetrics and Gynecology, Yubei District Maternal and Child Health Hospital, Chongqing, China
| | - Dan Jiang
- Department of Obstetrics and Gynecology, Yubei District Maternal and Child Health Hospital, Chongqing, China
| | - Huiqin Xiao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Aixing Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yong Shao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Hamud A, Cohen MJ, Hochner-Celnikier D, Bar-Oz B, Ackerman Z. Gradual dosing of ursodeoxycholic acid in mothers with intrahepatic cholestasis of pregnancy may improve composite neonatal outcome. Ann Hepatol 2024; 29:101490. [PMID: 38403070 DOI: 10.1016/j.aohep.2024.101490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/10/2023] [Accepted: 01/03/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION AND OBJECTIVES Intrahepatic cholestasis of pregnancy (ICP) is often accompanied by fetal and maternal complications. MATERIALS AND METHODS Retrospective review of the clinical course of women with ICP and their neonates treated at our medical center over a 10-year period. Special attention was paid to the maternal and neonatal response to 2 different modes of ursodeoxycholic acid (UDCA) administration. RESULTS Neonates of mothers with high total bile acid levels had a poorer composite neonatal outcome. Twenty-seven women who presented at an advanced stage of their pregnancies did not receive UDCA. UDCA was administered in 2 modes: either a full dose at admission (76 women) or a gradually increasing dose until the desired dosage was reached (25 women). The mean gestational age at delivery for the 94 neonates that were exposed to full UDCA dose was the lowest (36±2.3 weeks for the full dose, 37±1.4 weeks for the 30 neonates from the gradually increasing dose, 38±1.6 weeks for the 29 neonates from the no treatment group, p<0.001). The group of neonates that were exposed to full UDCA dose had the highest rate of unfavorable composite neonatal outcome (53% for full dose, 30% for gradually increasing dose, 24% for the no treatment group, p=0.006). CONCLUSIONS Compared to the administration of a full UDCA dose, the administration of a gradually increasing dose of UDCA may be associated with a greater gestational age at delivery and fewer events of unfavorable composite neonatal outcomes. These novel findings should be retested prospectively in a large cohort of patients.
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Affiliation(s)
- Amir Hamud
- Department of Medicine, Hadassah-Hebrew University Medical Center and the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Matan J Cohen
- Clalit Health Services, Jerusalem District, affiliated to the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Drorith Hochner-Celnikier
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center and the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Benjamin Bar-Oz
- Department of Neonatology, Hadassah-Hebrew University Medical Center and the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Zvi Ackerman
- Department of Medicine, Hadassah-Hebrew University Medical Center and the Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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10
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İpek G, Tanaçan A, Peker A, Ağaoğlu Z, Kara Ö, Şahin D. Systemic Inflammation Response Index as a diagnostic and prognostic predictor of intrahepatic cholestasis of pregnancy: A case-control study from a tertiary center. Int J Gynaecol Obstet 2024; 165:717-722. [PMID: 37922220 DOI: 10.1002/ijgo.15216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/15/2023] [Accepted: 10/12/2023] [Indexed: 11/05/2023]
Abstract
OBJECTIVE To investigate the diagnostic and prognostic value of the Systemic Inflammation Response Index (SIRI) in intrahepatic cholestasis of pregnancy (ICP). METHODS The present case-control study comprised 386 participants, including 192 women with ICP and 194 gestational age-matched pregnant women. Increased fasting biliary acid (FBA) levels (≥10 μmol/L) were accepted as ICP criteria. SIRI values were calculated for the first trimester (SIRI 1), time of diagnosis (SIRI 2), and time of delivery (SIRI 3). The ICP and control groups were compared based on SIRI values, and on obstetrical and neonatal outcomes. The ICP subgroups based on FBA levels (severe ICP [FBA ≥40 μmol/L] and mild ICP [FBA <40 μmol/L]) were also compared for SIRI and pregnancy outcomes. RESULTS Adverse outcomes were significantly higher in the ICP group (P < 0.001). SIRI 2 and SIRI 3 showed negative significant differences between the ICP and control groups, with P values of 0.001 and 0.009, respectively. A significant difference in ICP severity subgroups (P = 0.046) was observed for SIRI 3. In receiver operating characteristics curve analyses, optimal cut-off values for the prediction of ICP were found to be 2.01 and 2.08 for SIRI 2 and SIRI 3, respectively. A cut-off value 1.74 was determined to predict the disease severity for SIRI 3. CONCLUSION SIRI has clinical significance in accordance with the inflammatory etiology of ICP. SIRI might be used with other clinical and laboratory findings for ICP diagnosis and prediction.
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Affiliation(s)
- Göksun İpek
- Division of Perinatology, Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Atakan Tanaçan
- Division of Perinatology, Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Ayça Peker
- Division of Perinatology, Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Zahid Ağaoğlu
- Division of Perinatology, Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Özgür Kara
- Division of Perinatology, Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Dilek Şahin
- Division of Perinatology, Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
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11
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Malarkiewicz P, Nowacka U, Januszaniec A, Mankiewicz A, Kozłowski S, Issat T. Intrahepatic Cholestasis of Pregnancy during COVID-19 Pandemic. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:676. [PMID: 38674322 PMCID: PMC11052128 DOI: 10.3390/medicina60040676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: Intrahepatic cholestasis of pregnancy (ICP) stands as one of the most prevalent concerns in maternal-fetal medicine, presenting a significant risk to fetal health and often associated with liver dysfunction. Concurrently, the coronavirus-19 (COVID-19) infection can lead to hepatic cell injury through both direct and indirect pathways. Hypothetically, these two conditions may coincide, influencing each other. This study aimed to comparatively assess the incidence and severity of ICP before and during the COVID-19 pandemic. Methods: A retrospective cohort study was conducted, comparing the incidence and severity of ICP between January 2018 and February 2020 (pre-COVID-19 period) and March 2020 to March 2022 (COVID-19 period) across two hospitals, encompassing 7799 deliveries. The diagnosis of ICP was established using the ICD-10 code and defined as total bile acids (BA) levels ≥ 10 μmol/L. Statistical analysis included descriptive statistics, Chi-square and Mann-Whitney U tests, as well as multiple or logistic regression analysis. Results: A total of 226 cases of ICP were identified. The incidence of mild cholestasis (BA < 40 μmol/L) was lower during the pandemic compared to before (3% before versus 2%, p < 0.05), while the incidence of moderate and severe ICP remained unchanged (0.6% before vs. 0.4%, p = 0.2). Overall, the total incidence of ICP was lower during the pandemic (3.6% before versus 2.4%, p = 0.01). No significant differences were observed in severity (as defined by BA and liver function test levels), rates of caesarean section, or neonatal birth weights. Conclusions: During the COVID-19 pandemic, the total incidence of ICP appeared to be lower. However, this reduction was primarily observed in cases of mild ICP, potentially indicating challenges in detection or reduced access to medical services during this period. The incidence of moderate and severe ICP remained unchanged, suggesting that these forms of the condition were unaffected by the pandemic's circumstances.
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Affiliation(s)
- Paulina Malarkiewicz
- Department of Obstetrics and Gynecology, School of Medicine, Collegium Medicum of the University of Warmia and Mazury, al. Warszawska 30, 10-082 Olsztyn, Poland
| | - Urszula Nowacka
- Department of Obstetrics and Gynecology, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Aleksandra Januszaniec
- Department of Obstetrics and Gynecology, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Alicja Mankiewicz
- Department of Obstetrics and Gynecology, Olsztyn Specialist Hospital, Żołnierska 18; 10-561 Olsztyn, Poland
| | - Szymon Kozłowski
- Department of Obstetrics and Gynecology, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
| | - Tadeusz Issat
- Department of Obstetrics and Gynecology, Institute of Mother and Child, Kasprzaka 17a, 01-211 Warsaw, Poland
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12
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Cao L, Ling X, Yan J, Feng D, Dong Y, Xu Z, Wang F, Zhu S, Gao Y, Cao Z, Zhang M. Clinical and genetic study of ABCB4 gene-related cholestatic liver disease in China: children and adults. Orphanet J Rare Dis 2024; 19:157. [PMID: 38610052 PMCID: PMC11010299 DOI: 10.1186/s13023-024-03179-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND ABCB4 gene-related cholestatic liver diseases have a wide spectrum of clinical and genetic variations. The correlation between genotype and clinical phenotype still unclear. This study retrospectively analyzed the clinical and pathological characteristics of 23 patients with ABCB4 gene-related cholestatic liver diseases. Next-generation sequencing was used to identify the genetic causes. RESULTS The 23 included patients (15 children and 8 adults) were diagnosed as progressive familial intrahepatic cholestasis type 3 (PFIC3), drug-induced liver injury (DILI), cirrhosis cholestasis, cirrhosis, and mild liver fibrosis. Nineteen patients underwent liver pathological examination of the liver, exhibiting fibrosis, small bile duct hyperplasia, CK7(+), Cu(+), bile duct deletion, and cirrhosis. Thirty ABCB4 variants were identified, including 18 novel variants. CONCLUSION ABCB4 gene-related cholestatic liver diseases have a wide spectrum of clinical and genetic variations. Biallelic ABCB4 mutation carriers tended to severe PFIC3, which mostly occurs in children; while ABCB4 non-biallelic variants can lead to milder ICP, LACP, DILI or overlapping, mostly in adults. Thus, the ABCB4 genotype has a specific correlation with the phenotype, but there are exceptions. Non-biallelic null mutations can cause severe diseases. The mechanisms underlying this genetic phenotype require further investigation.
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Affiliation(s)
- Lili Cao
- Department of Hepatology, Fifth Medical Center, PLA General Hospital, No.100, West Fourth Ring Road, Fengtai District, Beijing, 100039, China
| | - Xiuxin Ling
- Grandomics Biosciences, Beijing, 100098, China
| | - Jianguo Yan
- Department of Hepatology, Fifth Medical Center, PLA General Hospital, No.100, West Fourth Ring Road, Fengtai District, Beijing, 100039, China
| | - Danni Feng
- Department of Hepatology, Fifth Medical Center, PLA General Hospital, No.100, West Fourth Ring Road, Fengtai District, Beijing, 100039, China
| | - Yi Dong
- Department of Hepatology, Fifth Medical Center, PLA General Hospital, No.100, West Fourth Ring Road, Fengtai District, Beijing, 100039, China
| | - Zhiqiang Xu
- Department of Hepatology, Fifth Medical Center, PLA General Hospital, No.100, West Fourth Ring Road, Fengtai District, Beijing, 100039, China
| | - Fuchuan Wang
- Department of Hepatology, Fifth Medical Center, PLA General Hospital, No.100, West Fourth Ring Road, Fengtai District, Beijing, 100039, China
| | - Shishu Zhu
- Department of Hepatology, Fifth Medical Center, PLA General Hospital, No.100, West Fourth Ring Road, Fengtai District, Beijing, 100039, China
| | - Yinjie Gao
- Department of Hepatology, Fifth Medical Center, PLA General Hospital, No.100, West Fourth Ring Road, Fengtai District, Beijing, 100039, China
| | - Zhenhua Cao
- Grandomics Biosciences, Beijing, 100098, China
| | - Min Zhang
- Department of Hepatology, Fifth Medical Center, PLA General Hospital, No.100, West Fourth Ring Road, Fengtai District, Beijing, 100039, China.
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13
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Li X, Liang X, Gu X, Zou M, Cao W, Liu C, Wang X. Ursodeoxycholic acid and 18β-glycyrrhetinic acid alleviate ethinylestradiol-induced cholestasis via downregulating RORγt and CXCR3 signaling pathway in iNKT cells. Toxicol In Vitro 2024; 96:105782. [PMID: 38244730 DOI: 10.1016/j.tiv.2024.105782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/04/2023] [Accepted: 01/15/2024] [Indexed: 01/22/2024]
Abstract
Estrogen-induced intrahepatic cholestasis (IHC) is a mild but potentially serious risk and urges for new therapeutic targets and effective treatment. Our previous study demonstrated that RORγt and CXCR3 signaling pathway of invariant natural killer T (iNKT) 17 cells play pathogenic roles in 17α-ethinylestradiol (EE)-induced IHC. Ursodeoxycholic acid (UDCA) and 18β-glycyrrhetinic acid (GA) present a protective effect on IHC partially due to their immunomodulatory properties. Hence in present study, we aim to investigate the effectiveness of UDCA and 18β-GA in vitro and verify the accessibility of the above targets. Biochemical index measurement indicated that UDCA and 18β-GA presented efficacy to alleviate EE-induced cholestatic cytotoxicity. Both UDCA and 18β-GA exhibited suppression on the CXCL9/10-CXCR3 axis, and significantly restrained the expression of RORγt in vitro. In conclusion, our observations provide new therapeutic targets of UDCA and 18β-GA, and 18β-GA as an alternative treatment for EE-induced cholestasis.
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Affiliation(s)
- Xinyu Li
- State Key Laboratory of Natural Medicines, New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Xiaojing Liang
- State Key Laboratory of Natural Medicines, New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Xiaoxia Gu
- Department of Obstetrics and Gynecology, Zhongda Hospital, Southeast University, Nanjing 210009, China
| | - Mengzhi Zou
- State Key Laboratory of Natural Medicines, New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Weiping Cao
- Departments of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang 212001, China.
| | - Chunhui Liu
- Physics and Chemistry Test Center of Jiangsu Province, 210042 Nanjing, China.
| | - Xinzhi Wang
- State Key Laboratory of Natural Medicines, New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China.
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14
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Sarker MR, Debolt CA, Canfield D, Ferrara L. History of Cholestasis is not Associated with Worsening Outcomes in Subsequent Pregnancy with Cholestasis. Am J Perinatol 2024. [PMID: 38423120 DOI: 10.1055/a-2278-9539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Intrahepatic cholestasis of pregnancy is associated with adverse pregnancy outcomes including intrauterine fetal demise, spontaneous preterm labor, and meconium-stained amniotic fluid. Studies have yet to determine if patients with a history of pregnancy complicated by cholestasis had an association with more severe adverse outcomes in a subsequent pregnancy complicated by cholestasis. STUDY DESIGN Retrospective cohort study of multiparous, singleton, nonanomalous live gestations complicated by cholestasis at Elmhurst Hospital Center from 2005 to 2019. We compared rates of adverse outcomes in multiparous pregnancies complicated by cholestasis with versus without prior cholestasis. Our primary outcome was rates of spontaneous preterm labor. Our secondary outcomes included rates of iatrogenic preterm birth, meconium-stained amniotic fluid, cesarean delivery for nonreassuring fetal heart tracing. Chi-square and multivariate regression tests were used to determine the strength of association. In all analyses, a p-value less than 0.05 and 95% confidence interval not crossing 1.00 indicated statistical significance. Mount Sinai Icahn School of Medicine Institutional Review Board approval was obtained for this project. RESULTS Of the 795 multiparous pregnancies complicated by cholestasis, 618 (77.7%) had no prior history of cholestasis and 177 (23.3%) had prior history of cholestasis. Multiparous pregnancies with history of cholestasis had higher rates of prior preterm birth, earlier gestational age at diagnosis and delivery, and were more likely to receive ursodeoxycholic acid therapy. Pregnancies with history of cholestasis were not associated with spontaneous preterm labor in subsequent pregnancies with cholestasis, but history of cholestasis was associated with iatrogenic preterm birth and neonatal intensive care unit (NICU) admission. After adjusting for confounders, the association with iatrogenic preterm birth and NICU admission were no longer statistically significant. There was no significant association between history of cholestasis and other adverse obstetric outcomes. CONCLUSION Findings suggests that history of prior cholestasis is not associated with worsening outcomes in subsequent pregnancies complicated by cholestasis. KEY POINTS · Prior cholestasis may not alter risk in subsequent pregnancies.. · Unclear relationship between cholestasis and hepatobiliary disease.. · Studies needed to develop cholestasis screening protocol..
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Affiliation(s)
- Minhazur R Sarker
- Department of Obstetrics, Gynecology and Reproductive Science, University of California San Diego, San Diego, California
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York
| | - Chelsea A Debolt
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York
| | - Dana Canfield
- Department of Obstetrics, Gynecology and Reproductive Science, University of California San Diego, San Diego, California
| | - Lauren Ferrara
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York
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15
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Myszkowski S, Ayuk PTY. Intra-hepatic cholestasis of pregnancy: Management challenges. Case Rep Womens Health 2024; 41:e00576. [PMID: 38616966 PMCID: PMC11009878 DOI: 10.1016/j.crwh.2023.e00576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 04/16/2024] Open
Affiliation(s)
- Stephanie Myszkowski
- Department of Obstetrics, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, United Kingdom
| | - Paul T.-Y. Ayuk
- Department of Obstetrics, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, United Kingdom
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16
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Obiegbusi CN, Dong XJ, Obiegbusi SC, Jin X, Okoene IK. Predictors of Adverse Fetal Outcomes in Intrahepatic Cholestasis of Pregnancy (ICP): a Narrative Review. Reprod Sci 2024; 31:341-351. [PMID: 37626275 DOI: 10.1007/s43032-023-01329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023]
Abstract
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.
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Affiliation(s)
- Chidera Nneji Obiegbusi
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Jing Dong
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Samuel Chigbo Obiegbusi
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Jin
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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17
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Cai QY, Li ZH, Deng BN, Luo X, Lan X, Chen Y, Liang LF, Liu CY, Liu TH, Wang YX, Wang L. 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. J Hypertens 2024; 42:143-152. [PMID: 37737865 PMCID: PMC10712991 DOI: 10.1097/hjh.0000000000003577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/03/2023] [Accepted: 08/25/2023] [Indexed: 09/23/2023]
Abstract
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.
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Affiliation(s)
- Qin-Yu Cai
- Department of Obstetrics, Women and Children's Hospital of Chongqing Medical University
- Joint International Research Laboratory of Reproduction & Development, Chongqing Medical University, Yuzhong District of Chongqing
| | - Zhuo-Hang Li
- Department of Obstetrics, Women and Children's Hospital of Chongqing Medical University
- Medical Laboratory Department, Traditional Chinese Medicine Hospital of Yaan, Sichuan
| | - Bei-Ning Deng
- Department of Obstetrics, Women and Children's Hospital of Chongqing Medical University
- Joint International Research Laboratory of Reproduction & Development, Chongqing Medical University, Yuzhong District of Chongqing
| | - Xin Luo
- Joint International Research Laboratory of Reproduction & Development, Chongqing Medical University, Yuzhong District of Chongqing
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, China
| | - Xia Lan
- Department of Obstetrics, Women and Children's Hospital of Chongqing Medical University
| | - Ya Chen
- Department of Obstetrics, Women and Children's Hospital of Chongqing Medical University
| | - Li-Fang Liang
- Department of Obstetrics, Women and Children's Hospital of Chongqing Medical University
- Joint International Research Laboratory of Reproduction & Development, Chongqing Medical University, Yuzhong District of Chongqing
| | - Chen-Yang Liu
- Joint International Research Laboratory of Reproduction & Development, Chongqing Medical University, Yuzhong District of Chongqing
| | - Tai-Hang Liu
- Joint International Research Laboratory of Reproduction & Development, Chongqing Medical University, Yuzhong District of Chongqing
| | - Ying-Xiong Wang
- Joint International Research Laboratory of Reproduction & Development, Chongqing Medical University, Yuzhong District of Chongqing
| | - Lan Wang
- Department of Obstetrics, Women and Children's Hospital of Chongqing Medical University
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18
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Marenco-Flores A, Sierra L, Goyes D, Kahan T, Patwardhan VR, Bonder A. Managing pruritus in chronic liver disease: An in-depth narrative review. Clin Liver Dis (Hoboken) 2024; 23:e0187. [PMID: 38872783 PMCID: PMC11168844 DOI: 10.1097/cld.0000000000000187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/20/2024] [Indexed: 06/15/2024] Open
Affiliation(s)
- Ana Marenco-Flores
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Leandro Sierra
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Daniela Goyes
- Department of Internal Medicine, Division of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tamara Kahan
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vilas R. Patwardhan
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alan Bonder
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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19
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Sentilhes L, Sénat MV, Bouchghoul H, Delorme P, Gallot D, Garabedian C, Madar H, Sananès N, Perrotin F, Schmitz T. [Intrahepatic cholestasis of pregnancy: French College of Obstetricians and Gynecologists guidelines for clinical practice]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:493-510. [PMID: 37806861 DOI: 10.1016/j.gofs.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
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.
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Affiliation(s)
- L Sentilhes
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France.
| | - M-V Sénat
- Service de gynécologie-obstétrique, hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - H Bouchghoul
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - P Delorme
- Service de gynécologie-obstétrique, hôpital Trousseau, AP-HP, Paris, France
| | - D Gallot
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - C Garabedian
- Service de gynécologie-obstétrique, CHU de Lille, université de Lille, ULR 2694-METRICS, 59000 Lille, France
| | - H Madar
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - N Sananès
- Service de gynécologie-obstétrique, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - F Perrotin
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Tours, Tours, France
| | - T Schmitz
- Service de gynécologie obstétrique, hôpital Robert-Debré, AP-HP, Paris, France
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Perri A, Patti ML, Velardi M, Sbordone A, Prontera G, Fattore S, D’Andrea V, Tana M, Vento G. Bile Acids Pneumonia: A Respiratory Distress Syndrome in Early-Term Neonates. J Clin Med 2023; 12:6565. [PMID: 37892703 PMCID: PMC10607698 DOI: 10.3390/jcm12206565] [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: 08/14/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) complicates among 0.2-2% of pregnancies and has been associated with adverse perinatal outcomes, including sudden stillbirth, meconium strained fluid, preterm birth, perinatal asphyxia, and transient tachypnea of the newborn. The diagnosis of "bile acids pneumonia" was previously proposed and a causative role of bile acids (BA) was supposed with a possible mechanism of action including surfactant dysfunction, inflammation, and chemical pneumonia. In the last few years, the role of lung ultrasound (LUS) in the diagnosis and management of neonatal respiratory distress syndrome has grown, and LUS scores have been introduced in the literature, as an effective predictor of the need for surfactant treatment among neonates with respiratory distress syndrome. We present four cases of infants born from pregnancies complicated by ICP, who developed respiratory distress syndrome early after birth. Lung ultrasound showed the same pattern for all infants, corresponding to a homogeneous alveolar-interstitial syndrome characterized by a diffuse coalescing B-line pattern (white lung). All infants evaluated require non-invasive respiratory support and in three cases surfactant administration, despite the near-term gestational age, with rapid improvement of respiratory disease and a good clinical outcome.
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Affiliation(s)
- Alessandro Perri
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.V.); (A.S.); (G.P.); (S.F.); (V.D.); (M.T.); (G.V.)
- Department of Woman and Child Health and Public Health, Child Health Area, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Maria Letizia Patti
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.V.); (A.S.); (G.P.); (S.F.); (V.D.); (M.T.); (G.V.)
| | - Margherita Velardi
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.V.); (A.S.); (G.P.); (S.F.); (V.D.); (M.T.); (G.V.)
| | - Annamaria Sbordone
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.V.); (A.S.); (G.P.); (S.F.); (V.D.); (M.T.); (G.V.)
| | - Giorgia Prontera
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.V.); (A.S.); (G.P.); (S.F.); (V.D.); (M.T.); (G.V.)
| | - Simona Fattore
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.V.); (A.S.); (G.P.); (S.F.); (V.D.); (M.T.); (G.V.)
| | - Vito D’Andrea
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.V.); (A.S.); (G.P.); (S.F.); (V.D.); (M.T.); (G.V.)
- Department of Woman and Child Health and Public Health, Child Health Area, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Milena Tana
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.V.); (A.S.); (G.P.); (S.F.); (V.D.); (M.T.); (G.V.)
- Department of Woman and Child Health and Public Health, Child Health Area, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giovanni Vento
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (M.V.); (A.S.); (G.P.); (S.F.); (V.D.); (M.T.); (G.V.)
- Department of Woman and Child Health and Public Health, Child Health Area, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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21
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Xiong L, Tang M, Xing S, Yang X. The role of noncoding RNA and its diagnostic potential in intrahepatic cholestasis of pregnancy: a research update. Front Genet 2023; 14:1239693. [PMID: 37900174 PMCID: PMC10611463 DOI: 10.3389/fgene.2023.1239693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a common liver disorder that generally occurs during the second or third trimester of pregnancy. It rarely causes any harm to the mother; however, it can result in short- and long-term complications in the offspring. Therefore, it is crucial to diagnose and treat this condition to avoid poor pregnancy outcomes. The identification of novel markers with potential diagnostic, prognostic, and therapeutic utility in ICP has gained attention. Noncoding RNAs (ncRNAs), including microRNA, long noncoding RNA, and circular RNA, are a type of transcripts that are not translated into proteins. They possess vital biological functions, including transcriptional and translational regulation and DNA, RNA, and protein interactions. The pathogenesis of ICP is related to the aberrant expression of several circulating or placenta-related ncRNAs. In this review, we summarized all recent findings on ncRNAs and ICP and outlined the concepts that form the basis for the early diagnosis and targeted treatment of ICP.
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Affiliation(s)
- Liling Xiong
- Obstetrics Department, Chengdu Women’s and Children’s Center Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Mi Tang
- GCP Institution, Chengdu Women’s and Children’s Center Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Shasha Xing
- GCP Institution, Chengdu Women’s and Children’s Center Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiao Yang
- Obstetrics Department, Chengdu Women’s and Children’s Center Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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22
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White SW. Intrahepatic cholestasis of pregnancy: Contemporary management. Aust N Z J Obstet Gynaecol 2023; 63:623-624. [PMID: 37775914 DOI: 10.1111/ajo.13753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Scott W White
- The Western Australian Centre for Health Research for Women and Babies, The University of Western Australia, Perth, Western Australia, Australia
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
- Maternal Fetal Medicine Service, King Edward Memorial Hospital, Perth, Western Australia, Australia
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23
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Hague WM, Briley A, Callaway L, Dekker Nitert M, Gehlert J, Graham D, Grzeskowiak L, Makris A, Markus C, Middleton P, Peek MJ, Shand A, Stark M, Waugh J. Intrahepatic cholestasis of pregnancy - Diagnosis and management: A consensus statement of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ): Executive summary. Aust N Z J Obstet Gynaecol 2023; 63:656-665. [PMID: 37431680 DOI: 10.1111/ajo.13719] [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: 03/22/2023] [Accepted: 05/24/2023] [Indexed: 07/12/2023]
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy liver disease, characterised by pruritus and increased total serum bile acids (TSBA), Australian incidence 0.6-0.7%. ICP is diagnosed by non-fasting TSBA ≥19 μmol/L in a pregnant woman with pruritus without rash without a known pre-existing liver disorder. Peak TSBA ≥40 and ≥100 μmol/L identify severe and very severe disease respectively, associated with spontaneous preterm birth when severe, and with stillbirth, when very severe. Benefit-vs-risk for iatrogenic preterm birth in ICP remains uncertain. Ursodeoxycholic acid remains the best pharmacotherapy preterm, improving perinatal outcome and reducing pruritus, although it has not been shown to reduce stillbirth.
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Affiliation(s)
- William M Hague
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Annette Briley
- Women's Health & Midwifery Research, College of Nursing & Health Sciences, Bedford Park, South Australia, Australia
| | - Leonie Callaway
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Marloes Dekker Nitert
- School of Chemistry and Molecular Biosciences, The University of Queensland, St Lucia, Queensland, Australia
| | - Jessica Gehlert
- Department of Obstetrics and Gynaecology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Dorothy Graham
- King Edward Memorial Hospital, Subiaco, Western Australia, Australia
| | - Luke Grzeskowiak
- College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Angela Makris
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Corey Markus
- College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Philippa Middleton
- SA Health and Medical Research Institute, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Michael J Peek
- College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Antonia Shand
- Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Michael Stark
- Women's and Children's Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jason Waugh
- Auckland City Hospital, Auckland, New Zealand
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24
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Estin ML, Campbell AIK, Watkins VY, Dotters-Katz SK, Brady CW, Federspiel JJ. Risk of stillbirth in United States patients with diagnosed intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol 2023; 229:453.e1-453.e8. [PMID: 37348778 PMCID: PMC10651178 DOI: 10.1016/j.ajog.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy is associated with a 4- to 10-fold increase in the risk of stillbirth in the absence of intervention, leading to recommendations for antenatal assessment, ursodiol use, and often preterm or early term delivery. OBJECTIVE This study aimed to determine whether current management strategies for intrahepatic cholestasis of pregnancy mitigate the elevated risk of stillbirth at a population level. STUDY DESIGN This was a retrospective cohort study using the 2015-2020 National Readmissions Database, an administrative database developed by the United States Agency for Healthcare Research and Quality. Our study identified delivery hospitalizations, gestational age at delivery, occurrence of intrahepatic cholestasis of pregnancy and stillbirth, and comorbid conditions using the International Classification of Diseases diagnosis and procedure codes. Moreover, this study compared the timing of delivery and stillbirth rates of pregnant patients with intrahepatic cholestasis of pregnancy vs those without intrahepatic cholestasis of pregnancy at the time of delivery hospitalization. RESULTS This study identified a cohort of 9,987,705 delivery hospitalizations in the National Readmissions Database, corresponding to a weighted national estimate of 18,609,207 births. Of these births, 152,040 (0.8%) were noted to have an intrahepatic cholestasis of pregnancy diagnosis. Patients with an intrahepatic cholestasis of pregnancy diagnosis were older, with small differences in comorbidities, such as a higher rate of gestational diabetes mellitus, than patients without an intrahepatic cholestasis of pregnancy diagnosis at delivery hospitalization. The overall rates of stillbirth were lower among those with intrahepatic cholestasis of pregnancy than among those without intrahepatic cholestasis of pregnancy (252 vs 386 per 100,000 deliveries; risk difference, 133 fewer per 100,000 deliveries; 95% confidence interval, 98-170), a finding that persisted after adjustment for insurance status, socioeconomic factors, and comorbid conditions (risk difference, 160 fewer stillbirths per 100,000 deliveries; 95% confidence interval, 127-194). Furthermore, although patients with intrahepatic cholestasis of pregnancy were more likely to deliver before term than those without intrahepatic cholestasis of pregnancy (30.1% vs 9.3%; P<.001), increased rates of stillbirth were not noted at any point after stratification of the cohort by gestational age at delivery. CONCLUSION Patients with intrahepatic cholestasis of pregnancy diagnosis codes delivered earlier than those without intrahepatic cholestasis of pregnancy diagnosis codes, but the percentage of births affected by stillbirth was lower, even when stratifying for gestational age at birth. These results may provide reassurance to patients receiving an intrahepatic cholestasis of pregnancy diagnosis that current management does mitigate stillbirth risk in intrahepatic cholestasis of pregnancy.
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Affiliation(s)
| | | | | | | | - Carla W Brady
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jerome J Federspiel
- Departments of Obstetrics and Gynecology; Population Health Sciences, Duke University School of Medicine, Durham, NC
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25
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Xie F, Agrawal S, Johnson EF, Wieland CN, Davis DMR, Theiler RN, Lehman JS. Updates on the dermatopathology of pregnancy-associated skin conditions. Hum Pathol 2023; 140:173-195. [PMID: 37209919 DOI: 10.1016/j.humpath.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023]
Abstract
Pathologists provide valuable input in the dermatological care of pregnant patients in various contexts. This article provides dermatopathology updates on cutaneous changes associated with pregnancy, organized based on the following classification system: physiological skin changes in pregnancy, specific dermatoses of pregnancy, dermatoses modified in pregnancy, and skin neoplasms in pregnancy. Awareness of the impact of pregnancy on the skin by pathologists is important, as this is an opportunity to contribute to diagnostic precision in this patient population.
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Affiliation(s)
- Fangyi Xie
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Shruti Agrawal
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Emma F Johnson
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Carilyn N Wieland
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Dawn Marie R Davis
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Regan N Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA.
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26
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Dong XR, Chen QQ, Xue ML, Wang L, Wu Q, Luo TF. Effect of polyene phosphatidylcholine/ursodeoxycholic acid/ademetionine on pregnancy outcomes in intrahepatic cholestasis. World J Clin Cases 2023; 11:6431-6439. [PMID: 37900240 PMCID: PMC10600986 DOI: 10.12998/wjcc.v11.i27.6431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 06/25/2023] [Accepted: 07/14/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that occurs in pregnant women and can lead to a range of adverse pregnancy outcomes. The condition is typically marked by pruritus (itching) and elevated levels of liver enzymes and bile acids. The standard treatment for ICP has generally been ursodeoxycholic acid and ademetionine 1,4-butanedisulfonate, but the efficacy of this approach remains less than optimal. Recently, polyene phosphatidylcholine has emerged as a promising new therapeutic agent for ICP due to its potential hepatoprotective effects. AIM To evaluate the effect of polyene phosphatidylcholine/ursodeoxycholic acid/ ademetionine 1,4-butanedisulfonate on bile acid levels, liver enzyme indices, and pregnancy outcomes in patients with ICP. METHODS From June 2020 to June 2021, 600 patients with ICP who were diagnosed and treated at our hospital were recruited and assigned at a ratio of 1:1 via random-number table method to receive either ursodeoxycholic acid/ademetionine 1,4-butanedisulfonate (control group, n = 300) or polyene phosphatidylcholine/ursodeoxycholic acid/ademetionine 1,4-butanedisulfonate (combined group, n = 300). Outcome measures included bile acids levels, liver enzyme indices, and pregnancy outcomes. RESULTS Prior to treatment, no significant differences were observed between the two groups (P > 0.05). Post-treatment, patients in both groups had significantly lower pruritus scores, but the triple-drug combination group had lower scores than the dual-drug combination group (P < 0.05). The bile acid levels decreased significantly in both groups, but the decrease was more significant in the triple-drug group (P < 0.05). The triple-drug group also exhibited a greater reduction in the levels of certain liver enzymes and a lower incidence of adverse pregnancy outcomes compared to the dual-drug group (P < 0.05). CONCLUSION Polyene phosphatidylcholine/ursodeoxycholic acid/ademetionine 1,4-butanedisulfonate effectively relieves pruritus and reduces bile acid levels and liver enzyme indices in patients with ICP, providing a positive impact on pregnancy outcome and a high safety profile. Further clinical trials are required prior to clinical application.
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Affiliation(s)
- Xiao-Rui Dong
- Department of Obstetrics, Women’s Hospital School of Medicine Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Qian-Qian Chen
- Department of Obstetrics, Women’s Hospital School of Medicine Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Meng-Ling Xue
- Department of Obstetrics, Women’s Hospital School of Medicine Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Ling Wang
- Department of Obstetrics, Women’s Hospital School of Medicine Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Qin Wu
- Department of Obstetrics, Women’s Hospital School of Medicine Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Teng-Fei Luo
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital, Hangzhou 310016, Zhejiang Province, China
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Mitta K, Tsakiridis I, Dagklis T, Michos G, Zachomitros F, Mamopoulos A, Zavlanos A, Athanasiadis A. Selective feticide reverses intrahepatic cholestasis of pregnancy in twins discordant for growth: A case report. Case Rep Womens Health 2023; 39:e00529. [PMID: 37534193 PMCID: PMC10393552 DOI: 10.1016/j.crwh.2023.e00529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023] Open
Abstract
Twin gestations are associated with an increased risk of intrahepatic cholestasis in pregnancy (ICP), probably attributed to the elevated pregnancy hormones. We report a case of a dichorionic diamniotic twin pregnancy, at the third trimester, complicated with ICP and severe, selective fetal growth restriction (sFGR). A 32-year-old primiparous woman with a dichorionic, diamniotic twin gestation conceived via in vitro fertilization (IVF) presented with pruritus at the maternity care unit at 26+4 weeks of pregnancy. Following a detailed assessment, she was diagnosed with severe sFGR and ICP. During her hospitalization, selective feticide of the FGR fetus was decided and a remarkable improvement in the symptoms and the laboratory findings of ICP was noticed. The incidence of ICP is reported to be higher in twin pregnancies, especially those conceived via IVF, compared with singletons. The optimal timing of delivery and management of twin pregnancies complicated with ICP remain unclear. In our case, selective reduction of the FGR fetus led to the resolution of ICP.
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Affiliation(s)
| | - Ioannis Tsakiridis
- Corresponding author at: Konstantinoupoleos 49, 54642 Thessaloniki, Greece.
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Williamson C, Nana M, Poon L, Kupcinskas L, Painter R, Taliani G, Heneghan M, Marschall HU, Beuers U. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. J Hepatol 2023; 79:768-828. [PMID: 37394016 DOI: 10.1016/j.jhep.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 07/04/2023]
Abstract
Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.
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29
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Cai QY, Li X, Yang Y, Luo X, Luo SJ, Xiong J, He ZY, Chen Y, Mou YW, Hu JY, Yang S, Lan X, Liu TH. Rational use of drugs to alleviate adverse outcomes caused by COVID-19 quarantine in women with intrahepatic cholestasis of pregnancy. Front Med (Lausanne) 2023; 10:1122873. [PMID: 37608824 PMCID: PMC10441112 DOI: 10.3389/fmed.2023.1122873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/21/2023] [Indexed: 08/24/2023] Open
Abstract
Purpose This study aimed to investigate the impacts of home quarantine on pregnancy outcomes of women with intrahepatic cholestasis of pregnancy (ICP) during the COVID-19 outbreak and whether the rational use of drugs will change these impacts. Methods This multi-center study was conducted to compare the pregnancy outcomes in women with ICP between the home quarantine group and the non-home quarantine group in southwest China. Propensity score matching was performed to confirm the pregnancy outcomes of the medication group and the non-medication group in women with ICP during the epidemic period. Results A total of 3,161 women with ICP were enrolled in this study, including 816 in the home quarantine group and 2,345 in the non-home quarantine group. Women with ICP in the home quarantine group had worse pregnancy outcomes, such as a growing risk of gestational diabetes mellitus A1, fetal growth restriction, pre-eclampsia, preterm delivery, and even stillbirth. Drug therapy could alleviate some adverse pregnancy outcomes caused by home quarantine, including pre-eclampsia, preterm delivery, and meconium-stained amniotic fluid. Conclusion COVID-19 quarantine would increase the incidence of ICP and lead to adverse pregnancy outcomes in women with ICP. The rational use of drugs reduced some obstetrical complications and improved partial pregnancy outcomes. Our findings suggested that the government and hospitals should enhance their management and life guidance for women with ICP and speed up developing home quarantine guidelines.
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Affiliation(s)
- Qin-Yu Cai
- Department of Bioinformatics, The School of Basic Medicine, Chongqing Medical University, Chongqing, China
- The Joint International Research Laboratory of Reproduction and Development, Ministry of Education, Chongqing, China
| | - Xia Li
- Department of Bioinformatics, The School of Basic Medicine, Chongqing Medical University, Chongqing, China
- The Joint International Research Laboratory of Reproduction and Development, Ministry of Education, Chongqing, China
| | - Yin Yang
- Department of Infection Controlling Section, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Luo
- The Joint International Research Laboratory of Reproduction and Development, Ministry of Education, Chongqing, China
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shu-Juan Luo
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Xiong
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zong-Yan He
- Department of Bioinformatics, The School of Basic Medicine, Chongqing Medical University, Chongqing, China
- The Joint International Research Laboratory of Reproduction and Development, Ministry of Education, Chongqing, China
| | - Yuan Chen
- Department of Bioinformatics, The School of Basic Medicine, Chongqing Medical University, Chongqing, China
- The Joint International Research Laboratory of Reproduction and Development, Ministry of Education, Chongqing, China
| | - Yi-Wei Mou
- Department of Bioinformatics, The School of Basic Medicine, Chongqing Medical University, Chongqing, China
- The Joint International Research Laboratory of Reproduction and Development, Ministry of Education, Chongqing, China
| | - Ji-Yuan Hu
- Department of Bioinformatics, The School of Basic Medicine, Chongqing Medical University, Chongqing, China
- The Joint International Research Laboratory of Reproduction and Development, Ministry of Education, Chongqing, China
| | - Shu Yang
- Department of Bioinformatics, The School of Basic Medicine, Chongqing Medical University, Chongqing, China
- The Joint International Research Laboratory of Reproduction and Development, Ministry of Education, Chongqing, China
| | - Xia Lan
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Tai-Hang Liu
- Department of Bioinformatics, The School of Basic Medicine, Chongqing Medical University, Chongqing, China
- The Joint International Research Laboratory of Reproduction and Development, Ministry of Education, Chongqing, China
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Li C, Li N, Liu C, Yin S. Causal association between gut microbiota and intrahepatic cholestasis of pregnancy: mendelian randomization study. BMC Pregnancy Childbirth 2023; 23:568. [PMID: 37543573 PMCID: PMC10403878 DOI: 10.1186/s12884-023-05889-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/01/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Previous observational cohort studies have shown that the composition of the gut microbiota is related to the risk of intrahepatic cholestasis of pregnancy (ICP), although it is unclear if the association is causative. This study used Mendelian randomization (MR) to systematically examine whether the gut microbiota was causally linked to ICP. METHODS We obtained the genome-wide association study (GWAS) summary statistics of gut microbiota and ICP from published GWASs. Maximum likelihood (ML), MR-Egger regression, weighted median, inverse variance weighted (IVW), and weighted model were used to investigate the causal association between gut microbiota and ICP. We further conducted a series of sensitivity analyses to confirm the robustness of the primary results of the MR analyses. Reverse MR analysis was performed on the bacterial taxa that were reported to be causally linked to ICP risk in forwarding MR analysis to evaluate the possibility of reverse causation. RESULTS MR analysis revealed that phylum Tenericutes (OR: 1.670, 95%CI: 1.073-2.598, P = 0.023), class Bacteroidia (OR: 1.644, 95%CI: 1.031-2.622, P = 0.037), class Mollicutes (OR: 1.670, 95%CI: 1.073-2.598, P = 0.023), and order Bacteroidales (OR: 1.644, 95%CI: 1.031-2.622, P = 0.037), and were positively associated with the risk of ICP. And we identified that the relative abundance of genus Dialister (OR: 0.562, 95%CI: 0.323-0.977, P = 0.041), genus Erysipelatoclostridium (OR: 0.695, 95%CI: 0.490-0.987, P = 0.042), genus Eubacterium (brachy group) (OR: 0.661, 95%CI: 0.497-0.880, P = 0.005), genus Eubacterium (hallii group) (OR: 0.664, 95%CI: 0.451-0.977, P = 0.037), genus Holdemania (OR: 0.590, 95%CI: 0.414-0.840, P = 0.003), genus Ruminococcus (torques group) (OR: 0.448, 95%CI: 0.235-0.854, P = 0.015), and genus Veillonella (OR: 0.513, 95%CI: 0.294-0.893, P = 0.018) were related to a lower risk of ICP. Additional sensitivity analyses confirmed the robustness of the association between specific gut microbiota composition and ICP. No evidence of reverse causality from ICP to identified bacterial taxa was found in the findings of the reverse MR analyses. CONCLUSIONS Under MR assumptions, our findings propose new evidence of the relationship between gut microbiota and ICP risk. Our results show that the gut microbiota may be useful target of intervention for ICP.
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Affiliation(s)
- Chuang Li
- Department of Obstetrics & Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China
- Liaoning Key Laboratory of Maternal-Fetal Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China
| | - Na Li
- Department of Obstetrics & Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China
- Liaoning Key Laboratory of Maternal-Fetal Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China
| | - Caixia Liu
- Department of Obstetrics & Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China
- Liaoning Key Laboratory of Maternal-Fetal Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China
| | - Shaowei Yin
- Department of Obstetrics & Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China.
- Liaoning Key Laboratory of Maternal-Fetal Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China.
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Li J, Chen J, Lee PMY, Zhang J, Li F, Ren T. Familial clustering of intrahepatic cholestasis of pregnancy: A nationwide population-based study in Denmark. Hepatology 2023; 78:389-396. [PMID: 36815353 DOI: 10.1097/hep.0000000000000328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 01/12/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND AND AIMS Genetics plays a role in the pathogenesis of intrahepatic cholestasis of pregnancy (ICP); however, empirical evidence on familial clustering of ICP is scarce. We aimed to assess the extent of familial recurrence of ICP. APPROACH AND RESULTS This population-based cohort study included all 668,461 primiparous women who gave birth between 1995 and 2018 in Denmark. Women diagnosed with ICP were included to the index cohort. Kinship with index women was determined with the Danish Civil Registration System. Log-binomial regression was used to calculate the relative recurrence risk (RRR) of ICP in relatives of index women. A total of 6722 (1.0%) primiparous women were diagnosed with ICP. In co-twins (n=57), first-degree (n=2279), second-degree (n=1373), and third-degree (n=1758) relatives of the index women, the incidence of ICP reached 5.3%, 2.6%, 0.7%, and 1.4%, respectively, corresponding to adjusted RRRs of 4.82 (95% CI, 1.60-14.48), 2.54 (1.98-3.26), 0.81 (0.44-1.51), and 1.15 (0.77-1.71), respectively. The first-degree relatives of women who had recurrent ICP or first-trimester ICP seemed to be at higher risks [RRR, 4.30 (2.85-6.48), 3.04 (1.93-4.77), respectively]. A minor increased risk was observed in nonbiological relatives [RRR, 1.35 (1.05-1.73); n=4274, including women's full-brothers' partner and women's husbands' full sisters]. CONCLUSIONS Co-twins and first-degree relatives of ICP patients were at ~5- and ~2.5-fold increased risk of ICP, respectively. No increased risk was observed in second-degree and third-degree relatives. Recurrent ICP and first-trimester ICP might indicate a higher degree of family clustering. Further investigation is needed to investigate the increased risk of ICP in nonbiological relatives.
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Affiliation(s)
- Jiong Li
- State Key Laboratory of Reproductive Medicine, Department of Epidemiology, Nanjing Medical University, Nanjing, China
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Jiawen Chen
- Department of Dermatology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Priscilla Ming Yi Lee
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Jun Zhang
- Ministry of Education - Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fei Li
- Ministry of Education - Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Developmental and Behavioural Paediatric & Child Primary Care, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tai Ren
- Ministry of Education - Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Developmental and Behavioural Paediatric & Child Primary Care, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Selinger CP, Rosiou K, Broglio G, Lever G, Chiu CM, Stocker LJ, Chipeta H, Glanville T. Antenatal thiopurine exposure in women with IBD is associated with intrahepatic cholestasis of pregnancy. Expert Opin Drug Saf 2023; 22:1091-1097. [PMID: 37417244 DOI: 10.1080/14740338.2023.2234813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/05/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Pregnant women with inflammatory bowel disease (IBD) continue thiopurines to maintain remission. Other studies have reported intrahepatic cholestasis of pregnancy (ICP) in IBD pregnancies exposed to thiopurines. We aimed to investigate whether thiopurines are associated with an increased risk of ICP. RESEARCH DESIGN AND METHODS Single-center retrospective cohort study comparing incidence of ICP in thiopurine-exposed versus non-exposed patients with IBD compared with age-matched pregnant controls. RESULTS The IBD cohort consisted of 386 pregnancies in 243 patients with IBD, with 386 age-matched controls. In patients with IBD, ICP was significantly more common among thiopurine-exposed pregnancies (9.0% vs 1.8%; odds ratio [95% confidence interval] = 5.34 [1.78-16.02]; p = 0.021). IBD patients with thiopurine exposure were significantly more likely to experience ICP compared to non-IBD controls (9.0% vs 1.3%; p < 0.001). Patients with IBD not exposed to thiopurines had a comparable ICP incidence with controls (1.8% vs 1.3%; p = 0.75). Severe ICP occurred in 80% of thiopurine-exposed ICP cases versus 40% in non-exposed (p = 0.25), versus 20% in controls (p = 0.09). CONCLUSION Thiopurine exposure was associated with a significantly increased risk of ICP among patients with IBD compared to non-exposed IBD patients and age-matched general population controls. The course of ICP was not significantly different in thiopurine-exposed cases.
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Affiliation(s)
| | | | - Giacomo Broglio
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds, UK
- Gastroenterology, IRCCS Fondazione Policlinico San Matteo, Internal Medicine, Pavia, Italy
| | - Gillian Lever
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds, UK
| | - Chun Ming Chiu
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds, UK
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Mohagheghzadeh A, Badr P, Mohagheghzadeh A, Hemmati S. Hypericum perforatum L. and the Underlying Molecular Mechanisms for Its Choleretic, Cholagogue, and Regenerative Properties. Pharmaceuticals (Basel) 2023; 16:887. [PMID: 37375834 PMCID: PMC10300974 DOI: 10.3390/ph16060887] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Any defects in bile formation, secretion, or flow may give rise to cholestasis, liver fibrosis, cirrhosis, and hepatocellular carcinoma. As the pathogenesis of hepatic disorders is multifactorial, targeting parallel pathways potentially increases the outcome of therapy. Hypericum perforatum has been famed for its anti-depressive effects. However, according to traditional Persian medicine, it helps with jaundice and acts as a choleretic medication. Here, we will discuss the underlying molecular mechanisms of Hypericum for its use in hepatobiliary disorders. Differentially expressed genes retrieved from microarray data analysis upon treatment with safe doses of Hypericum extract and intersection with the genes involved in cholestasis are identified. Target genes are located mainly at the endomembrane system with integrin-binding ability. Activation of α5β1 integrins, as osmo-sensors in the liver, activates a non-receptor tyrosine kinase, c-SRC, which leads to the insertion of bile acid transporters into the canalicular membrane to trigger choleresis. Hypericum upregulates CDK6 that controls cell proliferation, compensating for the bile acid damage to hepatocytes. It induces ICAM1 to stimulate liver regeneration and regulates nischarin, a hepatoprotective receptor. The extract targets the expression of conserved oligomeric Golgi (COG) and facilitates the movement of bile acids toward the canalicular membrane via Golgi-derived vesicles. In addition, Hypericum induces SCP2, an intracellular cholesterol transporter, to maintain cholesterol homeostasis. We have also provided a comprehensive view of the target genes affected by Hypericum's main metabolites, such as hypericin, hyperforin, quercitrin, isoquercitrin, quercetin, kaempferol, rutin, and p-coumaric acid to enlighten a new scope in the management of chronic liver disorders. Altogether, standard trials using Hypericum as a neo-adjuvant or second-line therapy in ursodeoxycholic-acid-non-responder patients define the future trajectories of cholestasis treatment with this product.
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Affiliation(s)
- Ala Mohagheghzadeh
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz 71468-64685, Iran;
| | - Parmis Badr
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz 71468-64685, Iran; (P.B.); (A.M.)
| | - Abdolali Mohagheghzadeh
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz 71468-64685, Iran; (P.B.); (A.M.)
- Department of Phytopharmaceuticals (Traditional Pharmacy), School of Pharmacy, Shiraz University of Medical Sciences, Shiraz 71468-64685, Iran
| | - Shiva Hemmati
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz 71468-64685, Iran;
- Biotechnology Research Center, Shiraz University of Medical Sciences, Shiraz 71468-64685, Iran
- Department of Pharmaceutical Biology, Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur 56000, Malaysia
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Xie S, Wei S, Ma X, Wang R, He T, Zhang Z, Yang J, Wang J, Chang L, Jing M, Li H, Zhou X, Zhao Y. Genetic alterations and molecular mechanisms underlying hereditary intrahepatic cholestasis. Front Pharmacol 2023; 14:1173542. [PMID: 37324459 PMCID: PMC10264785 DOI: 10.3389/fphar.2023.1173542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Abstract
Hereditary cholestatic liver disease caused by a class of autosomal gene mutations results in jaundice, which involves the abnormality of the synthesis, secretion, and other disorders of bile acids metabolism. Due to the existence of a variety of gene mutations, the clinical manifestations of children are also diverse. There is no unified standard for diagnosis and single detection method, which seriously hinders the development of clinical treatment. Therefore, the mutated genes of hereditary intrahepatic cholestasis were systematically described in this review.
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Affiliation(s)
- Shuying Xie
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Shizhang Wei
- Department of Anatomy, Histology and Embryology, School of Basic Medical Sciences, Health Science Center, Peking University, Beijing, China
| | - Xiao Ma
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ruilin Wang
- Department of Pharmacy, 5th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Tingting He
- Department of Pharmacy, 5th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhao Zhang
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ju Yang
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jiawei Wang
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lei Chang
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Manyi Jing
- Department of Pharmacy, Chinese PLA General Hospital, Beijing, China
| | - Haotian Li
- Department of Pharmacy, Chinese PLA General Hospital, Beijing, China
| | - Xuelin Zhou
- Department of Pharmacology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Yanling Zhao
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
- Department of Pharmacy, Chinese PLA General Hospital, Beijing, China
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Ebhohon E, Chung RT. Systematic review: efficacy of therapies for cholestatic pruritus. Therap Adv Gastroenterol 2023; 16:17562848231172829. [PMID: 37255856 PMCID: PMC10226044 DOI: 10.1177/17562848231172829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/13/2023] [Indexed: 06/01/2023] Open
Abstract
Background Pruritus is a symptom of several cholestatic liver diseases (CLDs) that can impair health-related quality of life (HRQoL). Despite evidence-based guideline therapy, managing cholestatic pruritus (CP) remains challenging, thus making the need for newer, more effective therapeutic agents more evident. Objective Our study evaluated the efficacy of existing CP therapies. Design Systematic review. Data sources From inception until March 2023, we conducted a comprehensive search of MEDLINE, Cochrane, EMBASE, Scopus, ClinicalTrial.gov, and other sources, including pharmaceutical webpages and conference proceedings published in English that reported on CP interventions. Methods Two reviewers independently conducted screening and full-text review of articles with extraction conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The methodological quality of studies included in our qualitative synthesis was assessed by using the Cochrane ROBINS-I and ROBINS-II tools for interventional studies and the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The primary outcome assessed in our systematic review was the severity of CP after therapy. Results Of 3293 screened articles, 92 studies were eligible for inclusion in the qualitative synthesis. Some patients' HRQoL improved with evidence-based standard therapy. Others, particularly those with severe and refractory CP, often required conversion to or addition of experimental noninvasive (e.g., ondansetron) or extracorporeal liver support to alleviate CP. In addition, studies investigating a newer class drug, the ileal bile acid transporter inhibitor (IBATi), demonstrate its effectiveness in reducing serum bile acid and alleviating CP with sustained improvement noted in patients with the inherited childhood cholestatic disorders - progressive familial intrahepatic cholestasis and Alagille syndrome. Conclusion Our findings consolidate data on the efficacy of guideline-based approaches and newer therapies for CP. While the initial findings are promising, additional clinical trials will be needed to determine the full extent of IBATi's efficacy and potential use in treating other common CLDs. These results provide a foundation for future research and highlight the need for continued investigation into the management and treatment of CLDs.
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Affiliation(s)
| | - Raymond T. Chung
- Gastrointestinal Division, Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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36
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Ma Y, Wang H, Yang J, Xin M, Wu X. Gentamicin alleviates cholestatic liver injury by decreasing gut microbiota-associated bile salt hydrolase activity in rats. Eur J Pharmacol 2023; 951:175790. [PMID: 37179041 DOI: 10.1016/j.ejphar.2023.175790] [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: 01/30/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/15/2023]
Abstract
Intrahepatic cholestasis lacks effective therapeutic drugs. The gut microbiota-associated bile salt hydrolases (BSH) may be a potential therapeutic target. In this study, oral administration of gentamicin (GEN) decreased the serum and hepatic levels of total bile acid in 17α-ethynylestradiol (EE)-induced cholestatic male rats, significantly improved the serum levels of hepatic biomarkers and reversed the histopathological changes in the liver. In healthy male rats, the serum and hepatic levels of total bile acid were also decreased by GEN, the ratio of primary to secondary bile acids, and conjugated to unconjugated bile acids was significantly increased, and the urinary excretion of total bile acid was elevated. 16S rDNA sequencing of the ileal contents revealed that GEN treatment substantially reduced the abundance of Lactobacillus and Bacteroides both of which expressed BSH. Consistently, BSH activity analysis by the generation of d5-chenodeoxycholic acid from d5-taurochenodeoxycholic acid in situ showed BSH was significantly inhibited in the ileal contents of rats treated with GEN. This finding led to an increased proportion of hydrophilic conjugated bile acids and facilitated the urinary excretion of total bile acids, thereby decreasing serum and hepatic total bile acids and reversing liver injury related to cholestasis. Our results provide important evidence that BSH can be a potential drug target for treating cholestasis.
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Affiliation(s)
- Yanrong Ma
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China.
| | - Huan Wang
- School of Pharmacy, Lanzhou University, Lanzhou, 730000, China.
| | - Jinru Yang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China.
| | - Mingyan Xin
- School of Pharmacy, Lanzhou University, Lanzhou, 730000, China.
| | - Xinan Wu
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China; School of Pharmacy, Lanzhou University, Lanzhou, 730000, China.
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37
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Grady J, Clifford C, Treadwell MC, Parikh ND, Satishchandran A. The Use of Fenofibrate for Intrahepatic Cholestasis of Pregnancy. J Hepatol 2023:S0168-8278(23)00237-4. [PMID: 37084798 DOI: 10.1016/j.jhep.2023.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023]
Affiliation(s)
- John Grady
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Caitlin Clifford
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, MI
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, MI
| | - Neehar D Parikh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI.
| | - Abhishek Satishchandran
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
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Gut microbiota alters host bile acid metabolism to contribute to intrahepatic cholestasis of pregnancy. Nat Commun 2023; 14:1305. [PMID: 36894566 PMCID: PMC9998625 DOI: 10.1038/s41467-023-36981-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a female pregnancy-specific disorder that is characterized by increased serum bile acid and adverse fetal outcomes. The aetiology and mechanism of ICP are poorly understood; thus, existing therapies have been largely empiric. Here we show that the gut microbiome differed significantly between individuals with ICP and healthy pregnant women, and that colonization with gut microbiome from ICP patients was sufficient to induce cholestasis in mice. The gut microbiomes of ICP patients were primarily characterized by Bacteroides fragilis (B. fragilis), and B. fragilis was able to promote ICP by inhibiting FXR signaling via its BSH activity to modulate bile acid metabolism. B. fragilis-mediated FXR signaling inhibition was responsible for excessive bile acid synthesis and interrupted hepatic bile excretion to ultimately promote the initiation of ICP. We propose that modulation of the gut microbiota-bile acid-FXR axis may be of value for ICP treatment.
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Xu J, Zhou F, Wang X, Mo C. Role of ferroptosis in pregnancy related diseases and its therapeutic potential. Front Cell Dev Biol 2023; 11:1083838. [PMID: 36968201 PMCID: PMC10031498 DOI: 10.3389/fcell.2023.1083838] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
Ferroptosis is a form of regulated cell death characterized by iron overload, overwhelming lipid peroxidation, and disruption of antioxidant systems. Emerging evidence suggests that ferroptosis is associated with pregnancy related diseases, such as spontaneous abortion, pre-eclampsia, gestational diabetes mellitus, intrahepatic cholestasis of pregnancy, and spontaneous preterm birth. According to these findings, inhibiting ferroptosis might be a potential option to treat pregnancy related diseases. This review summarizes the mechanisms and advances of ferroptosis, the pathogenic role of ferroptosis in pregnancy related diseases and the potential medicines for its treatment.
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Affiliation(s)
- Jinfeng Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Fan Zhou
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- *Correspondence: Chunheng Mo, ; Xiaodong Wang,
| | - Chunheng Mo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- *Correspondence: Chunheng Mo, ; Xiaodong Wang,
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Horgan R, Bitas C, Abuhamad A. Intrahepatic cholestasis of pregnancy: a comparison of Society for Maternal-Fetal Medicine and the Royal College of Obstetricians and Gynaecologists' guidelines. Am J Obstet Gynecol MFM 2023; 5:100838. [PMID: 36503152 DOI: 10.1016/j.ajogmf.2022.100838] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/16/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
This study reviewed the literature regarding the diagnosis, antepartum surveillance, and timing of delivery of pregnancies complicated by intrahepatic cholestasis of pregnancy, comparing the guidelines published by the Society for Maternal-Fetal Medicine in February 2021 and those published by the Royal College of Obstetricians and Gynaecologists in the United Kingdom in June 2022. Several key differences exist in the clinical guidelines between the 2 organizations. With regard to the diagnosis of intrahepatic cholestasis of pregnancy, the Society for Maternal-Fetal Medicine considers any elevation in bile acids above the upper limit of normal in the setting of maternal pruritus diagnostic of intrahepatic cholestasis of pregnancy, whereas the Royal College of Obstetricians and Gynaecologists requires a pregnancy-specific elevated bile acid level of ≥19 mmol/L for diagnosis. Regarding the treatment of intrahepatic cholestasis of pregnancy, the Society for Maternal-Fetal Medicine recommends ursodeoxycholic acid as the first-line treatment of maternal symptoms. In contrast, the Royal College of Obstetricians and Gynaecologists specifically recommends against the routine use of ursodeoxycholic acid for intrahepatic cholestasis of pregnancy because of a lack of evidence regarding both maternal and fetal benefit. The Society for Maternal-Fetal Medicine recommends fetal surveillance at a gestational age when abnormal fetal testing would result in delivery being performed, whereas the Royal College of Obstetricians and Gynaecologists does not recommend any fetal testing beyond fetal kick count assessment. The Society for Maternal-Fetal Medicine recommends delivery at 36 to 39 weeks' gestation for intrahepatic cholestasis of pregnancy with bile acids <100 mmol/L and delivery at 36 weeks for bile acid levels >100 mmol/L. The Royal College of Obstetricians and Gynaecologists recommends serial assessment of bile acids with delivery timing stratified between 35- and 40-weeks' gestation according to bile acid levels.
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Affiliation(s)
- Rebecca Horgan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA.
| | - Christiana Bitas
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Alfred Abuhamad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
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Gamma-Glutamyl Transferase: A Friend against Cholestatic Itch? A Retrospective Observational Data Analysis in Patients with Extrahepatic Cholestasis. Int J Hepatol 2023; 2023:2903171. [PMID: 36816714 PMCID: PMC9931488 DOI: 10.1155/2023/2903171] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/19/2023] [Accepted: 01/28/2023] [Indexed: 02/24/2023] Open
Abstract
Methods We included 235 patients with chronic extrahepatic cholestasis due to pancreatic cancer, cholangiocarcinoma, or papillary carcinoma. Results GGT was significantly higher in patients without pruritus (median 967, IQR 587-1571) compared to patients with pruritus (median 561 IQR 266-1084 IU/l) (p < 0.01). In contrast, median alkaline phosphatase (AP) was 491 U/L (IQR; 353-684) in patients with pruritus and was not significantly different from 518 U/L (IQR; 353-726) in patients without pruritus (p = 0.524). Direct bilirubin was significantly higher in patients with pruritus compared to patients without pruritus (168 μmol/L (IQR; 95-256) vs. 120 μmol/L (IQR; 56.75-185.5)) (p < 0.01). After correcting for the extent of cholestasis via direct bilirubin, the negative association between GGT and pruritus remained significant and became stronger (p < 0.001). Conclusion Serum GGT activity is inversely associated with the presence of cholestatic itch in patients with chronic extrahepatic cholestasis.
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Kong W, Li X, Zou M, Zhang Y, Cai H, Zhang L, Wang X. iNKT17 cells play a pathogenic role in ethinylestradiol-induced cholestatic hepatotoxicity. Arch Toxicol 2023; 97:561-580. [PMID: 36329302 DOI: 10.1007/s00204-022-03403-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
IL-17 is closely associated with inflammation in intrahepatic cholestasis (IHC). Targeting IL-17 ameliorates IHC in mice. Invariant natural killer T (iNKT) cells are predominantly enriched in the liver and they mediate drug-induced liver injury through their secreted cytokines. However, whether iNKT17 cells are involved in ethinylestradiol (EE)-induced IHC remains unclear. In the present study, the administration of EE (10 mg/kg in vivo and 6.25 μM in vitro) promoted the activation and expansion of iNKT17 cells, which contributed to a novel hepatic iNKT17/Treg imbalance. iNKT cell-deficient Jα18-/- mice and the RORγt inhibitor digoxin (20 μg) alleviated EE-induced cholestatic hepatotoxicity and downregulated the IL-17 signalling pathway. In contrast, the co-administration of EE with recombinant IL-17 (1 μg) to Jα18-/- mice induced cholestatic hepatotoxicity and increased the infiltration of hepatic neutrophils and monocytes. Importantly, the administration of IL-17-/- iNKT cells (3.5 × 105) to Jα18-/- mice resulted in the attenuation of hepatotoxicity and the recruitment of fewer hepatic neutrophils and monocytes than the adoptive transfer of wild-type iNKT cells. These results indicated that iNKT17 cells could exert pathogenic effects. The recruitment and activation of iNKT17 cells could be attributed to the high level of CXCR3 expression on their surface. CXCL10 deficiency ameliorated EE-induced cholestatic liver damage, reduced hepatic CXCR3+ iNKT cells and inhibited RORγt expression. These findings suggest that iNKT17 cells play a key role in EE-induced cholestatic liver injury via CXCR3-mediated recruitment and activation. Our study provides new insights and therapeutic targets for cholestatic diseases.
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Affiliation(s)
- Weichao Kong
- New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Xinyu Li
- New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Mengzhi Zou
- New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Yiying Zhang
- Division of Biosciences, University College London, London, WC1E 6BT, UK
| | - Heng Cai
- New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Luyong Zhang
- New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China.
- Center for Drug Research and Development, Guangdong Pharmaceutical University, Guangzhou, 510006, China.
| | - Xinzhi Wang
- New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China.
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Karim G, Giri D, Kushner T, Reau N. Evaluation of Liver Disease in Pregnancy. Clin Liver Dis 2023; 27:133-155. [PMID: 36400462 DOI: 10.1016/j.cld.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Liver disease in pregnancy often requires diagnostic and therapeutic considerations that are unique to pregnancy. Liver disease in pregnancy is commonly thought of as either liver disease unique to pregnancy, chronic liver disease, or liver disease coincidental to pregnancy. This review summarizes the approach to evaluation of liver disease in pregnancy.
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Affiliation(s)
- Gres Karim
- Department of Medicine, Mount Sinai Beth Israel, 350 East 17th Street, 20th Floor, New York, NY 10003, USA
| | - Dewan Giri
- Department of Medicine, Mount Sinai Beth Israel, 350 East 17th Street, 20th Floor, New York, NY 10003, USA
| | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1123, New York, NY 10023, USA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1123, New York, NY 10023, USA.
| | - Nancy Reau
- Division of Hepatology, Rush University Medical Center, 1725 West Harrison Street
- Suite 319, Chicago, IL 60612, USA
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Ma Z, Liu Y, Chai L, Jin G, Sun Y, Zhou S, Yin P, Wang S, Zhu Y, Zhang D, Lu S, Zhu B. Metabolic changes in bile acids with pregnancy progression and their correlation with perinatal complications in intrahepatic cholestasis of pregnant patients. Sci Rep 2023; 13:1608. [PMID: 36709211 PMCID: PMC9884190 DOI: 10.1038/s41598-022-22974-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/21/2022] [Indexed: 01/30/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a rare liver disease occurring during pregnancy that is characterized by disordered bile acid (BA) metabolism. It is related to adverse clinical outcomes in both the mother and fetus. Our aim was to evaluate the BA metabolism profiles in different types of ICP and investigate the association between specific BAs and perinatal complications in ICP patients. We consecutively evaluated 95 patients with ICP, in which 53 patients were diagnosed with early-onset ICP (EICP) and 42 patients were diagnosed with late-onset ICP (LICP). Concentrations of 15 BA components were detected using high-performance liquid chromatography tandem mass spectrometry. Clinical information was abstracted from the medical records. The percentage of conjugated bile acids increased in ICP patients. Specifically, taurocholic acid (TCA) accumulated in LICP patients, and glycocholic acid (GCA) predominated in EICP patients. A higher preterm birth incidence was observed among ICP patients. Albumin, total bile acids, total bilirubin and GCA percentage values at ICP diagnosis predicts 83.5% of preterm birth in EICP, and the percentage of TCA in total bile acids at ICP diagnosis predicts 93.2% of preterm birth in LICP. This analysis showed that the BA metabolism profiles of EICP and LICP were distinct. Increased hepatic load was positively correlated with preterm birth in EICP. An elevated TCA percentage in total bile acids provides a biomarker to predict preterm birth in LICP.
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Affiliation(s)
- Zhixin Ma
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yifeng Liu
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lin Chai
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guochen Jin
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yanni Sun
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shaomin Zhou
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Peiyuan Yin
- Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Siwen Wang
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yuning Zhu
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Dan Zhang
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shiming Lu
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China. .,Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
| | - Bo Zhu
- Key Laboratory of Reproductive Genetics, and Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China. .,Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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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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Distribution of endotoxin in maternal and fetal body with intrahepatic cholestasis of pregnancy and its association with adverse fetal outcome. BMC Pregnancy Childbirth 2022; 22:920. [PMID: 36482374 PMCID: PMC9733156 DOI: 10.1186/s12884-022-05235-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 11/20/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy is a pregnancy-specific liver disease. In this study, we sought to explore the distribution of lipopolysaccharide in the maternal body, and its effect on the fetal body in the intrahepatic cholestasis of pregnancy mice. It provides a new sight for the clinical treatment of women with intrahepatic cholestasis of pregnancy. METHODS The serum levels of lipopolysaccharide and lipopolysaccharide binding protein in women with intrahepatic cholestasis of pregnancy were analyzed. To assess the association between lipopolysaccharide levels and adverse fetal outcomes, ursodeoxycholic acid, resveratrol, and phosphatidylinositol-3-kinase inhibitor were employed in intrahepatic cholestasis of pregnancy mice, and we studied the fluorescence intensity and distribution of lipopolysaccharide in mice with intrahepatic cholestasis of pregnancy. RESULTS Our data indicated significantly elevated levels of lipopolysaccharide and lipopolysaccharide binding protein in women with intrahepatic cholestasis of pregnancy. In vivo fluorescence imaging revealed that the intensity of lipopolysaccharide in mice with intrahepatic cholestasis of pregnancy was higher than that in the control group, and decreased after ursodeoxycholic and resveratrol treatment. The fluorescence intensity analysis indicated that lipopolysaccharide levels in maternal liver, placenta, fetal brain and fetal liver were significantly higher in the intrahepatic cholestasis pregnancy mice group than in the control group. CONCLUSIONS This study provided evidence of endotoxin distribution in maternal liver, placenta, fetal liver and fetal brain in mice with intrahepatic cholestasis of pregnancy. Ursodeoxycholic acid and resveratrol treatment effectively reduced lipopolysaccharide levels in pregnant mice with intrahepatic cholestasis of pregnancy.
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Wu K, Yin B, Li S, Zhu X, Zhu B. Prevalence, risk factors and adverse perinatal outcomes for Chinese women with intrahepatic cholestasis of pregnancy: a large cross-sectional retrospective study. Ann Med 2022; 54:2966-2974. [PMID: 36271887 PMCID: PMC9624205 DOI: 10.1080/07853890.2022.2136400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-related liver disorder and may cause adverse perinatal outcomes. This large cross-sectional retrospective study aimed to evaluate the prevalence and related risk factors of ICP and determine the adverse perinatal outcomes. METHODS This large cohort study from 1 January 2018 to 31 December 2019, included 39,742 eligible pregnant women. Data were extracted from the institutional electronic medical record database and analyzed using univariate and multivariate logistic regression models to determine the risk factors and adverse perinatal outcomes of ICP. RESULTS The overall prevalence of ICP was 3.81%. It was significantly higher in hepatitis B surface antigen (HBsAg) positive than negative women in all age groups, and in women with pre-pregnancy BMI underweight and obesity aged <25 years and ≥35 years than the other age groups. Multivariate logistic regression models showed an increased risk of ICP associated with maternal age <25 years and ≥35 years, pre-pregnancy underweight and obesity, HBsAg positive status, twin pregnancies, low maternal education, inadequate gestational weight gain, multiparous, in vitro fertilization, caesarean section history and the number of abortions ≥2. The presence of ICP was associated with increased risk of maternal outcomes of caesarean section and preterm birth, and neonatal outcomes of low birth weight and neonatal unit admission in singleton and twin pregnancies. CONCLUSION This study identified the prevalence, possible risk factors, and associated adverse perinatal outcomes of ICP, which provides useful information for clinicians to identify, counsel, and provide timely management for women at risk.KEY MESSAGESMaternal age <25 and ≥35, pre-pregnancy BMI underweight and obesity, hepatitis B surface antigen-positive status, twin pregnancies, low maternal education, inadequate gestational weight gain, multiparous, in vitro fertilization, caesarean section history and the number of abortions ≥2 are associated with an increased risk of ICP.Further, pregnancies with ICP are associated with an increased risk of maternal outcomes of caesarean section and preterm birth and neonatal outcomes of low birth weight and neonatal unit admission in singleton and twin pregnancies.
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Affiliation(s)
- Kaiqi Wu
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Binin Yin
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuai Li
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaojun Zhu
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bo Zhu
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Xu T, Deng C, Zhan Y, Hu Q, Huang G, Wang X, Guo B, Yu H, Wang X. Perinatal outcomes associated with ICP in twin pregnancies were worse than singletons: an almost 5-year retrospective cohort study. BMC Pregnancy Childbirth 2022; 22:820. [PMID: 36335293 PMCID: PMC9636774 DOI: 10.1186/s12884-022-05160-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Intrahepatic cholestasis of pregnancy (ICP) is associated with an increased risk of adverse perinatal outcomes leading to high perinatal morbidity and mortality. However, few studies have examined twin pregnancies complicated by ICP. To assess the perinatal outcomes of twin pregnancies with ICP, a retrospective cohort study was conducted. Methods A total of 633 twin pregnancies and 1267 singleton pregnancies with ICP were included. In addition, a correlation study was performed on the matched total bile acid (TBA) levels from maternal serum, fetal umbilical venous blood, and amniotic fluid of 33 twin pregnancies from twin groups. Results When compared to singletons, twin pregnancies with ICP had a higher risk of cesarean section (CS) (96.4% vs. 76.1%), preterm birth (PTB) (82.6% vs. 19.7%), fetal distress (2.0% vs. 1.3%), and neonatal intensive care unit (NICU) admission (23.6% vs. 5.1%), which was significantly related to increasing TBA levels (P < 0.05). In twin pregnancies with TBA ≥100 μmol/L, the incidences of CS, PTB, fetal distress, neonatal asphyxia, and meconium-stained amniotic fluid were 94.4, 100, 11.1, 5.6, and 36.1%, respectively. Furthermore, the maximum maternal TBA levels were positively correlated with TBA levels in the amniotic fluid (r = 0.61, P < 0.05) and umbilical cord blood (r = 0.44, P < 0.05), and a similar correlation was found for maternal TBA levels at delivery. TBA levels in umbilical cord blood and amniotic fluid also had a significant and positive correlation (r = 0.52, P < 0.05). Conclusions Twin pregnancies with ICP had a higher risk for adverse perinatal outcomes than singletons, which was associated with higher TBA levels. TBA can be transported through the placenta and is involved in uterus-placenta-fetal circulation.
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Wang J, Wen J, Ma X, Yang J, Zhang Z, Xie S, Wei S, Jing M, Li H, Lang L, Zhou X, Zhao Y. Validation of MAPK signalling pathway as a key role of paeoniflorin in the treatment of intrahepatic cholestasis of pregnancy based on network pharmacology and metabolomics. Eur J Pharmacol 2022; 935:175331. [DOI: 10.1016/j.ejphar.2022.175331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 11/30/2022]
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Brombach C, Tong W, Giussani DA. Maternal obesity: new placental paradigms unfolded. Trends Mol Med 2022; 28:823-835. [PMID: 35760668 DOI: 10.1016/j.molmed.2022.05.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 01/24/2023]
Abstract
The prevalence of maternal obesity is increasing at an alarming rate, and is providing a major challenge for obstetric practice. Adverse effects on maternal and fetal health are mediated by complex interactions between metabolic, inflammatory, and oxidative stress signaling in the placenta. Endoplasmic reticulum (ER) stress and activation of the unfolded protein response (UPR) are common downstream pathways of cell stress, and there is evidence that this conserved homeostatic response may be a key mediator in the pathogenesis of placental dysfunction. We summarize the current literature on the placental cellular and molecular changes that occur in obese women. A special focus is cast onto placental ER stress in obese pregnancy, which may provide a novel link for future investigation.
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Affiliation(s)
| | - Wen Tong
- Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge CB2 3EL, UK; Centre for Trophoblast Research, University of Cambridge, Cambridge CB2 3EG, UK; Cambridge Strategic Research Initiative in Reproduction, Cambridge CB2 3EL, Cambridge UK.
| | - Dino A Giussani
- Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge CB2 3EL, UK; Centre for Trophoblast Research, University of Cambridge, Cambridge CB2 3EG, UK; Cambridge Strategic Research Initiative in Reproduction, Cambridge CB2 3EL, Cambridge UK; Cambridge Cardiovascular Centre for Research Excellence, Cambridge CB2 0QQ, UK.
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