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Zhou Q, Yuan Y, Wang Y, He Z, Liang Y, Qiu S, Chen Y, He Y, Lv Z, Liu H. The severity of intrahepatic cholestasis during pregnancy increases risks of adverse outcomes beyond stillbirth: evidence from 15,826 patients. BMC Pregnancy Childbirth 2024; 24:476. [PMID: 38997626 PMCID: PMC11241884 DOI: 10.1186/s12884-024-06645-2] [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: 03/13/2024] [Accepted: 06/17/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND What kinds of fetal adverse outcomes beyond stillbirth directly correlate to the severity of intrahepatic cholestasis during pregnancy (ICP) remained tangled. Herein, we conducted a retrospective cohort study and a dose-response meta-analysis to speculate the association between the severity of ICP and its adverse outcomes. METHODS We retrospectively collected a cohort of ICP patients from electronic records from Guangzhou Women and Children's Medical Center between Jan 1st, 2018, and Dec 31st, 2022. Also, we searched PubMed, Cochrane, Embase, Scopus, and Web of Science to extract prior studies for meta-analysis. The Kruskal-Wallis test, a one-way or two-way variants analysis (ANOVA), and multi-variant regression are utilized for cohort study. One stage model, restricted cubic spline analysis, and fixed-effect model are applied for dose-response meta-analysis. The data analysis was performed using the R programme. RESULTS Our cohort included 1,289 pregnant individuals, including 385 mild ICP cases, 601 low moderate ICP cases, 282 high moderate ICP cases, and 21 severe ICP cases. The high moderate bile acid levels were correlated to preterm birth [RR = 2.14, 95%CI 1.27 to 3.62), P < 0.01], and preterm premature rupture of membranes [RR = 0.34, 95%CI 0.19 to 0.62), P < 0.01]. We added our cases to cases reported by other studies included in the meta-analysis. There were 15,826 patients included in dose-response meta-analysis. The severity of ICP was associated with increased risks of stillbirth, spontaneous preterm birth, iatrogenic preterm birth, preterm birth, admission to neonatal intensive care unit, and meconium-stained fluid (P < 0.05). CONCLUSIONS Our study shows the correlation between the severity of ICP and the ascending risks of stillbirth, preterm birth, and meconium-stained fluid, providing new threshold TBA levels. PROSPERO REGISTRATION NUMBER CRD42023472634.
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Affiliation(s)
- Qiulun Zhou
- Clinical Data Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yi Yuan
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Yuying Wang
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Zhuoqi He
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Yannei Liang
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Suyi Qiu
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Yiting Chen
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Yiru He
- School of Pediatrics, Guangzhou Medical University, Guangzhou, China
| | - Zi Lv
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Huishu Liu
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
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Avsar HA, Atlıhan U, Ata C, Erkılınc S. Intrahepatic cholestasis of pregnancy and its association with preeclampsia and gestational diabetes: a retrospective analysis. Arch Gynecol Obstet 2024; 310:221-227. [PMID: 38625544 DOI: 10.1007/s00404-024-07507-0] [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: 12/12/2023] [Accepted: 04/03/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE To evaluate maternal and neonatal outcomes in patients with intrahepatic cholestasis of pregnancy (ICP). METHODS Patients who gave birth in our hospital between January 2018 and March 2022 were retrospectively reviewed from the hospital database and patient file records. The study comprised 1686 patients, 54 in the ICP group and 1632 controls. Patients who had ICP after 20 weeks of gestation and were monitored and delivered at our facility were enrolled. Maternal demographic and obstetric characteristics data were examined. Perinatal outcomes were also assessed. Logistic regression analysis was used to determine adverse maternal outcomes. RESULTS The mean age was 29 years. ART, GDM, and preeclampsia were significantly higher in the ICP group. The mean serum bile acid level was 19.3 ± 3 μmol/L in the ICP group. There was a higher risk of GDM and pre-eclampsia in women with ICP compared with those without and a significant association between ICP and adverse perinatal outcomes. There was a statistically significant relation between the presence of ICP and spontaneous preterm delivery, iatrogenic preterm delivery, 5th-minute Apgar scores < 7, and NICU requirement. No significant relationship was found between the presence of ICP and SGA and meconium. There was a significant relationship between the presence of ICP, mode of delivery, and PPH (p < 0.05). Those with ICP had a lower gestational week and birth weight, and higher rates of cesarean delivery and PPH. CONCLUSION ICP should prompt close monitoring and management to mitigate the potential exacerbation of adverse outcomes, including preeclampsia, GDM, and preterm birth.
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Affiliation(s)
- Huseyin Aytug Avsar
- Department of Obstetrics and Gynecology, Izmir Demokrasi University, Buca Seyfi Demirsoy Training and Research Hospital, Izmir, Turkey
| | | | - Can Ata
- Department of Obstetrics and Gynecology, Izmir Demokrasi University, Buca Seyfi Demirsoy Training and Research Hospital, Izmir, Turkey.
| | - Selcuk Erkılınc
- Department of Obstetrics and Gynecology, Izmir Demokrasi University, Buca Seyfi Demirsoy Training and Research Hospital, Izmir, Turkey
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Peng T, Cui J, Ni Z, Tang Y, Cao X, Li S, Cheng X, Huang J. Methyl-CpG-binding protein 2 regulates CYP27A1-induced myometrial contraction during preterm labor. Mol Hum Reprod 2024; 30:gaae016. [PMID: 38704863 DOI: 10.1093/molehr/gaae016] [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: 09/17/2023] [Revised: 03/25/2024] [Indexed: 05/07/2024] Open
Abstract
Persistent and intense uterine contraction is a risk factor for preterm labor. We previously found that methyl-CpG-binding protein 2 (MeCP2), as a target of infection-related microRNA miR-212-3p, may play an inhibitory role in regulating myometrium contraction. However, the molecular mechanisms by which MeCP2 regulates myometrial contraction are still unknown. In this study, we found that MeCP2 protein expression was lower in myometrial specimens obtained from preterm labor cases, compared to those obtained from term labor cases. Herein, using RNA sequence analysis of global gene expression in human uterine smooth muscle cells (HUSMCs) following siMeCP2, we show that MeCP2 silencing caused dysregulation of the cholesterol metabolism pathway. Notably, MeCP2 silencing resulted in the upregulation of CYP27A1, the key enzyme involved in regulating cholesterol homeostasis, in HUSMCs. Methylation-specific PCR, chromatin immunoprecipitation, and dual luciferase reporter gene technology indicated that MeCP2 could bind to the methylated CYP27A1 promoter region and repress its transcription. Administration of siCYP27A1 in a lipopolysaccharide (LPS)-induced preterm labor mouse model delayed the onset of preterm labor. Human preterm myometrium and the LPS-induced preterm labor mouse model both showed lower expression of MeCP2 and increased expression of CYP27A1. These results demonstrated that aberrant upregulation of CYP27A1 induced by MeCP2 silencing is one of the mechanisms facilitating inappropriate myometrial contraction. CYP27A1 could be exploited as a novel therapeutic target for preterm birth.
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Affiliation(s)
- Ting Peng
- Department of Obstetrics, Changning Maternity & Infant Health Hospital, East China Normal University, Shanghai, China
- Department of Obstetrics, Shanghai Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Jiayan Cui
- Department of Pharmaceutical Sciences,Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Ziyun Ni
- Department of Pharmaceutical Sciences,Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Yao Tang
- Department of Obstetrics, Shanghai Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xiaojing Cao
- Department of Pharmaceutical Sciences,Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Sihan Li
- Department of Pharmaceutical Sciences,Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Xixi Cheng
- Department of Obstetrics, Shanghai Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Jin Huang
- Department of Pharmaceutical Sciences,Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, School of Pharmacy, East China University of Science and Technology, Shanghai, China
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Zhu Y, Xu L, Beejadhursing R, Li F. Maternal and neonatal outcomes of intrahepatic cholestasis of pregnancy after in vitro fertilization. BMC Pregnancy Childbirth 2024; 24:44. [PMID: 38191339 PMCID: PMC10773009 DOI: 10.1186/s12884-024-06248-x] [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: 04/03/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is an idiopathic disease of pregnancy. Little is known about how it specifically affects pregnancies resulting from in vitro fertilization (IVF). Our aim is to evaluate the impact of IVF on the perinatal outcomes of ICP. METHODS A retrospective study of 242 patients with intrahepatic cholestasis of pregnancy, comprising 36 conceived through IVF and 206 spontaneous conceptions (SC), enrolled between 2019 and 2021 was carried out. Data were analyzed from the medical archives of the Huazhong University of Science and Technology, Tongji Hospital. RESULTS Numerical values of transaminases (ALT, alanine aminotransferase; AST, aspartate aminotransferase) and serum total bile acid (TBA) are significantly lower in the IVF group than that in the spontaneous conceived group (p < 0.05). The incidence of gestational diabetes mellitus (GDM) was higher in the IVF group than in SC group (30.6% vs. 16%, p = 0.037). The cesarean section (CS) rates are higher in the IVF group (97.2% vs. 85.4%, p = 0.023). On the other hand, the prevalence of premature rupture of membranes (PROM) was higher in the SC group (10.7%) while none was reported in the IVF-ICP group. Other maternal comorbidities and neonatal outcomes were similar between the two groups. CONCLUSION ICP patients who underwent IVF are more likely to suffer from GDM. Therefore, monitoring and management of blood glucose should be strengthened during pregnancy. Fortunately, IVF does not seem to worsen the progression or outlook of ICP, so sticking to standard management practices is recommended.
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Affiliation(s)
- Ying Zhu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Le Xu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rajluxmee Beejadhursing
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Li
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Obiegbusi CN, Dong XJ, Obiegbusi SC. Pregnancy outcomes following antenatal screening for intrahepatic cholestasis of pregnancy (ICP). Taiwan J Obstet Gynecol 2023; 62:809-816. [PMID: 38008498 DOI: 10.1016/j.tjog.2023.09.001] [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] [Accepted: 06/15/2023] [Indexed: 11/28/2023] Open
Abstract
OBJECTIVE To evaluate the maternal and perinatal outcomes following antenatal screening for ICP using a retrospective approach. MATERIALS AND METHODS A retrospective study was conducted at the second affiliated hospital of Chongqing Medical University, Chongqing, China, from 2012 to 2017. Pregnant women registered for antenatal in our hospital were screened for ICP. The pregnant women with detailed delivery record and presenting with the diagnosis of ICP based on TBA level ≥10 mmol/L and abnormal liver enzymes were included in the study. METHOD The pregnant women with detailed delivery records presenting with the diagnosis of ICP based on TBA level ≥10 mmol/L and abnormal liver enzymes were included in the study. 1410 pregnant women were enrolled in this study. We selected 940 pregnant women without the diagnosis of ICP as our control and 470 pregnant women diagnosed with ICP as our case study. Data collection and sampling in the control group was done using microsoft excel (version 16.61) random number generator. RESULTS The mean age of the pregnant women and the gestational age at the time of diagnosis of ICP were 29.01 ± 4.3 years and 31.90 ± 8.83 weeks, respectively. It was found that a significant number of patients with ICP had a preterm birth and low birth weight (LBW), n = 151 (32.5%) P < 0.001 and n = 70 (14.9%) P < 0.001, respectively. A significant number of patients in the case group had a history of liver disease and gall bladder disease, p < 0.001 and p = 0.005, respectively, and a higher rate of GDM p < 0.001. Despite treatment, high TBA titer among ICP patients was associated with preterm delivery. CONCLUSION ICP in pregnancy leads to complications and poor perinatal outcomes. Fetal outcomes depend on the TBA levels; therefore, early diagnosis of ICP through routine screening followed by treatment is recommended in high-risk persons/areas.
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Affiliation(s)
- Chidera Nneji Obiegbusi
- The Second Affiliated Hospital of Chongqing Medical University, 288 Tianwen Avenue, Jiangnan Xincheng, Zone B, Chayuan, Nan'an District, Chongqing, China.
| | - Xiao Jing Dong
- The Second Affiliated Hospital of Chongqing Medical University, 288 Tianwen Avenue, Jiangnan Xincheng, Zone B, Chayuan, Nan'an District, Chongqing, China; The Second Affiliated Hospital of Chongqing Medical University, No.76 LinJiang Road, YuZhong District, Chongqing, China.
| | - Samuel Chigbo Obiegbusi
- The Second Affiliated Hospital of Chongqing Medical University, 288 Tianwen Avenue, Jiangnan Xincheng, Zone B, Chayuan, Nan'an District, Chongqing, China.
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Yang M, Liu S, Cai J, Sun X, Li C, Tan M, He B. Bile acids ameliorates lipopolysaccharide-induced endometritis in mice by inhibiting NLRP3 inflammasome activation. Life Sci 2023; 331:122062. [PMID: 37666389 DOI: 10.1016/j.lfs.2023.122062] [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: 05/09/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/06/2023]
Abstract
AIMS Endometritis is a common inflammatory disorder affecting the reproductive health in both humans and livestock. The NLR family pyrin domain containing 3 (NLRP3) inflammasome has recently been identified as a possible therapeutic target for several inflammatory disorders. Bile acids (BAs) have been shown to possess anti-inflammatory properties by inhibiting the activation of the NLRP3 inflammasome. However, whether BAs ameliorate endometritis by targeting NLRP3 inflammasome remain poorly understood. MAIN METHODS Female NLRP3+/+ and NLRP3-/- mice were subjected to uterine perfusion with lipopolysaccharide (LPS) to establish the endometritis model. For BAs pre-treatment, wild-type mice were administered oral gavage of BAs for seven days followed by uterine perfusion with LPS. All mice were euthanized and the uterine tissues were collected for analysis. KEY FINDINGS The abundances of NLRP3 and interleukin-1 beta (IL-1β) were significantly upregulated in the uterine tissues of endometritis mice. NLRP3 deficiency led to a reduction in the inflammatory response, neutrophil infiltration, and myeloperoxidase (MPO) activity in the uterus, as well as an inhibition of IL-1β secretion. Moreover, BAs pre-treatment successfully decreased LPS-induced upregulation of NLRP3, ASC, and Caspase1, lessened histopathological alteration in the uterus, and notably reduced MPO activity and secretion of IL-1β. SIGNIFICANCE NLRP3 inflammasome is a promising target for endometritis treatment and BAs exhibit anti-inflammatory properties by repressing NLRP3 inflammasome activation, making them a possible novel therapeutic strategy for endometritis.
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Affiliation(s)
- Miaoxin Yang
- Key Laboratory of Animal Physiology & Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, PR China
| | - Suyuan Liu
- Key Laboratory of Animal Physiology & Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, PR China
| | - Jiangxue Cai
- Key Laboratory of Animal Physiology & Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, PR China
| | - Xiaoxiao Sun
- Key Laboratory of Animal Physiology & Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, PR China
| | - Chenxuan Li
- Key Laboratory of Animal Physiology & Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, PR China
| | - Meiling Tan
- Key Laboratory of Animal Physiology & Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, PR China
| | - Bin He
- Key Laboratory of Animal Physiology & Biochemistry, Ministry of Agriculture and Rural Affairs, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing 210095, PR China; MOE Joint International Research Laboratory of Animal Health & Food Safety, Nanjing Agricultural University, Nanjing 210095, PR China.
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7
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Granese R, Calagna G, Alibrandi A, Martinelli C, Romeo P, Filomia R, Ferraro MI, Piccione E, Ercoli A, Saitta C. Maternal and Neonatal Outcomes in Intrahepatic Cholestasis of Pregnancy. J Clin Med 2023; 12:4407. [PMID: 37445442 DOI: 10.3390/jcm12134407] [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: 02/25/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
The aims of our study were to evaluate the maternal and fetal outcomes of intrahepatic cholestasis of pregnancy (ICP). In this observational, retrospective case-control study, we included all pregnant women who gave birth with a diagnosis of ICP between January 2010 and December 2020 at the Unit of Obstetrics and Gynecology, University Hospital of Messina. The data were compared with those from a control group of pregnant women who did not have ICP. One hundred twenty-nine and eighty-five patients were included, respectively, in the study and in the control group. There was a significant difference between the two groups in the incidence of hypothyroidism, thrombophilia, gestational diabetes, gestational hypertension, postpartum hemorrhage, and preterm delivery, which were more frequent in the ICP patients. No neonatal adverse events were recorded, although a significant difference in the meconium-stained amniotic fluid condition was noted. After a 24-month follow-up, 48/129 patients with ICP accepted to be reassessed by liver ultrasound, elastographic examination, and liver function blood tests. No patient showed signs of chronic liver disease. This study confirmed a higher probability of adverse short-term maternal outcomes in ICP pregnant patients, but a lower probability of adverse short-term fetal outcomes and the absence of a long-term maternal risk of chronic liver disease.
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Affiliation(s)
- Roberta Granese
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University Hospital "G. Martino", Via Consolare Valeria 1, Gazzi, 98100 Messina, Italy
| | - Gloria Calagna
- Obstetrics and Gynecology, "Villa Sofia Cervello" Hospital, University of Palermo, Via Trabucco 180, 90127 Palermo, Italy
| | - Angela Alibrandi
- Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Via dei Verdi, 98166 Messina, Italy
| | - Canio Martinelli
- Department of Human Pathology in Adulthood and Childhood, University Hospital "G. Martino", Via Consolare Valeria 1, Gazzi, 98100 Messina, Italy
| | - Paola Romeo
- Department of Human Pathology in Adulthood and Childhood, University Hospital "G. Martino", Via Consolare Valeria 1, Gazzi, 98100 Messina, Italy
| | - Roberto Filomia
- Department of Clinical and Experimental Medicine, University Hospital "G. Martino", Via Consolare Valeria 1, Gazzi, 98100 Messina, Italy
| | | | - Eleonora Piccione
- Family Counseling, ASP Messina, Via Trento 8, Brolo, 98100 Messina, Italy
| | - Alfredo Ercoli
- Department of Human Pathology in Adulthood and Childhood, University Hospital "G. Martino", Via Consolare Valeria 1, Gazzi, 98100 Messina, Italy
| | - Carlo Saitta
- Department of Clinical and Experimental Medicine, University Hospital "G. Martino", Via Consolare Valeria 1, Gazzi, 98100 Messina, Italy
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8
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Begum J, Singh S, Saharia GK, Panigrahi MK. Fetuin B may be a potential marker for predicting maternal and neonatal outcomes in intrahepatic cholestasis: Prospective case-control study. Turk J Obstet Gynecol 2023; 20:29-37. [PMID: 36908062 PMCID: PMC10013082 DOI: 10.4274/tjod.galenos.2023.37096] [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: 03/12/2023] Open
Abstract
Objective To investigate the levels of serum fetuin B in healthy pregnant women and women with intrahepatic cholestasis of pregnancy (IHCP) and their association with pregnancy outcomes. Materials and Methods This was a prospective case-control study, we included sixty singleton pregnant women with IHCP and sixty healthy-matched pregnant women in their third trimester. The serum fetuin B levels of these patients were analyzed. All the patients were followed up prospectively until delivery and data related to maternal, perinatal, and neonatal outcomes were obtained. Results Total bile acid levels and liver function tests were significantly higher in the IHCP group than in the control group (p<0.0001 and <0.0001, respectively). The serum fetuin B concentrations were higher in the IHCP group than in the control group, without any significant group difference (p=0.105). Preterm delivery, iatrogenic preterm delivery, and birth weight ≤2.500 gm are only significantly associated with serum fetuin B levels respectively (p<0.05). The diagnostic performance of serum bile acids [area under the curve (AUC)=0.998] was significantly better than that of fetuin B (AUC=0.586) (DeLong's test p≤0.001). Conclusion We neither noted a significant difference between the IHCP and control groups concerning the serum fetuin B levels nor could we correlate its levels with adverse maternal and perinatal outcomes except with birth weight, thereby serum fetuin B was not an effective marker for use in shedding light on the pathophysiology of IHCP.
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Affiliation(s)
- Jasmina Begum
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Sweta Singh
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Gautom Kumar Saharia
- Department of Biochemistry, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Manas Kumar Panigrahi
- Department of Medical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
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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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10
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Qian Y, Zhang Y, Fan X, Yan H, Li X, Fan Y, Song Y, Ma S, Hu Z, Gao X, Yang J. Nonalcoholic Fatty Liver Disease and Adverse Pregnancy Outcomes in Women With Normal Prepregnant Weight. J Clin Endocrinol Metab 2023; 108:463-471. [PMID: 36181486 DOI: 10.1210/clinem/dgac567] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 09/24/2022] [Indexed: 01/20/2023]
Abstract
CONTEXT Existing studies focusing on the effects of nonalcoholic fatty liver disease (NAFLD) combined with normal prepregnant weight on pregnancy outcomes are limited. OBJECTIVE This study aimed to explore the relationship between maternal NAFLD and adverse pregnancy outcomes in different body mass index (BMI) groups. METHODS Using an antenatal care and delivery database, we retrospectively analyzed women who delivered in Minhang Hospital affiliated to Fudan University, Shanghai, China from January 1, 2013, to June 30, 2020. NAFLD was confirmed by ultrasound in early pregnancy. A logistic regression model with adjustment for confounders was used to examine potential associations between NAFLD and pregnancy outcomes. RESULTS A total of 14 708 pregnant women (mean prepregnant BMI 21.0 [SD, 2.8] kg/m2) were included in our final study, of whom 554 (3.8%) had NAFLD. After fully adjusting for potential confounders, NAFLD significantly increased the risk of gestational diabetes mellitus (adjusted odds ratio 2.477; 95% CI, 1.885-3.254), gestational hypertension (3.054; 2.191-4.257), preeclampsia/eclampsia (3.994; 2.591-6.005), cesarean section (1.569; 1.315-1.872), preterm births (1.831; 1.229-2.727), and macrosomia (1.691; 1.300-2.198). It is notable that 83.9% (12 338) of women were of normal weight at the start of pregnancy (prepregnant 18.5 ≤ BMI < 24 kg/m2), and they still had higher odds of adverse pregnancy outcomes. CONCLUSION Women with NAFLD and a normal weight have a higher risk for adverse pregnancy outcomes. Pregnant women with NAFLD, regardless of obesity status, should be offered a more qualified surveillance to optimize pregnancy outcomes.
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Affiliation(s)
- Yiling Qian
- Department of Endocrinology and Metabolism, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Yu Zhang
- Department of Endocrinology and Metabolism, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Xiaofang Fan
- Department of Endocrinology and Metabolism, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Hongmei Yan
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xuesong Li
- Department of Endocrinology and Metabolism, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Yujuan Fan
- Department of Endocrinology and Metabolism, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Yuping Song
- Department of Endocrinology and Metabolism, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Shuai Ma
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zheng Hu
- Department of Obstetrics, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Xin Gao
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jialin Yang
- Department of Endocrinology and Metabolism, Minhang Hospital, Fudan University, Shanghai 201199, China
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11
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Abdelhafez MMA, Ahmed KAM, Than WW, Baharuddin DMP, Kadir F, Jeffree S, Hayati MF, Daud MNBM, Eldiastey AM, Tay KX. Intrahepatic cholestasis of pregnancy: from an obstetrician point of view. J OBSTET GYNAECOL 2022; 42:2550-2557. [PMID: 35666947 DOI: 10.1080/01443615.2022.2081801] [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: 01/06/2023]
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is the commonest among the specific dermatoses of pregnancy. The disease is characterised by intense pruritus and specifically by elevated bile acid levels and owing to the rarity of data published in this context, the disease carries a great challenge in both diagnosis and management. The disease is associated with significant maternal as well as perinatal adverse effects, hence, this article aims at improving the knowledge of the women's health carers with the up-to-date and evidence-based, whenever possible, recommendations while managing patients with ICP.
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Affiliation(s)
- Mohsen M A Abdelhafez
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Karim A M Ahmed
- Department of Dermatology, Helios Saint Johannes Klinikum, Duisburg, Germany
| | - Win Win Than
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Dg Marshitah Pg Baharuddin
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Fairrul Kadir
- Department of Emergency Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Saffree Jeffree
- Department of Public Health Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Mohammad Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | - Mohd Nazri Bin Mohd Daud
- Department of Public Health Medicine, Faculty of Medicine and Health Sciences, Family Medicine Unit, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
| | | | - Kai Xin Tay
- Faculty of Business, Economic, and Accountancy, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia
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12
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Sarker M, Zamudio AR, DeBolt C, Ferrara L. Beyond stillbirth: association of intrahepatic cholestasis of pregnancy severity and adverse outcomes. Am J Obstet Gynecol 2022; 227:517.e1-517.e7. [PMID: 36008054 DOI: 10.1016/j.ajog.2022.06.013] [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: 03/03/2022] [Revised: 06/01/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy is associated with adverse pregnancy outcomes, including sudden fetal cardiac arrhythmias, resulting in stillbirth. This association has been correlated with the total bile acid levels, which are a marker for disease severity. Studies are yet to determine if intrahepatic cholestasis of pregnancy severity is also associated with increased rates of other adverse neonatal outcomes. OBJECTIVE This study aimed to determine whether pregnancies complicated by intrahepatic cholestasis of pregnancy show a bile acid severity-based relationship with other adverse obstetrical outcomes beyond stillbirth alone. STUDY DESIGN This was a retrospective cohort study of singleton, nonanomalous gestations complicated by intrahepatic cholestasis of pregnancy at the Elmhurst Hospital Center from 2005 to 2019. Severity was defined by the peak total bile acid levels (μmol/L): mild (10-19), low moderate (20-39), high moderate (40-99), and severe (>100). We examined the rates of spontaneous preterm labor, fetal growth restriction, preterm prelabor rupture of membranes, iatrogenic preterm birth, meconium-stained amniotic fluid, cesarean delivery for nonreassuring fetal heart tracing, umbilical artery pH, neonatal intensive care unit admission, and neonatal birthweight. The chi-square, Fisher exact, Student t, Mann-Whitney, and multivariate regression tests were used to determine the association of intrahepatic cholestasis of pregnancy severity and adverse neonatal outcomes. In all analyses, mild severity was used as the base comparator. A P value of <.05 and 95% confidence interval not crossing 1.00 indicated statistical significance. RESULTS Of the 1202 pregnancies complicated by intrahepatic cholestasis of pregnancy, 306 (25.5%) were mild, 449 were low moderate (37.4%), 327 were high moderate (27.2%), and 120 were severe (10.0%). After adjusting for confounders, progressive intrahepatic cholestasis of pregnancy severity was associated with an increased risk of spontaneous preterm labor (low moderate adjusted odds ratio, 1.60; 95% confidence interval, 0.76-3.38; high moderate adjusted odds ratio, 3.49; 95% confidence interval, 1.69-7.22; severe adjusted odds ratio, 6.58; 95% confidence interval, 2.97-14.55), iatrogenic preterm birth (low moderate adjusted odds ratio, 1.54; 95% confidence interval, 0.95-2.52; high moderate adjusted odds ratio, 3.11; 95% confidence interval, 1.91-5.06; severe adjusted odds ratio, 4.94; 95% confidence interval, 2.81-8.71), and meconium-stained amniotic fluid (low moderate adjusted odds ratio, 1.33; 95% confidence interval, 0.75-2.36; high moderate adjusted odds ratio, 2.63; 95% confidence interval, 1.48-4.65; severe adjusted odds ratio, 3.91; 95% confidence interval, 1.98-7.69). There was no significant association between intrahepatic cholestasis of pregnancy severity and other adverse outcomes. CONCLUSION The findings suggest that intrahepatic cholestasis of pregnancy disease severity is associated with an increased risk of spontaneous preterm labor, iatrogenic preterm birth, and meconium-stained amniotic fluid. These findings provide valuable insight toward patient anticipatory counseling.
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Affiliation(s)
- Minhazur Sarker
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Andres Ramirez Zamudio
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chelsea DeBolt
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lauren Ferrara
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY
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13
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Ueda H, Honda A, Miyazaki T, Morishita Y, Hirayama T, Iwamoto J, Nakamoto N, Ikegami T. Sex-, age-, and organ-dependent improvement of bile acid hydrophobicity by ursodeoxycholic acid treatment: A study using a mouse model with human-like bile acid composition. PLoS One 2022; 17:e0271308. [PMID: 35819971 PMCID: PMC9275687 DOI: 10.1371/journal.pone.0271308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
Cyp2a12-/-Cyp2c70-/- double knockout (DKO) mice have a human-like hydrophobic bile acid (BA) composition and show reduced fertility and liver injury. Ursodeoxycholic acid (UDCA) is a hydrophilic and cytoprotective BA used to treat various liver injuries in humans. This study investigated the effects of orally administered UDCA on fertility and liver injury in DKO mice. UDCA treatment prevented abnormal delivery (miscarriage and preterm birth) in pregnant DKO mice, presumably by increasing the hydrophilicity of serum BAs. UDCA also prevented liver damage in six-week-old DKO mice, however liver injury emerged in UDCA-treated 20-week-old female, but not male, DKO mice. In 20-week-old male UDCA-treated DKO mice, conjugated plus unconjugated UDCA proportions in serum, liver, and bile were 71, 64, and 71% of the total BAs, respectively. In contrast, conjugated plus unconjugated UDCA proportions in serum, liver, and bile of females were 56, 34, and 58% of the total BAs, respectively. The UDCA proportion was considerably low in female liver only and was compensated by highly hydrophobic lithocholic acid (LCA). Therefore, UDCA treatment markedly reduced the BA hydrophobicity index in the male liver but not in females. This appears to be why UDCA treatment causes liver injury in 20-week-old female mice. To explore the cause of LCA accumulation in the female liver, we evaluated the hepatic activity of CYP3A11 and SULT2A1, which metabolize LCAs to more hydrophilic BAs. However, there was no evidence to suggest that either enzyme activity was lower in females than in males. As female mice have a larger BA pool than males, excessive loading of LCAs on the hepatic bile salt export pump (BSEP) may be the reason for the hepatic accumulation of LCAs in female DKO mice with prolonged UDCA treatment. Our results suggest that the improvement of BA hydrophobicity in DKO mice by UDCA administration is sex-, age-, and organ-dependent.
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Affiliation(s)
- Hajime Ueda
- Division of Gastroenterology and Hepatology, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Akira Honda
- Division of Gastroenterology and Hepatology, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan.,Joint Research Center, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Teruo Miyazaki
- Joint Research Center, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Yukio Morishita
- Diagnostic Pathology Division, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Takeshi Hirayama
- Division of Gastroenterology and Hepatology, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Junichi Iwamoto
- Division of Gastroenterology and Hepatology, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Nobuhiro Nakamoto
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Ikegami
- Division of Gastroenterology and Hepatology, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
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14
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Terrault NA, Williamson C. Pregnancy-Associated Liver Diseases. Gastroenterology 2022; 163:97-117.e1. [PMID: 35276220 DOI: 10.1053/j.gastro.2022.01.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 01/21/2022] [Accepted: 01/26/2022] [Indexed: 12/14/2022]
Abstract
The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.
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Affiliation(s)
- Norah A Terrault
- Gastrointestinal and Liver Disease Division, University of Southern California, Los Angeles, California, USA.
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15
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Cheng CY, Zeng GY, Wang T, Su YH, Xu FD, Luo H, Zhong HT, Chen XL. Predictive Value of Serum Cholic Acid and Lithocholic Acid for the Diagnosis in an Intrahepatic Cholestasis of Pregnancy Population with High Levels of Total Bile Acids and the Correlation with Placental Hypoxia-Inducible Factor-1α. Int J Womens Health 2022; 14:687-696. [PMID: 35586114 PMCID: PMC9109902 DOI: 10.2147/ijwh.s355156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/21/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Chu-Yun Cheng
- Department of Obstetrics, Dongguan Eighth People’s Hospital (Dongguan Children’s Hospital), Dongguan, Guangdong, 523325, People’s Republic of China
- Correspondence: Chu-Yun Cheng, Department of Obstetrics, Dongguan Eighth People’s Hospital (Dongguan children’s Hospital), No. 68, West Lake 3rd Road, Shilong Town, Dongguan, Guangdong, 523325, People’s Republic of China, Tel +86 13688988412, Email
| | - Guan-Yin Zeng
- Department of Obstetrics, Dongguan Eighth People’s Hospital (Dongguan Children’s Hospital), Dongguan, Guangdong, 523325, People’s Republic of China
| | - Tong Wang
- Department of Obstetrics, Dongguan Eighth People’s Hospital (Dongguan Children’s Hospital), Dongguan, Guangdong, 523325, People’s Republic of China
| | - Yan-Hua Su
- Department of Obstetrics, Dongguan Eighth People’s Hospital (Dongguan Children’s Hospital), Dongguan, Guangdong, 523325, People’s Republic of China
| | - Feng-Dan Xu
- Department of Neonatal Clinic, Dongguan Eighth People’s Hospital (Dongguan Children’s Hospital), Dongguan, Guangdong, 523325, People’s Republic of China
| | - Hong Luo
- Department of Obstetrics, Dongguan Eighth People’s Hospital (Dongguan Children’s Hospital), Dongguan, Guangdong, 523325, People’s Republic of China
| | - Hui-Ting Zhong
- Department of Obstetrics, Dongguan Eighth People’s Hospital (Dongguan Children’s Hospital), Dongguan, Guangdong, 523325, People’s Republic of China
| | - Xiu-Lan Chen
- Department of Obstetrics, Dongguan Eighth People’s Hospital (Dongguan Children’s Hospital), Dongguan, Guangdong, 523325, People’s Republic of China
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16
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Waspe J, Beronius A. Development of an Adverse Outcome Pathway for Intrahepatic Cholestasis of Pregnancy. Curr Res Toxicol 2022; 3:100065. [PMID: 35243364 PMCID: PMC8885608 DOI: 10.1016/j.crtox.2022.100065] [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: 10/29/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 12/04/2022] Open
Abstract
Adverse outcome pathways are an established method for knowledge synthesis in toxicology. This method has not yet been applied in the context of clinical research. There are opportunities to apply AOPs to the integration and synthesis of biomedical research. The AOP developed in this paper is an example of how the method could be used to investigate clinical questions.
Adverse Outcome Pathways (AOPs) are a research synthesis tool, used primarily by toxicologists for numerous applications including: hypothesis generation, data integration, biomarker determination, and identification of gaps in current knowledge. The AOP model provides a means for evaluating critical interactions between stressors and biological systems which result in adversity, meaning there is significant potential value in using this model in clinical research. However, AOPs have so far not been applied in this context, which may be attributable to the fact that the method is not yet streamlined with established practices in evidence-based medicine, such as systematic review. Here, we present one approach to developing a clinically focused AOP for intrahepatic cholestasis of pregnancy; aiming to enhance understanding of the mechanistic link between this common, gestational liver disease and its association with preterm birth. Mechanistic aspects of the disease pathogenesis, and use of AOPs to broaden inclusion and improve integration of in vitro and in vivo data in clinical research are discussed. We also demonstrate for the first time how central components of systematic review can be integrated into the development of an AOP.
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17
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Varlas VN, Bohîlțea R, Gheorghe G, Bostan G, Angelescu GA, Penes ON, Bors RG, Cloțea E, Bacalbasa N, Diaconu CC. State of the Art in Hepatic Dysfunction in Pregnancy. Healthcare (Basel) 2021; 9:1481. [PMID: 34828527 PMCID: PMC8618725 DOI: 10.3390/healthcare9111481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 12/21/2022] Open
Abstract
Hepatic dysfunction in pregnant women is always challenging for the obstetrician, as the spectrum of hepatic abnormalities can be very large and have various implications, both for mother and fetus. There is a diagnostic and therapeutic polymorphism of hepatic dysfunction in pregnancy and insufficient knowledge related to the etiopathogenesis and epidemiology of this disease. The clinical forms of hepatic dysfunction encountered in pregnancy can vary from liver diseases related to pregnancy (e.g., HELLP syndrome, intrahepatic cholestasis, hyperemesis gravidarum, or acute fatty liver of pregnancy) to de novo ones occurring in pregnancy, and pre-existing liver disease (cholelithiasis, Budd-Chiari syndrome, and cirrhosis). We performed a systematic literature search over 10 years. The review protocol assumed a search of two databases (PubMed®/MEDLINE and Web of Science Core Collection). The strategy regarding the management of these diseases involves multidisciplinary teams composed of different specialists (obstetricians, gastroenterologists and anesthetists) from specialized tertiary centers. Despite the improving prognosis of pregnant women with liver diseases, the risk of maternal-fetal complications remains very high. Therefore, it is necessary to ensure careful monitoring by a multidisciplinary team and to inform the patients of the potential risks.
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Affiliation(s)
- Valentin Nicolae Varlas
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
| | - Roxana Bohîlțea
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
| | - Gina Gheorghe
- Department of Internal Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Georgiana Bostan
- Department of Obstetrics and Gynecology, County Emergency Hospital “St. John the New”, 720034 Suceava, Romania;
| | - Gabriela Anca Angelescu
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
- Department of Internal Medicine, County Emergency Hospital Ilfov, 022115 Bucharest, Romania
| | - Ovidiu Nicolae Penes
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
- Department of Anesthesiology and Intensive Care, University Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Roxana Georgiana Bors
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
| | - Eliza Cloțea
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
| | - Nicolae Bacalbasa
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
- Department of Visceral Surgery, “Fundeni” Clinical Institute, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Camelia Cristina Diaconu
- Department of Internal Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
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18
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Ovadia C, Williamson C. Intrahepatic cholestasis of pregnancy: are we expecting too much from ursodeoxycholic acid? - Authors' reply. Lancet Gastroenterol Hepatol 2021; 6:886-887. [PMID: 34626560 DOI: 10.1016/s2468-1253(21)00304-6] [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: 08/08/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Caroline Ovadia
- Department of Women and Children's Health, Guy's Campus, King's College London, London SE1 1UL, UK
| | - Catherine Williamson
- Department of Women and Children's Health, Guy's Campus, King's College London, London SE1 1UL, UK.
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19
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Jurk SM, Kremer AE, Schleussner E. Intrahepatic Cholestasis of Pregnancy. Geburtshilfe Frauenheilkd 2021; 81:940-947. [PMID: 34393257 PMCID: PMC8354350 DOI: 10.1055/a-1522-5178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/02/2021] [Indexed: 12/29/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a rare but potentially serious complication of pregnancy, the main symptom of which is intense pruritus with elevated serum levels of bile acids. The elevated serum bile acid concentration is regarded as a predictor for poor perinatal outcome including intrauterine death. Ursodeoxycholic acid (UDCA) has become established as the treatment of choice in clinical management to achieve a significant improvement in symptoms and reduce the cholestasis. Pregnant women with severe intrahepatic cholestasis should always be managed in a perinatal centre with close interdisciplinary monitoring and treatment involving perinatologists and hepatologists to minimise the markedly increased perinatal morbidity and mortality as well as maternal symptoms.
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Affiliation(s)
| | - Andreas E Kremer
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Erlangen, Germany.,Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Switzerland
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20
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Ovadia C, Sajous J, Seed PT, Patel K, Williamson NJ, Attilakos G, Azzaroli F, Bacq Y, Batsry L, Broom K, Brun-Furrer R, Bull L, Chambers J, Cui Y, Ding M, Dixon PH, Estiú MC, Gardiner FW, Geenes V, Grymowicz M, Günaydin B, Hague WM, Haslinger C, Hu Y, Indraccolo U, Juusela A, Kane SC, Kebapcilar A, Kebapcilar L, Kohari K, Kondrackienė J, Koster MPH, Lee RH, Liu X, Locatelli A, Macias RIR, Madazli R, Majewska A, Maksym K, Marathe JA, Morton A, Oudijk MA, Öztekin D, Peek MJ, Shennan AH, Tribe RM, Tripodi V, Türk Özterlemez N, Vasavan T, Wong LFA, Yinon Y, Zhang Q, Zloto K, Marschall HU, Thornton J, Chappell LC, Williamson C. Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:547-558. [PMID: 33915090 PMCID: PMC8192305 DOI: 10.1016/s2468-1253(21)00074-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ursodeoxycholic acid is commonly used to treat intrahepatic cholestasis of pregnancy, yet its largest trial detected minimal benefit for a composite outcome (stillbirth, preterm birth, and neonatal unit admission). We aimed to examine whether ursodeoxycholic acid affects specific adverse perinatal outcomes. METHODS In this systematic review and individual participant data meta-analysis, we searched PubMed, Web of Science, Embase, MEDLINE, CINAHL, Global Health, MIDIRS, and Cochrane without language restrictions for relevant articles published between database inception, and Jan 1, 2020, using search terms referencing intrahepatic cholestasis of pregnancy, ursodeoxycholic acid, and perinatal outcomes. Eligible studies had 30 or more study participants and reported on at least one individual with intrahepatic cholestasis of pregnancy and bile acid concentrations of 40 μmol/L or more. We also included two unpublished cohort studies. Individual participant data were collected from the authors of selected studies. The primary outcome was the prevalence of stillbirth, for which we anticipated there would be insufficient data to achieve statistical power. Therefore, we included a composite of stillbirth and preterm birth as a main secondary outcome. A mixed-effects meta-analysis was done using multi-level modelling and adjusting for bile acid concentration, parity, and multifetal pregnancy. Individual participant data analyses were done for all studies and in different subgroups, which were produced by limiting analyses to randomised controlled trials only, singleton pregnancies only, or two-arm studies only. This study is registered with PROSPERO, CRD42019131495. FINDINGS The authors of the 85 studies fulfilling our inclusion criteria were contacted. Individual participant data from 6974 women in 34 studies were included in the meta-analysis, of whom 4726 (67·8%) took ursodeoxycholic acid. Stillbirth occurred in 35 (0·7%) of 5097 fetuses among women with intrahepatic cholestasis of pregnancy treated with ursodeoxycholic acid and in 12 (0·6%) of 2038 fetuses among women with intrahepatic cholestasis of pregnancy not treated with ursodeoxycholic acid (adjusted odds ratio [aOR] 1·04, 95% CI 0·35-3·07; p=0·95). Ursodeoxycholic acid treatment also had no effect on the prevalence of stillbirth when considering only randomised controlled trials (aOR 0·29, 95% CI 0·04-2·42; p=0·25). Ursodeoxycholic acid treatment had no effect on the prevalence of the composite outcome in all studies (aOR 1·28, 95% CI 0·86-1·91; p=0·22), but was associated with a reduced composite outcome when considering only randomised controlled trials (0·60, 0·39-0·91; p=0·016). INTERPRETATION Ursodeoxycholic acid treatment had no significant effect on the prevalence of stillbirth in women with intrahepatic cholestasis of pregnancy, but our analysis was probably limited by the low overall event rate. However, when considering only randomised controlled trials, ursodeoxycholic acid was associated with a reduction in stillbirth in combination with preterm birth, providing evidence for the clinical benefit of antenatal ursodeoxycholic acid treatment. FUNDING Tommy's, the Wellcome Trust, ICP Support, and the National Institute for Health Research.
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Affiliation(s)
- Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, UK
| | - Jenna Sajous
- Department of Women and Children's Health, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, King's College London, London, UK
| | - Kajol Patel
- Department of Women and Children's Health, King's College London, London, UK
| | | | - George Attilakos
- Department of Obstetrics and Gynaecology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Francesco Azzaroli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Yannick Bacq
- Department of Hepatology and Gastroenterology, University Hospital of Tours, Tours, France
| | - Linoy Batsry
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Kelsey Broom
- Bendigo Healthcare Group, Bendigo, VIC, Australia
| | - Romana Brun-Furrer
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Laura Bull
- Department of Medicine and Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Jenny Chambers
- Women's Health Research Centre, Imperial College London, London, UK
| | - Yue Cui
- School of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Min Ding
- School of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Peter H Dixon
- Department of Women and Children's Health, King's College London, London, UK
| | - Maria C Estiú
- Ramón Sardá Mother's and Children's Hospital, Buenos Aires, Argentina
| | | | - Victoria Geenes
- Department of Women and Children's Health, King's College London, London, UK
| | - Monika Grymowicz
- Department of Gynecological Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Berrin Günaydin
- Department of Anesthesiology and Reanimation, Gazi University School of Medicine, Ankara, Turkey
| | - William M Hague
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | | | - Yayi Hu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Ugo Indraccolo
- Maternal-Infantile Department, Complex Operative Unit of Obstetrics and Gynecology Alto Tevere Hospital of Città di Castello, Città di Castello, Italy
| | | | - Stefan C Kane
- Department of Maternal-Fetal Medicine, Royal Women's Hospital, Parkville, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Ayse Kebapcilar
- Department of Gynecology and Obstetrics, Selcuk University, Konya, Turkey
| | | | - Katherine Kohari
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Jūratė Kondrackienė
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Maria P H Koster
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | - Richard H Lee
- Department of Obstetrics and Gynecology, Keck School of Medicine University of Southern California, Los Angeles, CA, USA
| | - Xiaohua Liu
- Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Anna Locatelli
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, Monza, Italy
| | - Rocio I R Macias
- Department of Physiology and Pharmacology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institute of Biomedical Research of Salamanca, University of Salamanca, Salamanca, Spain
| | - Riza Madazli
- Department of Obstetrics and Gynecology, Istanbul University, Cerrahpaşa, Istanbul, Turkey
| | - Agata Majewska
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Kasia Maksym
- Department of Obstetrics and Gynaecology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jessica A Marathe
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Adam Morton
- Department of Obstetric Medicine, Mater Health Services Public Hospital, Brisbane, QLD, Australia
| | - Martijn A Oudijk
- Department of Obstetrics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Deniz Öztekin
- Department of Obstetrics and Gynecology, İzmir Bakircay University, İzmir, Turkey
| | - Michael J Peek
- ANU Medical School, College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
| | - Andrew H Shennan
- Department of Women and Children's Health, King's College London, London, UK
| | - Rachel M Tribe
- Department of Women and Children's Health, King's College London, London, UK
| | - Valeria Tripodi
- Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Naciye Türk Özterlemez
- Department of Anesthesiology and Reanimation, Gazi University School of Medicine, Ankara, Turkey
| | - Tharni Vasavan
- Department of Women and Children's Health, King's College London, London, UK
| | - L F Audris Wong
- Department of Women's and Newborn, Gold Coast University Hospital, Southport, QLD, Australia
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Qianwen Zhang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Keren Zloto
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Jim Thornton
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
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21
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Abstract
Intrahepatic cholestasis of pregnancy is a common disorder of pregnancy manifested by pruritus and elevated bile acids. The etiology of cholestasis is poorly understood and management is difficult due to the paucity of data regarding its diagnosis, treatment, and related adverse outcomes. In this article, we review the epidemiology, pathophysiology, risk factors, laboratory findings, complications, treatment, management, and current evidence surrounding intrahepatic cholestasis of pregnancy.
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Hagenbeck C, Pecks U, Lammert F, Hütten MC, Borgmeier F, Fehm T, Schleußner E, Maul H, Kehl S, Hamza A, Keitel V. [Intrahepatic cholestasis of pregnancy]. GYNAKOLOGE 2021; 54:341-356. [PMID: 33896963 PMCID: PMC8056200 DOI: 10.1007/s00129-021-04787-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 12/19/2022]
Abstract
Die Schwangerschaftscholestase („intrahepatic cholestasis of pregnancy“, ICP) ist die häufigste schwangerschaftsspezifische Lebererkrankung. Das Leitsymptom Juckreiz sowie eine begleitende Serumkonzentrationserhöhung von Gallensäuren und/oder der Alaninaminotransferase (ALT) sind wegweisend in der Diagnosestellung. Die mütterliche Prognose ist gut. Das fetale Outcome ist abhängig von der Gallensäurenkonzentration. Die ICP ist dabei sowohl mit Frühgeburt als auch mit intrauterinem Fruchttod (IUFT) assoziiert. Dieser ist Folge einer akuten fetalen Asphyxie, nicht einer chronischen uteroplazentaren Dysfunktion. Ein prädiktives Monitoring, z. B. durch Kardiotokographie (CTG) oder Ultraschall gibt es nicht. Eine medikamentöse Therapie mit Ursodeoxycholsäure (UDCA) bessert den Juckreiz, aber beeinflusst das fetale Outcome nicht nachweislich. Eine Entbindungsindikation ist in Abhängigkeit von Gallensäurenkonzentration und Gestationsalter gegeben. In Folgeschwangerschaften besteht ein hohes Wiederholungsrisiko.
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Affiliation(s)
- Carsten Hagenbeck
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Deutschland
| | - Ulrich Pecks
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Frank Lammert
- Klinik für Innere Medizin II, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg, Deutschland
| | - Matthias C. Hütten
- Neonatologie, Maastricht Universitair Medisch Centrum+, Maastricht, Niederlande
| | - Felix Borgmeier
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Deutschland
| | - Tanja Fehm
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Deutschland
| | | | - Holger Maul
- Frauenklinik, Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Deutschland
| | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Amr Hamza
- Kantonsspital Baden, Baden, Schweiz
- Klinikum für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universität des Saarlandes, Homburg, Deutschland
| | - Verena Keitel
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universität Düsseldorf, Düsseldorf, Deutschland
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23
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Intrahepatic Cholestasis of Pregnancy and Associated Adverse Maternal and Fetal Outcomes: A Retrospective Case-Control Study. Gastroenterol Res Pract 2021; 2021:6641023. [PMID: 33833795 PMCID: PMC8016576 DOI: 10.1155/2021/6641023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/02/2021] [Accepted: 03/10/2021] [Indexed: 12/11/2022] Open
Abstract
Objective Intrahepatic cholestasis of pregnancy (ICP) is a common pregnancy-related liver disease and is associated with an increased risk of adverse neonatal outcomes. Ursodeoxycholic acid (UDCA) is the most effective treatment. This study was aimed at investigating the adverse outcomes of ICP and evaluating the effects of treatment with UDCA in patients with ICP. Methods We included 114 women with ICP and 3725 women without ICP (no-ICP group) who delivered in our hospital between September 2017 and August 2019. The prevalence of ICP in this study was 3.15%. We matched each woman with ICP to five controls. Of all the 114 women with ICP, 73 (64.04%) received UDCA while 41 (35.96%) did not. Logistic multivariate regression analysis was used to compare the adverse outcomes between those with ICP and matched controls as well as between those who received UDCA (UDCA group) and those who did not (non-UDCA group). Results Compared with controls, women with ICP were more likely to have preeclampsia (adjusted odds ratio, aOR = 16.74, 95% CI 5.29-52.98), cesarean section (aOR = 1.76, 95% CI 1.10-2.81), and preterm birth (aOR = 24.35, 95% CI 2.74-216.67). Administration of UDCA reduced the rate of preterm birth (1.37% vs. 14.63%, aOR = 0.10, 95% CI 0.01-0.90). Conclusion ICP increased the risk of preeclampsia, cesarean section, and preterm birth. UDCA could reduce the rate of preterm birth.
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24
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Lee RH, Mara Greenberg, Metz TD, Pettker CM, Pettker CM. Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy: Replaces Consult #13, April 2011. Am J Obstet Gynecol 2021; 224:B2-B9. [PMID: 33197417 DOI: 10.1016/j.ajog.2020.11.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Intrahepatic cholestasis of pregnancy is a hepatic disorder characterized by pruritus and an elevation in serum bile acid levels. Although intrahepatic cholestasis of pregnancy poses little risk for women, this condition carries a significant risk for the fetus, including complications such as preterm delivery, meconium-stained amniotic fluid, and stillbirth. The purpose of this Consult is to review the current literature on intrahepatic cholestasis of pregnancy and provide recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend measurement of serum bile acid and liver transaminase levels in patients with suspected intrahepatic cholestasis of pregnancy (GRADE 1B); (2) we recommend that ursodeoxycholic acid be used as the first-line agent for the treatment of maternal symptoms of intrahepatic cholestasis of pregnancy (GRADE 1A); (3) we suggest that patients with a diagnosis of intrahepatic cholestasis of pregnancy begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal fetal testing results or at the time of diagnosis if the diagnosis is made later in gestation (GRADE 2C); (4) we recommend that patients with total bile acid levels of ≥100 μmol/L be offered delivery at 36 0/7 weeks of gestation, given that the risk of stillbirth increases substantially around this gestational age (GRADE 1B); (5) we recommend delivery between 36 0/7 and 39 0/7 weeks of gestation for patients with intrahepatic cholestasis of pregnancy and total bile acid levels of <100 μmol/L (GRADE 1C); (6) we recommend administration of antenatal corticosteroids for fetal lung maturity for patients delivering before 37 0/7 weeks of gestation if not previously administered (GRADE 1A); (7) we recommend against preterm delivery at <37 weeks of gestation in patients with a clinical diagnosis of intrahepatic cholestasis of pregnancy without laboratory confirmation of elevated bile acid levels (GRADE 1B).
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Affiliation(s)
| | | | | | | | - Christian M Pettker
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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25
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Intrahepatic Cholestasis in Pregnancy: Review of the Literature. J Clin Med 2020; 9:jcm9051361. [PMID: 32384779 PMCID: PMC7290322 DOI: 10.3390/jcm9051361] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is the most common hepatic disorder related to pregnancy in women. It usually develops within the third trimester of pregnancy and presents with pruritus as well as elevated levels of bile acid and/or alanine aminotransferase. Clinical signs quickly resolve after delivery; however, there is a high risk of the disorder recurring in subsequent pregnancies. ICP is associated with an increased risk of perinatal complications (premature birth, respiratory disorders, even stillbirth). Elevated levels of gestational hormones and genetic predispositions are important factors for the development of ICP; among the latter, mutations in hepatobiliary transport proteins (multidrug resistance protein 3-MDR3, bile salt export pump- BSEP) play a major role. Clinical and biochemical symptoms of ICP include pruritus and increased levels of total bile acids (TBA). Serum levels of TBA should be monitored in ICP patients throughout the pregnancy as concentrations above 40 μmol/L, which define that severe ICP isassociated with an increased risk of fetal complications. Therapeutic management is aimed at reducing the clinical symptoms, normalizing maternal biochemistry and preventing complications to the fetus. Pharmacological treatment of intrahepatic cholestasis of pregnancy consists of the administration of ursodeoxycholic acid to lower the levels of TBA and possibly reduce pruritus. If the treatment fails, premature delivery should be considered.
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26
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You S, Cui AM, Hashmi SF, Zhang X, Nadolny C, Chen Y, Chen Q, Bush X, Hurd Z, Ali W, Qin G, Deng R. Dysregulation of bile acids increases the risk for preterm birth in pregnant women. Nat Commun 2020; 11:2111. [PMID: 32355283 PMCID: PMC7193585 DOI: 10.1038/s41467-020-15923-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 04/03/2020] [Indexed: 12/13/2022] Open
Abstract
Preterm birth (PTB) is the leading cause of perinatal mortality and newborn complications. Bile acids are recognized as signaling molecules regulating a myriad of cellular and metabolic activities but have not been etiologically linked to PTB. In this study, a hospital-based cohort study with 36,755 pregnant women is conducted. We find that serum total bile acid levels directly correlate with the PTB rates regardless of the characteristics of the subjects and etiologies of liver disorders. Consistent with the findings from pregnant women, PTB is successfully reproduced in mice with liver injuries and dysregulated bile acids. More importantly, bile acids dose-dependently induce PTB with minimal hepatotoxicity. Furthermore, restoring bile acid homeostasis by farnesoid X receptor activation markedly reduces PTB and dramatically improves newborn survival rates. The findings thus establish an etiologic link between bile acids and PTB, and open an avenue for developing etiology-based therapies to prevent or delay PTB.
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Affiliation(s)
- Sangmin You
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Ai-Min Cui
- Nantong Maternal and Child Health Hospital, Nantong University, Nantong, China
| | - Syed F Hashmi
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Xinmu Zhang
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Christina Nadolny
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Yuan Chen
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Qiwen Chen
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Xin Bush
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Zachary Hurd
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Winifer Ali
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Gang Qin
- Department of Epidemiology and Biostatistics, School of Public Health, Nantong University, 226006, Nantong, Jiangsu Province, China
| | - Ruitang Deng
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA.
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27
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Raffone A, Troisi J, Boccia D, Travaglino A, Capuano G, Insabato L, Mollo A, Guida M, Zullo F. Metabolomics in endometrial cancer diagnosis: A systematic review. Acta Obstet Gynecol Scand 2020; 99:1135-1146. [PMID: 32180221 DOI: 10.1111/aogs.13847] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/10/2020] [Accepted: 03/09/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Endometrial cancer (EC) is the most common gynecological malignancy in the developed world. The prognosis of EC strongly depends on tumor stage, hence the importance of improving diagnosis. Metabolomics has recently appeared as a promising test for a non-invasive diagnosis of several diseases. Nevertheless, no metabolic marker has been approved for use in the routine practice. We aimed to provide an overview of metabolomics findings in the diagnosis of EC. MATERIAL AND METHODS A systematic review was performed by searching eight electronic databases from their inception to October 2019 for studies assessing metabolomics in EC diagnosis. Extracted data included characteristics of patients and EC, serum concentration of metabolites in women with and without EC and its association with EC diagnosis, tumor behavior and pathological characteristics. RESULTS Six studies with 732 women (356 cases and 376 controls) were included. Several metabolites were found able to predict the presence of EC, tumor behavior (progression and recurrence) and pathological characteristics (histotype, myometrial invasion and lymph vascular space invasion). CONCLUSIONS Metabolomics might be suitable for a non-invasive diagnosis and screening of EC, offering the possibility to predict tumor behavior and pathological characteristics. Further studies are necessary to validate these results.
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Affiliation(s)
- Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Jacopo Troisi
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Baronissi, Italy.,Theoreo srl, Montecorvino Pugliano, Italy.,European Biomedical Research Institute of Salerno (EBRIS), Salerno, Italy
| | - Dominga Boccia
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Giovanfrancesco Capuano
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Luigi Insabato
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Mollo
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Baronissi, Italy
| | - Maurizio Guida
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Fulvio Zullo
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
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28
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Cauldwell M, Mackie FL, Steer PJ, Henehghan MA, Baalman JH, Brennand J, Johnston T, Dockree S, Hedley C, Jarvis S, Khan S, McAuliffe FM, Mackillop L, Penna L, Smith B, Trivedi P, Verma S, Westbrook R, Winifield S, Williamson C. Pregnancy outcomes in women with primary biliary cholangitis and primary sclerosing cholangitis: a retrospective cohort study. BJOG 2020; 127:876-884. [DOI: 10.1111/1471-0528.16119] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2020] [Indexed: 12/17/2022]
Affiliation(s)
- M Cauldwell
- Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital London UK
| | - FL Mackie
- Academic Department of Obstetrics and Gynaecology Birmingham Women’s and Children’s NHS Foundation Trust Birmingham UK
| | - PJ Steer
- Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital London UK
| | | | - JH Baalman
- UCD Perinatal Research Centre School of Medicine University College Dublin National Maternity Hospital Dublin Ireland
| | - J Brennand
- Department of Obstetrics Queen Elizabeth Hospital Glasgow Glasgow UK
| | - T Johnston
- Academic Department of Obstetrics and Gynaecology Birmingham Women’s and Children’s NHS Foundation Trust Birmingham UK
| | - S Dockree
- Women’s Centre Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - C Hedley
- Department of Obstetrics King’s College Hospital London UK
| | - S Jarvis
- Department of Obstetrics Queen Charlotte’s and Chelsea Hospital London UK
| | - S Khan
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - FM McAuliffe
- UCD Perinatal Research Centre School of Medicine University College Dublin National Maternity Hospital Dublin Ireland
| | - L Mackillop
- Women’s Centre Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - L Penna
- Department of Obstetrics King’s College Hospital London UK
| | - B Smith
- Department of Hepatology Hammersmith Hospital London UK
| | - P Trivedi
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - S Verma
- Department of Clinical and Experimental Medicine Brighton and Sussex Medical School Brighton UK
- Department of Gastroenterology and Hepatology Brighton and Sussex University Hospitals Brighton UK
| | - R Westbrook
- Department of Hepatology Royal Free Hospital London UK
| | - S Winifield
- Department of Obstetrics Leeds Teaching Hospitals Leeds UK
| | - C Williamson
- Department of Women and Children’s Health King’s College London London UK
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Unexplained First Trimester Intrahepatic Cholestasis of Pregnancy: A Case Report and Literature Review. Case Rep Obstet Gynecol 2019; 2019:4980610. [PMID: 32089914 PMCID: PMC7024080 DOI: 10.1155/2019/4980610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/30/2019] [Indexed: 12/27/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a condition that usually affects the 3rd 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.
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30
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Manna LB, Ovadia C, Lövgren-Sandblom A, Chambers J, Begum S, Seed P, Walker I, Chappell LC, Marschall HU, Williamson C. Enzymatic quantification of total serum bile acids as a monitoring strategy for women with intrahepatic cholestasis of pregnancy receiving ursodeoxycholic acid treatment: a cohort study. BJOG 2019; 126:1633-1640. [PMID: 31483939 PMCID: PMC6899621 DOI: 10.1111/1471-0528.15926] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate enzymatic total serum bile acid quantification as a monitoring strategy for women with intrahepatic cholestasis of pregnancy (ICP) treated with ursodeoxycholic acid (UDCA). DESIGN Cohort. SETTING One UK university hospital. POPULATION 29 ICP cases treated with UDCA. METHODS Serial samples were collected prospectively throughout gestation. Total serum bile acids were measured enzymatically and individual bile acids by high-performance liquid chromatography-tandem mass spectrometry. Data were log-transformed and analysed with random effects generalised least square regression. MAIN OUTCOME MEASURES The relationship between enzymatic total bile acid measurements and individual bile acid concentrations after UDCA treatment. RESULTS In untreated women, cholic acid was the principal bile acid (51%) and UDCA concentrations were <0.5%, whereas UDCA constituted 60% (IQR 43-69) of serum bile acids following treatment and cholic acid fell to <20%. Changes in the total bile acid measurement reflected similar alterations in the concentrations of the pathologically elevated bile acids, e.g. a two-fold increase in enzymatic total bile acids is accompanied by approximately a two-fold increase in cholic acid and chenodeoxycholic acid at most UDCA doses (P < 0.001). Most of the effects of UDCA on cholic acid occur in the first week of treatment (60% relative reduction, P = 0.025, 95% CI 0.2-0.9, from 10 micromol/l (4.7-17.6) to 3.5 micromol/l (1.4-7.5). CONCLUSION Ursodeoxycholic acid becomes the main component of the bile acid measurement after treatment. Enzymatic total bile acid assays are good predictors of both cholic acid and chenodeoxycholic acid, the primary bile acids that are raised prior to treatment. TWEETABLE ABSTRACT Ursodeoxycholic acid constitutes approximately 60% of the bile acid measurement and reduces pathological cholic acid in treated women.
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Affiliation(s)
- L B Manna
- Division of Women and Children's Health, King's College London, London, UK
| | - C Ovadia
- Division of Women and Children's Health, King's College London, London, UK
| | - A Lövgren-Sandblom
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
| | - J Chambers
- Division of Women and Children's Health, King's College London, London, UK.,Women's Health Research Centre, Imperial College Healthcare NHS Trust, London, UK
| | - S Begum
- Division of Women and Children's Health, King's College London, London, UK
| | - P Seed
- Division of Women and Children's Health, King's College London, London, UK
| | - I Walker
- Clinical Biochemistry, Frimley Health NHS trust, Wexham Park Hospital, Slough, UK
| | - L C Chappell
- Division of Women and Children's Health, King's College London, London, UK
| | - H-U Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - C Williamson
- Division of Women and Children's Health, King's College London, London, UK
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31
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Batsry L, Zloto K, Kalter A, Baum M, Mazaki-Tovi S, Yinon Y. Perinatal outcomes of intrahepatic cholestasis of pregnancy in twin versus singleton pregnancies: is plurality associated with adverse outcomes? Arch Gynecol Obstet 2019; 300:881-887. [PMID: 31346701 DOI: 10.1007/s00404-019-05247-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/10/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE To determine the rate of obstetric and neonatal complications associated with intrahepatic cholestasis of pregnancy in twin versus singleton gestations. METHODS A retrospective cohort study including patients diagnosed with intrahepatic cholestasis of pregnancy at a single tertiary center between 2011 and 2016. Women were allocated into two groups: twin pregnancies (n = 56) and singleton pregnancies (n = 186). Obstetric and neonatal outcomes were compared between the two groups. RESULTS Intrahepatic cholestasis of pregnancy was diagnosed earlier in gestation in twin compared to singleton pregnancies (33.1 ± 2.8 vs. 35.1 ± 3.0 weeks, respectively; adjusted P < 0.001). Maternal serum levels of fasting total bile acids were significantly higher in twin pregnancies compared to singletons [27 (IQR 16-44) vs. 16 (IQR 10-26) µmol/L, respectively; P = 0.01]. None of the pregnancies in our cohort was complicated by fetal death. Apgar score at 5 min and umbilical artery and vein PH at delivery were comparable between the two groups. CONCLUSIONS Intrahepatic cholestasis of pregnancy in twin pregnancies appears to be more severe compared to singletons, as reflected by an earlier presentation and higher levels of maternal serum total bile acids. Large prospective studies are required to customize a management strategy specific for women with twin pregnancies and intrahepatic cholestasis of pregnancy.
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Affiliation(s)
- Linoy Batsry
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel. .,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Keren Zloto
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Kalter
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Micha Baum
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shali Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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32
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Yeap SP, Harley H, Thompson R, Williamson KD, Bate J, Sethna F, Farrell G, Hague WB. Biliary transporter gene mutations in severe intrahepatic cholestasis of pregnancy: Diagnostic and management implications. J Gastroenterol Hepatol 2019; 34:425-435. [PMID: 29992621 DOI: 10.1111/jgh.14376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Clinical syndromes associated with biallelic mutations of bile acid (BA) transporters usually present in childhood. Subtle mutations may underlie intrahepatic cholestasis of pregnancy (ICP) and oral contraceptive steroid (OCS) induced cholestasis. In five women with identified genetic mutations of such transporters, with eight observed pregnancies complicated by ICP, we examined relationships between transporter mutations, clinical phenotypes, and treatment outcomes. METHODS Gene mutation analysis for BA transporter deficiencies was performed using Next Generation/Sanger sequencing, with analysis for gene deletions/duplications. RESULTS Intrahepatic cholestasis of pregnancy was early-onset (9-32 weeks gestation) and severe (peak BA 74-370 μmol/L), with premature delivery (28+1 -370 weeks gestation) in 7/8 pregnancies, in utero passage of meconium in 4/8, but overall good perinatal outcomes, with no stillbirths. There was generally no response to ursodeoxycholic acid and variable responses to rifampicin and chelation therapies; naso-biliary drainage appeared effective in 2/2 episodes persisting post-partum in each of the two sisters. Episodic jaundice occurring spontaneously or provoked by non-specific infections, and OCS-induced cholestasis, had previously occurred in 3/5 women. Two cases showed biallelic heterozygosity for several ABCB11 mutations, one was homozygous for an ABCB4 mutation and a fourth case was heterozygous for another ABCB4 mutation. CONCLUSIONS Early-onset or recurrent ICP, especially with previous spontaneous or OCS-induced episodes of cholestasis and/or familial cholestasis, may be attributable to transporter mutations, including biallelic mutations of one or more transporters. Response to standard therapies for ICP is often incomplete; BA sequestering therapy or naso-biliary drainage may be effective. Optimized management can produce good outcomes despite premature birth and evidence of fetal compromise.
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Affiliation(s)
- Sze Pheh Yeap
- Liver Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hugh Harley
- Liver Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | | | | | - John Bate
- Liver Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Farah Sethna
- Department of Obstetrics and Gynaecology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Geoffrey Farrell
- Liver Research Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia.,The Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - William Bill Hague
- Obstetric Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia
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33
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Chao S, Xiaojun L, Haizhen W, Ludi F, Shaozhen L, Zhiwen S, Weiliang H, Chunhong J, Ying W, Fan W, Yunfei G. Lithocholic acid activates mTOR signaling inducing endoplasmic reticulum stress in placenta during intrahepatic cholestasis of pregnancy. Life Sci 2018; 218:300-307. [PMID: 30605648 DOI: 10.1016/j.lfs.2018.12.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/12/2018] [Accepted: 12/27/2018] [Indexed: 12/23/2022]
Abstract
AIMS Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific disorder, which increases risks of adverse fetal outcomes. However, the pathophysiology is not fully understood. Here, we explored the roles of mTOR signaling and ER stress in placenta during ICP. MATERIALS AND METHODS Placental tissues were collected from normal and ICP pregnancies. mTOR signaling and endoplasmic reticulum stress were detected by immunohistochemistry in the placenta. The human placenta trophoblast cell line HTR-8/SVneo was used in vitro experiment. KEY FINDINGS ICP placenta displayed histological abnormalities with fewer trophoblasts. Moreover, the expression of Bip and the phosphorylation of pS6(S235/236) or pAkt(S473) were higher comparing with normal placenta. In in vitro studies, the bile acids specifically to lithocholic acid rather than taurocholic acid or ursodeoxycholic acid, drastically increased the phosphorylation of pS6K1(T389), pS6(S235/236), or pAkt(S473), whereas the mTOR inhibitor can prohibit the upregulation. Similarly, the expressions of IRE1α and BiP increased sharply under lithocholic acid (20 μM) administration, while the same inhibitor can also decrease the expression. Additionally, transmission electron microscopy showed enlarged endoplasmic reticulum lumen under the lithocholic acid treatment. Furthermore, the cell viability reduced sharply under treatment with different dose of lithocholic acid. The mTOR inhibitor can reverse the decrease of cell viability to some extent. SIGNIFICANCE Bile acid can activate mTOR signaling which resulted in endoplasmic reticulum stress, leading to trophocyte viability decrease. mTOR pathway activation may be associated with the pathophysiology of ICP.
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Affiliation(s)
- Sheng Chao
- Division of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Lin Xiaojun
- Division of Pediatrics, The Third Affiliated Hospital of Guangzhou medical University, Guangzhou 510150, China
| | - Wang Haizhen
- Division of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Fu Ludi
- Laboratory Animal Center, Guangzhou university of Chinese Medicine, Guangzhou 510006, China
| | - Liang Shaozhen
- Division of Pediatrics, The Third Affiliated Hospital of Guangzhou medical University, Guangzhou 510150, China
| | - Su Zhiwen
- Division of Pediatrics, The Third Affiliated Hospital of Guangzhou medical University, Guangzhou 510150, China
| | - Huang Weiliang
- Division of Pediatrics, The Third Affiliated Hospital of Guangzhou medical University, Guangzhou 510150, China
| | - Jia Chunhong
- Division of Pediatrics, The Third Affiliated Hospital of Guangzhou medical University, Guangzhou 510150, China
| | - Wang Ying
- Department of Pharmacy, The Third Affiliated Hospital of Guangzhou medical University, Guangzhou 510150, China
| | - Wu Fan
- Division of Pediatrics, The Third Affiliated Hospital of Guangzhou medical University, Guangzhou 510150, China.
| | - Gao Yunfei
- Division of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.
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34
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Abstract
Importance Intrahepatic cholestasis of pregnancy (ICP) complicates approximately 0.2% to 2% of pregnancies and can lead to increased fetal risks in pregnancy. Objective This review aims to increase the knowledge of women's health care providers regarding the diagnosis, management, and fetal risks associated with ICP. Results The diagnosis of ICP is based on symptoms of pruritus that typically include the palms and soles, as well as elevated bile acid levels. Other liver function tests such as alanine aminotransferase and aspartate aminotransferase are also frequently elevated, and other causes of liver dysfunction should be ruled out. Fetal risks of ICP include increased risk of preterm birth, meconium-stained amniotic fluid, respiratory distress syndrome, or stillbirth. There is evidence that as bile acid levels increase, so does the risk of adverse neonatal outcomes. Ursodeoxycholic acid treatment has been shown to improve maternal pruritus symptoms, as well as biochemical tests, but no treatment has been shown to definitively improve fetal outcomes. Conclusions and Relevance Providers should be aware of the signs and symptoms of ICP and provide accurate diagnosis and management of affected women. Women with a diagnosis of ICP should be treated with ursodeoxycholic acid to improve maternal symptoms. Given the increased risk of stillbirth in the setting of ICP, delivery may be considered at 37 weeks' gestation.
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35
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Sharifzadehgan S, Hermann M, Nedellec S, De Luca D, Benachi A. Intrahepatic cholestasis of pregnancy: Shorter duration of labor? Eur J Obstet Gynecol Reprod Biol 2018; 225:258-259. [PMID: 29680685 DOI: 10.1016/j.ejogrb.2018.03.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/23/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Shervine Sharifzadehgan
- Division of Obstetrics and Gynecology, «Antoine Béclère» Medical Center, South Paris University Hospitals, APHP, Paris, France; South Paris-Saclay University, Medical School, Paris, France.
| | - Monika Hermann
- Division of Obstetrics and Gynecology, «Antoine Béclère» Medical Center, South Paris University Hospitals, APHP, Paris, France; South Paris-Saclay University, Medical School, Paris, France
| | - Sophie Nedellec
- Division of Obstetrics and Gynecology, «Antoine Béclère» Medical Center, South Paris University Hospitals, APHP, Paris, France
| | - Daniele De Luca
- South Paris-Saclay University, Medical School, Paris, France; Division of Pediatrics and Neonatal Intensive Care Unit, «Antoine Béclère» Medical Center, South Paris University Hospitals, APHP, Paris, France
| | - Alexandra Benachi
- Division of Obstetrics and Gynecology, «Antoine Béclère» Medical Center, South Paris University Hospitals, APHP, Paris, France; South Paris-Saclay University, Medical School, Paris, France
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36
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Jurate K, Rimantas Z, Jolanta S, Vladas G, Limas K. Sensitivity and Specificity of Biochemical Tests for Diagnosis of Intrahepatic Cholestasis of Pregnancy. Ann Hepatol 2018; 16:569-573. [PMID: 28611260 DOI: 10.5604/01.3001.0010.0294] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Intrahepatic cholestasis of pregnancy (ICP) is linked with increased risk of fetal complications. An accurate diagnostic test is needed to diagnose this disorder on time. We aimed to assess sensitivity and specificity of laboratory tests used for diagnosis of intrahepatic cholestasis of pregnancy and determine more reliable cut-off values of transaminases. MATERIAL AND METHODS Sixty one symptomatic patients with ICP and 29 healthy pregnant women were included in the retrospective analysis. RESULTS ICP patients had higher total bile acids (TBA) levels than healthy women (32 vs. 6; P < 0.0001) due to increase in cholic acid (CA) and chenodeoxycholic acid (CDCA). CA/CDCA ratio was significantly higher in ICP patients compared to healthy pregnant women (1.13 vs. 0.68; P < 0.00002). TBA, CA, CDCA and CA/CDCA ratio demonstrate the following sensitivity (94%, 96%, 89%, 71.9%) and specificity (63%, 63%, 59%, 79.3%, respectively) for ICP diagnosis. Lowering cut-off values for ALT (31 U/L) and AST (30 U/L) resulted only in minimal increase of sensitivity to 92.2% vs. 90.1% for ALT and to 92.2%, vs. 90.6% for AST. CONCLUSION The present study did not reveal any single specific and sensitive marker for reliable diagnosis of ICP. Establishment of lower cut-off values for transaminases activity might only minimally increase the accuracy of diagnosing ICP.
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Affiliation(s)
- Kondrackiene Jurate
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Sumskiene Jolanta
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Gintautas Vladas
- Department of Obstetrics and Gynecology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kupcinskas Limas
- Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Audet-Delage Y, Villeneuve L, Grégoire J, Plante M, Guillemette C. Identification of Metabolomic Biomarkers for Endometrial Cancer and Its Recurrence after Surgery in Postmenopausal Women. Front Endocrinol (Lausanne) 2018; 9:87. [PMID: 29593653 PMCID: PMC5857535 DOI: 10.3389/fendo.2018.00087] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/23/2018] [Indexed: 11/24/2022] Open
Abstract
Endometrial cancer (EC) is the most frequent gynecological cancer in developed countries. Most EC occurs after menopause and is diagnosed as endometrioid (type I) carcinomas, which exhibit a favorable prognosis. In contrast, non-endometrioid (type II) carcinomas such as serous tumors have a poor prognosis. Our goal was to identify novel blood-based markers associated with EC subtypes and recurrence after surgery in postmenopausal women. Using mass spectrometry-based untargeted metabolomics, we examined preoperative serum metabolites among control women (n = 18) and those with non-recurrent (NR) and recurrent (R) cases of type I endometrioid (n = 24) and type II serous (n = 12) carcinomas. R and NR cases were similar with respect to pathological characteristics, body mass index, and age. A total of 1,592 compounds were analyzed including 14 different lipid classes. When we compared EC cases with controls, 137 metabolites were significantly different. A combination of spermine and isovalerate resulted in an age-adjusted area under the receiver-operating characteristic curve (AUCadj) of 0.914 (P < 0.001) for EC detection. The combination of 2-oleoylglycerol and TAG42:2-FA12:0 allowed the distinction of R cases from NR cases with an AUCadj of 0.901 (P < 0.001). Type I R cases were also characterized by much lower levels of bile acids and elevated concentrations of phosphorylated fibrinogen cleavage peptide, whereas type II R cases displayed higher levels of ceramides. The findings from our pilot study provide a detailed metabolomics study of EC and identify putative serum biomarkers for defining clinically relevant risk groups.
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Affiliation(s)
- Yannick Audet-Delage
- Centre Hospitalier Universitaire (CHU) de Québec Research Center, Faculty of Pharmacy, Laval University, Québec, QC, Canada
| | - Lyne Villeneuve
- Centre Hospitalier Universitaire (CHU) de Québec Research Center, Faculty of Pharmacy, Laval University, Québec, QC, Canada
| | - Jean Grégoire
- Gynecologic Oncology Service, CHU de Québec, Department of Obstetrics, Gynecology, and Reproduction, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Marie Plante
- Gynecologic Oncology Service, CHU de Québec, Department of Obstetrics, Gynecology, and Reproduction, Faculty of Medicine, Laval University, Québec, QC, Canada
| | - Chantal Guillemette
- Centre Hospitalier Universitaire (CHU) de Québec Research Center, Faculty of Pharmacy, Laval University, Québec, QC, Canada
- Canada Research Chair in Pharmacogenomi, Laval University, Québec, QC, Canada
- *Correspondence: Chantal Guillemette,
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38
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Lin J, Gu W, Hou Y. Diagnosis and prognosis of early-onset intrahepatic cholestasis of pregnancy: a prospective study. J Matern Fetal Neonatal Med 2017; 32:997-1003. [PMID: 29065754 DOI: 10.1080/14767058.2017.1397124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To explore the gestational age of early-onset intrahepatic cholestasis (ICP) of pregnancy, and to analyze the relationship between the clinical biochemical indices and pregnancy outcomes in order to arrive at a reasonable diagnosis and administer appropriate treatment. DESIGN This is a retrospective clinical study. POPULATION OR SAMPLE We selected 47,260 pregnant women who received prenatal care and underwent childbirth at the International Peace Maternity and Child Health Hospital affiliated to Shanghai Jiao Tong University from January 2014 to December 2016 for participating in this study. Of these 47,260 women, 407 developed ICP. METHODS To calculate the gestational week cutoff between early- and late-onset ICP by the receiver-operating characteristic (ROC) curve and Youden's index. Two independent samples t tests and chi square test were used to compare the differences in biochemical indices and pregnancy outcomes between the two groups. RESULTS We found that 34 weeks is the most appropriate cutoff gestational age for the diagnosis of early-onset ICP. Early-onset ICP is characterized by early onset, long disease duration and a higher incidence of preterm labor, fetal distress, and fetal low birth weight compared to late-onset ICP. CONCLUSIONS Thirty-four weeks is the most appropriate cutoff gestational age for the diagnosis of early-onset ICP. And to reduce the adverse pregnancy outcomes in cases of early-onset ICP, we suggest prolonging gestation up to 37 weeks as far as possible before selecting iatrogenic birth.
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Affiliation(s)
- Jing Lin
- a Department of Obstetrics, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University School of Medicine , Shanghai , China
| | - Wei Gu
- a Department of Obstetrics, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University School of Medicine , Shanghai , China
| | - Yanyan Hou
- a Department of Obstetrics, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University School of Medicine , Shanghai , China
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Mei Y, Gao L, Lin Y, Luo D, Zhou X, He L. Predictors of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy with dichorionic diamniotic twin pregnancies. J Matern Fetal Neonatal Med 2017; 32:472-476. [PMID: 29020816 DOI: 10.1080/14767058.2017.1384461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Youwen Mei
- Chengdu’s Women and Children’s Central Hospital, Chengdu, China
| | - Lan Gao
- Chengdu’s Women and Children’s Central Hospital, Chengdu, China
| | - Yonghong Lin
- Chengdu’s Women and Children’s Central Hospital, Chengdu, China
| | - Dan Luo
- Chengdu’s Women and Children’s Central Hospital, Chengdu, China
| | - Xine Zhou
- Chengdu’s Women and Children’s Central Hospital, Chengdu, China
| | - Li He
- Chengdu’s Women and Children’s Central Hospital, Chengdu, China
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40
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Abstract
The aim of the present work was to determine maternal and fetal outcomes of intrahepatic cholestasis of pregnancy (ICP) in twin pregnancies. All twin pregnancies delivered above 28 gestational weeks in West China Second University Hospital from January 2013 to May 2015 were included. Data on maternal demographics and obstetric complications together with fetal outcomes were collected. The risk of adverse maternal and fetal outcomes were determined in relation to ICP by crude odds ratios (OR) and adjusted ORs (aOR) with 95% confidence intervals (CI). Subgroup analysis concentrated on the effect of assisted reproductive technology (ART), ICP severity, and onset time. A total of 1,472 twin pregnancies were included, of which 362 were cholestasis patients and 677 were conceived by ART. Higher rates of preeclampsia (aOR 1.96; 95% CI 1.35, 2.85), meconium-stained amniotic fluid (aOR 3.10; 95% CI 2.10, 4.61), and preterm deliveries (aOR 3.20; 95% CI 2.35, 4.37) were observed in ICP patients. Subgroup analysis revealed higher incidences of adverse outcomes in severe and early onset ICP groups. In conclusion, adverse maternal and fetal outcomes were strongly associated with ICP in twin patients. Active management and close antenatal monitoring are needed, especially in the early onset and severe groups.
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41
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Huang GQ, Wang XD. New insights into diagnosis and treatment of intrahepatic cholestasis of pregnancy. Shijie Huaren Xiaohua Zazhi 2016; 24:3749-3756. [DOI: 10.11569/wcjd.v24.i26.3749] [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] [Indexed: 02/06/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific disease, characterized by maternal pruritus and abnormal serum biochemistries in the late second and third trimester of pregnancy. The symptoms and abnormal biochemistries resolve rapidly after fetal delivery. As a diagnosis of exclusion, the diagnosis of ICP is based on unexplained pruritus with other causes and impaired liver function presenting with elevated serum liver transaminases and/or bile acids. It is considered as severe ICP when bile acid ≥ 40 μmol/L during pregnancy. The pathogenesis of ICP is still unclear. Adverse perinatal outcomes associated with ICP are focused on increased risk of preterm, meconium-stained amniotic fluid, and perinatal mortality. Unpredictable fetal hypoxia may result in intrauterine fetal death, fetal distress during birth and even stillbirth, and lead to an increase of iatrogenic preterm and cesarean section. The etiology and pathogenesis of fetal stress in ICP are not yet clarified, which may be associated with impaired infrastructure and decreased stress-compensatory in human utero-placental-fetal unit, and related with vascular constriction of chorionic veins and umbilical cord due to elevated bile acids in fetal serum and amniotic fluid. The essential measures of standard treatment of ICP include: (1) monitoring and evaluation of disease, uterine contraction and fetus; (2) prevention and treatment of uterine contraction; (3) treatment with ursodeoxycholic acid (500-1500 mg/d) alone or in combination with S-adenosylmehionine (800-1000 mg/d) or rifampicin (300-1200 mg/d) to promote drainage of bile acids; (4) promotion of fetal growth and lung development; (5) treatment with vitamin K1 before delivery to prevent maternal and fetal hemorrhage; (6) and timely termination of pregnancy. Gestational weeks, fetal condition and severity of disease need to be taken into account when obstetricians decide the time of termination. Elective early delivery is still an effective measure to avoid stillbirth during prolongation of gestational weeks.
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Abstract
Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease during pregnancy, characterized by otherwise unexplained pruritus in late second and third trimester of pregnancy and elevated bile acids and/or transaminases. ICP is associated with an increased risk of adverse perinatal outcomes for the fetus and the later development of hepatobiliary disease for the mother. Bile acids should be monitored throughout pregnancy since fetal risk is increased at serum bile acids >40 µmol/l. Management of ICP consists of treatment with ursodeoxycholic acid, which reduces pruritus. Early elective delivery is common practice but should be performed on an individualized basis as long as strong evidence supporting this practice is lacking. Mothers should be followed-up for normalization of liver function tests 6-12 weeks after delivery. Future research in large-scale studies is needed to address the impact of ursodeoxycholic acid and early elective delivery on fetal outcome.
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Affiliation(s)
- Hanns-Ulrich Marschall
- a Department of Molecular and Clinical Medicine, University of Gothenburg, Sahlgrenska Academy, Institute of Medicine, S-41345 Gothenburg, Sweden
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Abstract
Intrahepatic cholestasis of pregnancy (ICP) is characterized by maternal pruritus, and elevated serum transaminases and bile acids. Genetic defects in at least 6 canalicular transporters have been found. Association studies stress the variability of genotypes, different penetrance, and influence of environmental factors. Serum autotaxin is a sensitive, specific, and robust diagnostic marker. Elevated maternal bile acids correlate with fetal complications. Long-term sequelae for mothers include the gallstone risk and chronic liver disease. There is an association between ICP and hepatitis C. Current treatment is ursodeoxycholic acid, owing to benefits on pruritus, liver function, safety, and decreased rates of adverse effects.
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Affiliation(s)
- Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani, 2, Padova 35128, Italy.
| | - Maria Teresa Gervasi
- Department of Obstetrics and Gynecology, Azienda Ospedaliera, Via Giustiniani, 2, Padova 35128, Italy
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Early induction of labor in high-risk intrahepatic cholestasis of pregnancy: what are the costs? Arch Gynecol Obstet 2016; 294:709-14. [PMID: 26825731 DOI: 10.1007/s00404-016-4019-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/08/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE Induction of labor among pregnant women with high levels of total bile acid (TBA) is common among clinicians. We examined, if women with intrahepatic cholestasis of pregnancy (ICP) and TBA ≥ 40 μmol/l have a higher risk of maternal-fetal complications, when labor is induced at 37 weeks of gestation, compared with induction of labor at term in women with low-risk ICP. METHODS Retrospective cohort study of 16,185 women delivering at Roskilde University Hospital in the period 2006-2011. Women with high-risk ICP (TBA ≥ 40 μmol/l) had labor induced at 37 weeks of gestation; women with low-risk ICP (TBA < 40 μmol/l) at term. OUTCOMES Mode of delivery, duration of induction procedures, highest level of TBA and alanine aminotransferase (ALT) and for the neonates: Apgar scores at 5 min, umbilical cord pHs and SBEs, NICU admissions and birthweights. RESULTS The incidences of ICP was 1.2 % (95 % CI 1.05-1.39 %) altogether and for high-risk ICP 0.4 % (95 % CI 0.27-0.46 %). No difference was found in mode of delivery, length of induction of labor nor in neonatal outcomes, except for an expected difference in birthweight. In high-risk ICP, ALT was not raised in 10.3 % (95 % CI 2.5-18.2 %). CONCLUSION Early induction of labor at 37 weeks of gestation seems justified in high-risk ICP, as, except for abbreviating gestational age by 9 days with 296 g smaller babies, induction of labor was not followed by detectable maternal-fetal disadvantages and is favored by an expected major reduction in ICP stillbirth risk.
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Grymowicz M, Czajkowski K, Smolarczyk R. Pregnancy course in patients with intrahepatic cholestasis of pregnancy treated with very low doses of ursodeoxycholic acid. Scand J Gastroenterol 2016; 51:78-85. [PMID: 26152830 DOI: 10.3109/00365521.2015.1064990] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Ursodeoxycholic acid (UDCA) has been proposed as the optimal pharmacological treatment for intrahepatic cholestasis of pregnancy (ICP). The lowest effective dosage of UDCA in women with ICP has not been established. The objective is to determine the risk of adverse pregnancy outcomes resulting from ICP and to measure changes in liver function parameters and pruritus severity in ICP patients treated with low doses of UDCA. MATERIAL AND METHODS ICP was diagnosed in 203 patients on the basis of pruritus and elevated liver biochemical parameters. Patients with total bile acids (TBA) ≥ 10 μmol/l (n = 157) received UDCA (300-450 mg/day; 4-6 mg/kg/day) until delivery. Maternal and fetal outcomes of women with ICP were compared with 100 patients without cholestasis. Patients with ICP were hospitalized for treatment and fetal surveillance. RESULTS There was no correlation between fetal and neonatal complication rates in ICP patients and biochemical markers of cholestasis. Significant declines in serum TBA (p = 0.003), bilirubin concentration (p = 0.026) and aminotransferase activity (p < 0.001) were observed during treatment with low doses of UDCA. Moreover, severity of pruritus was ameliorated during the 2 weeks of therapy (p = 0.037). A total of 17 patients (10.9%) did not respond to treatment. CONCLUSIONS UDCA at low doses improved biochemical markers and clinical symptoms in almost 90% of ICP patients.
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Affiliation(s)
- Monika Grymowicz
- a 1 Department of Gynecological Endocrinology, Warsaw Medical University , Warsaw, Poland
| | - Krzysztof Czajkowski
- b 2 II Department of Obstetrics and Gynaecology, Warsaw Medical University , Warsaw, Poland
| | - Roman Smolarczyk
- a 1 Department of Gynecological Endocrinology, Warsaw Medical University , Warsaw, Poland
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Liu X, Landon MB, Chen Y, Cheng W. Perinatal outcomes with intrahepatic cholestasis of pregnancy in twin pregnancies. J Matern Fetal Neonatal Med 2015; 29:2176-81. [PMID: 26364658 DOI: 10.3109/14767058.2015.1079612] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To describe perinatal outcomes of twin pregnancies complicated by intrahepatic cholestasis of pregnancy (ICP). METHODS We conducted a retrospective cohort study of women delivered at a large tertiary obstetric center in Shanghai, China from January 2006 to May 2014. Delivery data were abstracted from medical records of all twin gestations delivered at the hospital. RESULTS A total of 129/1922(6.7%) twin and 1190/92 273 singleton (1.3%) pregnancies were complicated by ICP. An increased risk of stillbirth among twin pregnancies was observed (3.9% and 0.8% in the ICP and non-ICP groups, respectively; aOR 5.75, 95% CI 2.00-16.6). Stillbirths with ICP and twins occurred between 33 and 35 weeks gestation compared to 36-38 weeks gestation among singletons. ICP in twins was also associated with an increased risk of preterm birth (<37 weeks) with an aOR of 4.17 (95% CI 2.47-7.04) and an aOR of 1.89 (95% CI 1.26-2.85) for delivery <35 weeks. Twin pregnancies complicated by ICP also had increased meconium staining of amniotic fluid and lower birth weight. CONCLUSIONS Twin pregnancies with ICP have significantly increased risks of adverse perinatal outcomes including stillbirth and preterm birth. Stillbirth occurs at an earlier gestational age in twin gestation compared to singletons, suggesting that earlier scheduled delivery should be considered in these women.
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Affiliation(s)
- Xiaohua Liu
- a Obstetrics Department , International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University , Shanghai , China and
| | - Mark B Landon
- b Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology , The Ohio State University College of Medicine , OH , USA
| | - Yan Chen
- a Obstetrics Department , International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University , Shanghai , China and
| | - Weiwei Cheng
- a Obstetrics Department , International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University , Shanghai , China and
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Zhang XQ, Zhang LJ, Yang WH, Draper ML. Effect of the maternal-fetal interface immunoregulation on the occurrence of intrahepatic cholestasis of pregnancy. World J Obstet Gynecol 2015; 4:40-45. [DOI: 10.5317/wjog.v4.i2.40] [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: 10/27/2014] [Revised: 01/14/2015] [Accepted: 02/02/2015] [Indexed: 02/05/2023] Open
Abstract
Maternal immune tolerance of the fetus is indispensable for a healthy pregnancy. Currently, the study of the immune microenvironment of the maternal-fetal interface has been a heated topic in reproductive immunology research. More and more studies show that the immune imbalance in the maternal-fetal interface plays a very important role in the incidence of intrahepatic cholestasis of pregnancy (ICP). However, the precise etiology and mechanism of immune imbalance in the occurrence of ICP is still unknown. In order to clarify the potential immunologic mechanisms of ICP, this review summarizes the recent studies of the decidual immunology microenvironment and the potential immunologic mechanisms related to the development of ICP.
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Puljic A, Kim E, Page J, Esakoff T, Shaffer B, LaCoursiere DY, Caughey AB. The risk of infant and fetal death by each additional week of expectant management in intrahepatic cholestasis of pregnancy by gestational age. Am J Obstet Gynecol 2015; 212:667.e1-5. [PMID: 25687562 DOI: 10.1016/j.ajog.2015.02.012] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 01/17/2015] [Accepted: 02/09/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of the study was to characterize the risk of infant and fetal death by each additional week of expectant management vs immediate delivery in pregnancies complicated by cholestasis. STUDY DESIGN This was a retrospective cohort study of 1,604,386 singleton, nonanomalous pregnancies of women between 34 and 40 weeks' gestation with and without intrahepatic cholestasis of pregnancy (ICP) in the state of California during the years of 2005-2008. International Classification of Diseases, 9th version, codes and linked hospital discharge and vital statistics data were utilized. For each week of gestation, the following outcomes were assessed: the risk of stillbirth, the risk of delivery (represented by the risk of infant death at a given week of gestation), and the composite risk of expectant management for 1 additional week. Composite risk combines the risk of stillbirth at this gestational age week plus the risk of infant death if delivered at the subsequent week of gestation. RESULTS Among women with ICP, the mortality risk of delivery is lower than the risk of expectant management at 36 weeks' gestation (4.7 vs 19.2 per 10,000). The risk of expectant management remains higher than delivery and continues to rise by week of gestation beyond 36 weeks. The risk of expectant management in women with ICP reaches a nadir at 35 weeks (9.1 per 10,000; 95% confidence interval, 1.4-16.9) and rises at 36 weeks (19.2 per 10,000; 95% confidence interval, 7.6-30.8). CONCLUSION Among women with ICP, delivery at 36 weeks' gestation would reduce the perinatal mortality risk as compared with expectant management. For later diagnoses, this would also be true at gestational ages beyond 36 weeks. Timing of delivery must take into account both the reduction in stillbirth risk balanced with the morbidities associated with preterm delivery.
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Sargın Oruç A, Seçkin B, Özcan N, Özyer S, Uzunlar Ö, Danışman N. Role of postprandial bile acids in prediction of perinatal outcome in intrahepatic cholestasis of pregnancy. J Obstet Gynaecol Res 2015; 40:1883-9. [PMID: 25056466 DOI: 10.1111/jog.12444] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 03/03/2014] [Indexed: 12/27/2022]
Abstract
AIM The aim of this study was to investigate the role of fasting and postprandial total bile acids (fTBA, ppTBA) in prediction of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy (ICP). MATERIAL AND METHODS A total of 111 patients, 57 with ICP and 54 controls, were evaluated for preterm birth (PTB), meconium-stained amnion (MSA), neonatal intensive-care unit admission and asphyxia. We further classified the ICP group as mild and severe. Logistic regression was performed to evaluate the associated biochemical and clinical parameters with adverse perinatal outcomes. RESULTS In the ICP group, PTB, asphyxia, admission to neonatal intensive-care unit, and MSA were more frequently observed (P = 0.001, P = 0.027, P = 0.006 and P = 0.030, respectively). In subgroup analysis, PTB was more frequent in severe ICP cases than in mild cases (P = 0.028). Fasting and ppTBA were positively correlated with serum aspartate aminotransferase and alanine aminotransferase levels. Postprandial TBA and difference between fasting and postprandial TBA levels were associated with asphyxia (P = 0.014 and P = 0.023, respectively). Gestational age at diagnosis and fTBA were associated with adverse perinatal outcomes (P = 0.001 and P = 0.025, respectively). CONCLUSION Postprandial TBA and difference of fasting and postprandial TBA are associated with asphyxia in ICP. The gestational age at diagnosis and fTBA are associated with adverse perinatal outcomes.
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Affiliation(s)
- Ayla Sargın Oruç
- Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
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Ersoy AO, Kirbas A, Ozler S, Ersoy E, Ozgu-Erdinc AS, Ergin M, Erkaya S, Uygur D, Danisman N. Maternal and fetal serum levels of caspase-cleaved fragments of cytokeratin-18 in intrahepatic cholestasis of pregnancy. J Matern Fetal Neonatal Med 2015; 29:562-6. [PMID: 25666739 DOI: 10.3109/14767058.2015.1011116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We aimed to investigate the relationship between intrahepatic cholestasis of pregnancy (ICP) and caspase-cleaved fragments of cytokeratin-18, also referred to as M30, a marker of apoptosis. METHODS In this case-control study, maternal and umbilical cord blood venous samples were obtained from 21 pregnant women with ICP and 22 healthy pregnant women as a control group. M30 levels were compared among the groups. RESULTS Maternal serum M30 levels were significantly higher in the severe ICP group than in the control (p < 0.001) and mild ICP groups (p = 0.006). The values were comparable between the mild ICP and the control groups. The umbilical cord serum M30 levels were also significantly greater in the severe ICP group than in the control group (p = 0.001). CONCLUSIONS Changes in M30 levels, as an apoptosis marker, may shed light on the pathogenesis of ICP. Explaining the mechanisms of bile acid (BA)-induced hepatocyte injury may contribute further therapeutic strategies for the treatment of human cholestatic diseases.
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Affiliation(s)
- Ali Ozgur Ersoy
- a Department of Perinatology , Zekai Tahir Burak Women's Health Care, Training and Research Hospital , Ankara , Turkey and
| | - Ayse Kirbas
- a Department of Perinatology , Zekai Tahir Burak Women's Health Care, Training and Research Hospital , Ankara , Turkey and
| | - Sibel Ozler
- a Department of Perinatology , Zekai Tahir Burak Women's Health Care, Training and Research Hospital , Ankara , Turkey and
| | - Ebru Ersoy
- a Department of Perinatology , Zekai Tahir Burak Women's Health Care, Training and Research Hospital , Ankara , Turkey and
| | - A Seval Ozgu-Erdinc
- a Department of Perinatology , Zekai Tahir Burak Women's Health Care, Training and Research Hospital , Ankara , Turkey and
| | - Merve Ergin
- b Department of Biochemistry , Ataturk Education and Research Hospital , Ankara , Turkey
| | - Salim Erkaya
- a Department of Perinatology , Zekai Tahir Burak Women's Health Care, Training and Research Hospital , Ankara , Turkey and
| | - Dilek Uygur
- a Department of Perinatology , Zekai Tahir Burak Women's Health Care, Training and Research Hospital , Ankara , Turkey and
| | - Nuri Danisman
- a Department of Perinatology , Zekai Tahir Burak Women's Health Care, Training and Research Hospital , Ankara , Turkey and
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