Impacts of different methods of conception on the perinatal outcome of intrahepatic cholestasis of pregnancy in twin pregnancies

Obstetric cholestasis and its impact on the maternal outcome

AIM

To evaluate the association of GDM and pre-eclampsia in women with obstetric cholestasis.

MATERIALS AND METHODS

Pregnant women with > 28 weeks gestation attending ANC, OPD and labor room of J.N.M.C.H, AMU, Aligarh UP (India) from 2020 to 2022 were included in the study after taking informed consent and ethical approval from the Institute. Women were divided into 2 groups, i.e. group 1 having 200 women with IHCP and group 2 having 200 healthy pregnant women; both the groups were followed up for the development of GDM and pre-eclampsia.

RESULTS

A statistically significant association was observed between IHCP and development of GDM [26.5% and odds ratio (OR) 1.64] and pre-eclampsia (17% and OR: 1.95) (p < 0.05), an also GDM and pre-eclampsia were found to be significantly associated with the severity of cholestasis (p < 0.05). Thus, on calculating OR, we found higher odds of developing GDM and pre-eclampsia in IHCP group with raised serum bile acid levels, maximum at 60 μmol/L level as compared to 10-40 μmol/L (GDM: OR: 8.647 and pre-eclampsia: OR: 6.303). Induction and cesarean rates were significantly higher in IHCP group (p < 0.05).

CONCLUSION

Our study concludes significant association of IHCP with GDM and pre-eclampsia as all three shares common pathogenetic pathways and greater risk of development at higher serum bile acid levels.

Perinatal outcomes and growth discordance of triplet pregnancies based on chorionicity: a retrospective cohort study

BACKGROUND

The worldwide occurrence of triplet pregnancy is estimated to be 0.093%, with a natural incidence of approximately 1 in 8000. This study aims to analyze the neonatal health status and birth weight discordance (BWD) of triplets based on chorionicity from birth until discharge.

METHODS

This was a retrospective study. We reviewed a total of 136 triplet pregnancies at our tertiary hospital between January 1, 2001, and December 31, 2021. Maternal and neonatal outcomes, inter-triplet BWD, neonatal morbidity, and mortality were analyzed.

RESULTS

Among all cases, the rates of intrauterine death, neonatal death, and perinatal death were 10.29, 13.07, and 24.26%, respectively. Thirty-seven of the cases resulted in fetal loss, including 13 with fetal anomalies. The maternal complications and neonatal outcomes of the 99 triplet pregnancies without fetal loss were compared across different chorionicities, including a dichorionic (DC) group (41 cases), trichorionic (TC) group (37 cases), and monochorionic (MC) group (21 cases). Neonatal hypoproteinemia (P < 0.001), hyperbilirubinemia (P < 0.019), and anemia (P < 0.003) exhibited significant differences according to chorionicity, as did the distribution of BWD (P < 0.001). More than half of the cases in the DC and TC groups had a BWD < 15%, while those in the MC group had a BWD < 50% (47.6%). TC pregnancy decreased the risk of neonatal anemia (adjusted odds ratio [AOR] = 0.084) and need for blood transfusion therapy after birth (AOR = 0.119). In contrast, a BWD > 25% increased the risk of neonatal anemia (AOR = 10.135) and need for blood transfusion after birth (AOR = 7.127). TC pregnancy, MCDA or MCTA, and BWD > 25% increased neonatal hypoproteinemia, with AORs of 4.629, 5.123, and 5.343, respectively.

CONCLUSIONS

The BWD differed significantly according to chorionicity. Additionally, TC pregnancies reduced the risk of neonatal anemia and need for blood transfusion, but increased the risk of neonatal hypoproteinemia. In contrast, the BWD between the largest and smallest triplets increased the risk of neonatal anemia and the need for blood transfusion. TC pregnancy, MCDA or MCTA, and BWD > 25% increased the risks of neonatal hypoproteinemia. However, due to the limited number of triplet pregnancies, further exploration of the underlying mechanism is warranted.

Maternal and perinatal outcomes in twin pregnancies following assisted reproduction: a systematic review and meta-analysis involving 802 462 pregnancies

BACKGROUND

ART is associated with higher rates of twin pregnancies than singleton pregnancies. Whether twin pregnancies conceived following ART have additional maternal and neonatal complications compared with non-ART twin pregnancies is not known.

OBJECTIVE AND RATIONALE

The objective was to quantify the risk of adverse maternal and perinatal outcomes among twin pregnancies conceived following ART compared with non-ART and natural conception. Existing reviews vary in the reported outcomes, with many studies including triplet pregnancies in the study population. Therefore, we aimed to perform an up-to-date review with an in-depth analysis of maternal and perinatal outcomes limited to twin pregnancies.

SEARCH METHODS

We searched electronic databases MEDLINE and EMBASE from January 1990 to May 2023 without language restrictions. All cohort studies reporting maternal and perinatal outcomes following ART compared with non-ART twin pregnancies and natural conception were included. Case-control studies, case reports, case series, animal studies, and in vitro studies were excluded. The Newcastle-Ottawa Scale was used to assess the methodological quality of the studies. Using random-effects meta-analysis, the estimates were pooled and the findings were reported as odds ratios (OR) with 95% CI.

OUTCOMES

We included 111 studies (802 462 pregnancies). Twin pregnancies conceived following ART were at higher risk of preterm birth at <34 weeks (OR 1.33, 95% CI 1.14-1.56, 29 studies, I2 = 73%), <37 weeks (OR 1.26, 95% CI 1.19-1.33, 70 studies, I2 = 76%), hypertensive disorders in pregnancy (OR 1.29, 95% CI 1.14-1.46, 59 studies, I2 = 87%), gestational diabetes mellitus (OR 1.61, 95% CI 1.48-1.75, 51 studies, I2 = 65%), and caesarean delivery (OR 1.80, 95% CI 1.65-1.97, 70 studies, I2 = 89%) compared with non-ART twins. The risks for the above maternal outcomes were also increased in the ART group compared with natural conception. Of the perinatal outcomes, ART twins were at significantly increased risk of congenital malformations (OR 1.17, 95% CI 1.05-1.30, 39 studies, I2 = 59%), birthweight discordance (>25% (OR 1.31, 95% CI 1.05-1.63, 7 studies, I2 = 0%)), respiratory distress syndrome (OR 1.32, 95% CI 1.09-1.60, 16 studies, I2 = 61%), and neonatal intensive care unit admission (OR 1.24, 95% CI 1.14-1.35, 32 studies, I2 = 87%) compared with non-ART twins. When comparing ART with natural conception, the risk of respiratory distress syndrome, intensive care admissions, and birthweight discordance >25% was higher among the ART group. Perinatal complications, such as stillbirth (OR 0.83, 95% CI 0.70-0.99, 33 studies, I2 = 49%), small for gestational age <10th centile (OR 0.90, 95% CI 0.85-0.95, 26 studies, I2 = 36%), and twin-twin transfusion syndrome (OR 0.45, 95% CI 0.25-0.82, 9 studies, I2 = 25%), were reduced in twin pregnancies conceived with ART versus those without ART. The above perinatal complications were also fewer amongst the ART group than natural conception.

WIDER IMPLICATIONS

ART twin pregnancies are associated with higher maternal complications than non-ART pregnancies and natural conception, with varied perinatal outcomes. Women seeking ART should be counselled about the increased risks of ART twin pregnancies and should be closely monitored in pregnancy for complications. We recommend exercising caution when interpreting the study findings owing to the study's limitations.

Severe Early-Onset Intrahepatic Cholestasis of Pregnancy Following Ovarian Hyperstimulation Syndrome with Pulmonary Presentation after In Vitro Fertilization: Case Report and Systematic Review of Case Reports

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-related liver disease, usually presented in the third trimester with pruritus, elevated transaminase, and serum total bile acids. Evidence shows that it can be developed in the first trimester, more commonly after in vitro fertilization (IVF) procedures, with the presence of ovarian hyperstimulation syndrome (OHSS).

METHODS

A literature search was conducted in the PubMed/MEDLINE database of case reports/studies reporting early-onset ICP in spontaneous and IVF pregnancies published until July 2023.

RESULTS

Thirty articles on early-onset ICP were included in the review analysis, with 19 patients who developed ICP in spontaneous pregnancy and 15 patients who developed ICP in IVF pregnancies with or without OHSS. Cases of 1st and 2nd trimester ICP in terms of "early-onset" ICP were pooled to gather additional findings.

CONCLUSIONS

Proper monitoring should be applied even before expected pregnancy and during IVF procedures in patients with known risk factors for OHSS and ICP development (patient and family history), with proper progesterone supplementation dosage and genetic testing in case of ICP recurrence.

Intrahepatic cholestasis of pregnancy after ovarian hyperstimulation syndrome with wild-type ABCB4 gene: a peculiar case and literature review

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) in the first trimester occurring after ovarian hyperstimulation syndrome (OHSS) is a rare condition and few cases are reported in the literature. Hyperestrogenism may explain this problem in genetically predisposed women. The objective of this article is to report one of these rare cases and offer an overview of the other published cases.

CASE PRESENTATION

We report a case of severe OHSS followed by ICP in the first trimester. The patient was admitted to the intensive care unit and was treated according to the guidelines for the management of OHSS. Moreover, the patient also received ursodeoxycholic acid for ICP, which brought to an improvement of her clinical conditions. The pregnancy continued without other complications until the 36th week of gestation, when the patient developed ICP in the third trimester and underwent cesarean section for increased bile acid levels and cardiotocographic (CTG) pathologic alterations. The newborn was a healthy baby weighing 2500 gr. We also reviewed other case reports published by other authors about this clinical condition. We present what is, to our knowledge, the first case of ICP developed in the first trimester of pregnancy after OHSS in which genetic polymorphisms of ABCB4 (MDR3) have been investigated.

CONCLUSIONS

ICP in the first trimester might be induced by elevated serum estrogen levels after OHSS in genetically predisposed women. In these women, it might be useful to check for genetic polymorphisms to know if they have a predisposition for ICP recurrence in the third trimester of pregnancy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic and prognostic value of blood inflammation and biochemical indicators for intrahepatic cholestasis of pregnancy in Chinese pregnant women

Intrahepatic cholestasis of pregnancy (ICP) is a common liver disease during pregnancy, that has serious complications. This study aimed to compare the blood inflammation and biochemical markers of pregnant women with ICP in Southwest China and analyse their diagnostic value for ICP. A controlled cross-sectional study was conducted, and routine blood and biochemical indicators of 304 diagnosed ICP patients and 363 healthy pregnant women undergoing routine prenatal examination were assessed. The blood inflammatory indicators and biochemical indicators were compared between the ICP groups and normal groups. In this study, the levels of the ALT, AST, GGT, TBIL and DBIL biochemical indicators and the levels of WBC, neutrophils, NLR and PLR inflammatory indicators in the ICP group were significantly higher than those in healthy pregnant women (p < 0.001). The PA and lymphocytes of the ICP group were significantly lower than those of the normal group (p < 0.001). ROC curves showed that ALT and the NLR had higher predictive value for ICP. The GGT, TBA and NLR of pregnant women with ICP in the preterm group were significantly higher than those in the term group, and the combined NLR and TBA had a certain predictive value for preterm birth.

Interactive effects of ambient air pollution and sunshine duration on the risk of intrahepatic cholestasis of pregnancy

INTRODUCTION

While the associations among ambient pollutants and various pregnancy complications are well documented, the effect of ambient pollutants on intrahepatic cholestasis of pregnancy (ICP) has not been examined. This study aimed to explore the effects of ambient pollutants and sunshine duration on ICP.

METHODS

The study enrolled 169,971 pregnant women who delivered between 2015 and 2020 in two hospitals. The associations between ICP and exposure to ambient pollutants and sunshine duration, averaged throughout different periods (including the 3 months before conception, 1st trimester and 2nd trimester), were estimated using a generalized linear model. The interaction effects of ambient pollutants and sunshine duration on ICP were estimated.

RESULTS

The fitted curves for ICP incidence were similar to the temporal trends of PM_2.5, PM₁₀, SO₂, CO and NO₂ but not that of O₃. The risk of ICP was significantly elevated following a 10-μg/m³ increase in PM_2.5 (aOR [adjusted odds ratio] = 1.057, 95% CI [confidence interval]: 1.017-1.099) and PM₁₀ (aOR = 1.043, 95% CI: 1.013-1.074) and a 1-h decrease in sunshine duration (aOR = 1.039, 95% CI: 1.011-1.068) during the 3 months before conception. In the second trimester, a 1-μg/m³ increase in the concentration of SO₂ was associated with an increased risk of ICP (aOR = 1.011, 95% CI: 1.001-1.021). Increased concentrations of PM_2.5 and PM₁₀ had interactive effects with reduced sunshine duration during the 3 months before conception on increasing the risk of ICP.

CONCLUSIONS

Exposure to PM_2.5 and PM₁₀ during the 3 months before conception and exposure to SO₂ in the second trimester were associated with an increased ICP risk. Reduced sunshine duration had an interactive effect with increased concentrations of PM_2.5 and PM₁₀ during the 3 months before conception on the occurrence of ICP.

The impact of assisted reproductive technology in twin pregnancies complicated by intrahepatic cholestasis: a five-year retrospective study

Background

Intrahepatic cholestasis of pregnancy is one of the common complications during pregnancy, and ursodeoxycholic acid has been recommended as the first-line drug. However, if the assisted reproductive technology may increase adverse perinatal outcomes of twin pregnancies complicated by intrahepatic cholestasis is disputed, we aimed to investigate perinatal outcomes between twin pregnancies by assisted reproductive technology versus spontaneous conception, based on these women accepted ursodeoxycholic acid treatment.

Methods

From January 2014 to January 2019, we retrospectively analysed the clinical data of twin pregnant women with intrahepatic cholestasis, excluding those who did not receive ursodeoxycholic acid treatment. In total, 864 women were included, among whom 500 conceived by assisted reproductive technology and 364 conceived by spontaneous conception. The primary assessment for perinatal outcomes included premature birth, meconium-stained amniotic fluid, low Apgar score, neonatal intensive care unit and still birth, and secondary indicators were serum bile acid and liver enzymes level during medication, so we also finished subgroup analysis based on different elevated bile acid level and drug usage. The statistical analysis was performed by SPSS 22.0.

Results

The study demonstrated that compared to spontaneous conception, assisted reproductive technology conceived twin pregnancies diagnosed as intrahepatic cholestasis earlier (p = 0.003), and lower birth weight (p = 0.001), less incidence of preterm delivery (p = 0.000) and neonatal intensive care unit admission (p = 0.001), but the rate of meconium-stained amniotic fluid, low Apgar score and still birth have no statistic differences. Moreover, the subgroup analysis showed no significant difference in elevated bile acid levels and medication between assisted reproductive technology and spontaneous conception groups.

Conclusions

The assisted reproductive technology may increase the risk of early-onset intrahepatic cholestasis in twin pregnancies, but it does not seem to increase adverse effects on bile acid levels and perinatal outcomes. Regardless of ursodeoxycholic acid used alone or combination, the effect of bile acid reduction and improving perinatal outcomes in twin pregnancies is limited. Our conclusions still need more prospective randomized controlled studies to confirm.

Safety and efficacy of in vitro fertilisation in patients with chronic liver disease and liver transplantation recipients

BACKGROUND & AIMS

Chronic liver disease and liver transplantation (LT) can delay both timing and ability of women to conceive. With increased awareness and availability of in vitro fertilisation (IVF), the need for accurate counselling is paramount. To date, minimal data exist on outcomes of IVF in patients with chronic liver disease, cirrhosis, or post-LT. We report the largest experience of IVF in women with liver-related subfertility (LRSF).

METHODS

A retrospective analysis was performed on 42 women with LRSF who had undergone 57 IVF cycles between 1990 and 2019.

RESULTS

Forty-two women with LRSF received IVF; 9 cycles in 6 women with cirrhosis, 14 cycles in 11 women post-LT, and 34 cycles in 25 women without cirrhosis. The main aetiologies of liver disease included HBV, HCV, and autoimmune hepatitis (AIH). Of 57 IVF cycles evaluated, 43 (75%) resulted in successful implantation. Eight (2 post-LT, 3 with cirrhosis, 4 without cirrhosis) resulted in miscarriage. The live birth rate (LBR) was 74% (32/43). Two of 9 (22%) patients with cirrhosis, 4/14 (29%) patients who were post-LT, and 6/34 (18%) patients without cirrhosis had unsuccessful IVF attempts. Nine of 57 (16%) IVF cycles resulted in new liver enzyme derangement during therapy, which improved after treatment completion. Six pregnancies (2 in patients who were post-LT, 4 without cirrhosis) were complicated by obstetric cholestasis (OC). Ovarian hyperstimulation syndrome (OHSS) was rare (n = 3, 7%). One patient with AIH-related cirrhosis decompensated after initiating IVF, warranting discontinuation of therapy. There were no maternal deaths. Three women developed a hypertensive disorder of pregnancy. Half the pregnancies resulted in premature deliveries (range 27-36 weeks).

CONCLUSIONS

In selected cases, IVF in women with LRSF can be successful. However, patients should be counselled on the potential increased risks of OHSS, OC, and prematurity.

LAY SUMMARY

Women with liver disease or those who have had a liver transplant can experience difficulties getting pregnant. In this study, we look at whether alternative approaches to achieve pregnancy are harmful in these women. Overall, there were no significant issues with the use of in vitro fertilisation in women with liver disease, but they need to be aware of potential risks, such as early delivery of the baby.

Maternal and Fetal Outcome in Intrahepatic Cholestasis of Pregnancy in a Multicultural Society Conducted at a Tertiary Care Hospital in Dubai

<b><i>Introduction:</i></b> Intrahepatic cholestasis of pregnancy (ICP) has been sparsely studied especially in the Middle East. The incidence and outcome of ICP varies worldwide. Its incidence in the Middle East and primary maternal and fetal outcome must be evaluated to ascertain the burden so that appropriate preventive and intervention measures can be formulated and implemented. <b><i>Objective:</i></b> To assess the incidence, associations, and maternal-fetal outcomes in ICP. <b><i>Design:</i></b> Case-control study. Settings: tertiary care hospital settings affiliated with the academic center in the UAE. Patients and methods: a total of 150 patients were included from October 2016 to September 2018 in the study with 75 cases of ICP and 75 controls matched according to age and date of delivery. The maternal risk factors attributable to ICP were recorded. Biochemical profile of mothers was monitored. Maternal and fetal outcomes were compared in 2 groups. Main outcomes measured: incidence and associations of ICP were evaluated. Maternal and fetal outcomes were compared in cases and controls. Sample size: 150. <b><i>Result:</i></b> The incidence of ICP in our study in the UAE was 1.0%. ICP has significant association with past obstetric cholestasis history (<i>p</i> value &#x3c;0.01, odds ratio [OR] 9.3, 95% CI: 2.1–41.8), gestational diabetes (<i>p</i> value &#x3c;0.05, OR 2.0, 95% CI: 1.0–3.8), pre-eclampsia (<i>p</i> value &#x3c;0.05, OR 7.2, 95% CI: 1.6–33.1), and undergoing induction of labor (<i>p</i> value &#x3c;0.01, OR 8.1, 95% CI: 3.7–17.8). The maternal bile acid level above 40 μmol/L is ­associated with higher chances of preterm delivery (<i>p</i> value &#x3c;0.01, OR 8.2, 95% CI: 3.0–22.5), intrauterine fetal demise (<i>p</i> value &#x3c;0.01), low birth weight (<i>p</i> value &#x3c;0.01, OR 13.6, 95% CI: 4.2–43.5), respiratory distress (<i>p</i> value &#x3c;0.05, OR 15.5, 95% CI: 1.8–132.7), poor Apgar score (<i>p</i> value &#x3c;0.05, OR 12.720, 95% CI: 1.5–111.4), and NICU admissions (<i>p</i> value &#x3c;0.01, OR 9.0, 95% CI: 1.8–45.9). <b><i>Conclusion:</i></b> ICP mothers have low incidence in the UAE and significant association with gestational diabetes and pre-eclampsia. High maternal bile acids above 40 μmol/L have poor fetal outcomes.

Intrahepatic cholestasis of pregnancy: are in vitro fertilization pregnancies at risk?

AIM

Single pregnancy patients with intrahepatic cholestasis of pregnancy (ICP) were divided into two groups according to the conception method, as spontaneous and in vitro fertilization (IVF). We aim to compare the maternal, laboratory and perinatal characteristics of both groups.

MATERIALS AND METHOD

The records of 10,929 patients who gave birth in the center between October 2011 and July 2019 were analyzed retrospectively from the data processing system records. Maternal, laboratory and perinatal characteristics of 109 single pregnancies (spontaneous n: 91; IVF n: 18) diagnosed with ICP were compared.

FINDINGS

The maternal demographic data of both groups were similar (p: .05). In both groups, gestational week, gestational age at birth, birth weight, neonatal intensive care admission rate, meconium-stained amniotic fluid, umbilical cord pH, the 5-minute APGAR score, and the presence of pregnancy complications were similar (p > .05).

RESULT

Although ICP is reported with a higher incidence in IVF pregnancies, ICP findings and prognosis are similar to those of spontaneous pregnancies.

Establishment of predictive model for analyzing clinical pregnancy outcome based on IVF-ET and ICSI assisted reproductive technology

In order to explore the predictive model for analyzing clinical pregnancy outcomes based on IVF-ET (in vitro fertilization and embryo transfer) and ICSI (Intracytoplasmic sperm injection) assisted reproductive technology (ART). Methods: this study selected the embryo transfer (fresh) patients who received IVF-ET or ICSI treatment in the First Affiliated Hospital of Guangxi Medical University as the subjects. Moreover, the controlled ovarian stimulation (COS) and follow-up were conducted to collect relevant data for analysis, and finally a prediction model was established. Results: The results showed that the patients were divided into different ovarian response groups at first. The age, bFSH and bFSH/bLH were the highest in the poor ovarian response group (POR), followed by the normal ovarian response group (NOR) and the lowest in the high ovarian response group (HOR). The area under the ROC curve was 0.669 according to the predictive model of pregnancy-related factors. The confidence interval of 94% was 0.629–0.697, with statistical significance (P = 0.000, P < 0.01). Conclusion: it can be concluded that in clinical pregnancy, for many related factors, regression equation can be used to establish a prediction model to diagnose the success rate of pregnancy. In conclusion, a prediction model can be built based on the relevant experimental results, to provide experimental reference ideas for increasing the success rate of ART in late clinical pregnancy, which is of great research significance.

The Impact of Assisted Reproductive Technology in Twin Pregnancies Complicated by Intrahepatic Cholestasis of Pregnancy: a Retrospective Cohort Study

INTRODUCTION

Our study aims to evaluate the perinatal outcomes in twin pregnancies diagnosed with intrahepatic cholestasis of pregnancy (ICP) and to compare these with normal healthy twin pregnancies for perinatal outcomes. The second outcome of the study was to determine whether in vitro fertilization-embryo transfer (IVF-ET) affects the perinatal outcome in ICP patients.

MATERIALS AND METHODS

In this study, 59 ICP and 641 healthy twin pregnancies were compared for perinatal outcomes retrospectively. According to the mode of conception, the twin pregnancies with ICP were divided into 2 groups. The twin pregnancies with ICP who were conceived with IVF were referred to as the IVF-ET group. The twin pregnancies with ICP who were conceived spontaneously or by ovulation induction and intrauterine insemination (IUI) were referred to as the non-IVF-ET group.

RESULTS

Twin pregnancies with ICP give birth significantly earlier than normal twin pregnancies (p ˂ 0.001). The diagnosis of ICP occurred significantly earlier in the IVF-ET pregnancy with ICP than in the non-IVF-ET group. In twin pregnancies with IVF-ET, patients delivered significantly earlier than in the non-IVF-ET group (p=0.002). Twin pregnancies with ICP were found to have significantly higher rates of meconium-stained amniotic fluid, postnatal intubation, and admission to the neonatal intensive care unit (NICU) than healthy twin pregnancies.

CONCLUSIONS

ICP is a risk factor for preterm delivery in twin pregnancies. In addition, ICP develops earlier and more frequently in twin pregnancies from IVF-ET than in those from non-IVF twin pregnancies, and the disease may be more serious.

Unexplained First Trimester Intrahepatic Cholestasis of Pregnancy: A Case Report and Literature Review

Intrahepatic cholestasis of pregnancy (ICP) is a condition that usually affects the 3^rd trimester-pregnant women and is associated with adverse pregnancy outcomes. We present a 31-year-old G2P1 patient with symptoms of ICP as early as 10 weeks of gestation (WG). Her pruritis was initially attributed to eczema. Due to the intensity of her discomfort and failure of topical treatment, ICP was suspected, total bile acid salt levels were taken and ursodeoxycholic acid was subsequently started at 18 WG. The patient was followed closely during her pregnancy to adjust the dose of the medication accordingly. Induction of labor was performed at 37 WG without complications. This case demonstrated the importance of clinical suspicion in the setting of such symptomatology in order not to miss or delay treatment of threatening conditions such as ICP.

Disrupted compensatory response mediated by Wolfram syndrome 1 protein and corticotrophin-releasing hormone family peptides in early-onset intrahepatic cholestasis pregnancy

INTRODUCTION

The most adverse perinatal outcome of intrahepatic cholestasis of pregnancy (ICP) is sudden fetal death related to acute fetoplacental hypoxia. Corticotrophin-releasing hormone (CRH), urocortin (UCN), and Wolfram syndrome 1 (WFS1) proteins may have a compensatory response to hypoxic stress.

METHODS

A total of 108 singleton pregnant women were divided into three groups: control, late-onset ICP, and early-onset ICP. Enzyme-linked immunosorbent assays were used to detected maternal serum CRH, UCN, and WFS1 levels. Western blotting and real-time polymerase chain reaction were conducted to quantify placental protein and mRNA levels of CRH, UCN, and WFS1. Pearson correlation scatterplots and Pearson correlation matrix were employed to testify the correlation.

RESULTS

Placental WFS1 had a positive relation with placental UCN (r = 0.69, P < 0.05) and serum UCN (r = 0.36, P < 0.05). Placental CRH was positively correlated with maternal serum CRH (r = 0.53, P < 0.05). Maternal serum and placental levels of CRH, UCN, and WFS1 significantly increased in the early-onset ICP group compared with the control group (P < 0.05). Placental levels of UCN and WFS1 in the early-onset ICP group were significantly elevated and higher in comparison with the late-onset ICP group (P < 0.05). However, the transcriptional levels of CRH, UCN, and WFS1 were impaired in the early-onset ICP group.

DISCUSSION

Our study revealed that transcription and translation of WFS1, CRH, and UCN were altered during pregnancies complicated by early-onset ICP. This disrupted compensatory response mediated by WFS1 and CRH family peptides in early-onset ICP may play a significant role in the pathogenesis of sudden fetal death in acute fetal hypoxia.

Effects of intrahepatic cholestasis of pregnancy on hepatic function, changes of inflammatory cytokines and fetal outcomes

The effects of intrahepatic cholestasis of pregnancy (ICP) on hepatic function, changes of inflammatory cytokines and fetal outcomes were studied. In total, 663 pregnant women admitted to Daqing Longnan Hospital from July 2016 to December 2017 were selected. There were, 40 cases with ICP enrolled in the observation group, and 40 normal pregnant women were recruited in the normal group. They were also grouped according to hepatic function and inflammatory cytokines, with 40 cases in each group. Neonatal Apgar scores were recorded. The correlations of serum cholylglycine (CG) in pregnant women with umbilical artery systolic-to-diastolic (S/D) ratio in the third trimester of pregnancy, the alanine aminotransferase level, the high-sensitivity C-reactive protein (hs-CRP) level, neonatal Apgar score and gestational week were analyzed. The birth weight in the observation group was lighter than that in the normal group (P<0.05); the gestational week at birth was earlier than that in the normal group (P<0.05); Apgar score at birth was lower than that in the normal group (P<0.05), and the levels of inflammatory cytokines were higher than those in the control group (P<0.05). Apgar scores of newborns at birth and at 1 and 5 min after birth in the normal hepatic function and normal inflammatory cytokine groups were higher than those in the abnormal hepatic function group (P<0.05). The serum CG level in pregnant women was positively correlated with umbilical artery S/D ratio, the alanine aminotransferase level and the hs-CRP level in the third trimester of pregnancy, but negatively correlated with neonatal Apgar score and gestational week. Among patients with ICP, the higher the GG level in the body is, the higher the alanine aminotransferase, inflammatory cytokine and umbilical artery S/D ratio will be, which may cause lower neonatal Apgar score, neonatal asphyxia and premature delivery.