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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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Li X, Liang X, Gu X, Zou M, Cao W, Liu C, Wang X. Ursodeoxycholic acid and 18β-glycyrrhetinic acid alleviate ethinylestradiol-induced cholestasis via downregulating RORγt and CXCR3 signaling pathway in iNKT cells. Toxicol In Vitro 2024; 96:105782. [PMID: 38244730 DOI: 10.1016/j.tiv.2024.105782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/04/2023] [Accepted: 01/15/2024] [Indexed: 01/22/2024]
Abstract
Estrogen-induced intrahepatic cholestasis (IHC) is a mild but potentially serious risk and urges for new therapeutic targets and effective treatment. Our previous study demonstrated that RORγt and CXCR3 signaling pathway of invariant natural killer T (iNKT) 17 cells play pathogenic roles in 17α-ethinylestradiol (EE)-induced IHC. Ursodeoxycholic acid (UDCA) and 18β-glycyrrhetinic acid (GA) present a protective effect on IHC partially due to their immunomodulatory properties. Hence in present study, we aim to investigate the effectiveness of UDCA and 18β-GA in vitro and verify the accessibility of the above targets. Biochemical index measurement indicated that UDCA and 18β-GA presented efficacy to alleviate EE-induced cholestatic cytotoxicity. Both UDCA and 18β-GA exhibited suppression on the CXCL9/10-CXCR3 axis, and significantly restrained the expression of RORγt in vitro. In conclusion, our observations provide new therapeutic targets of UDCA and 18β-GA, and 18β-GA as an alternative treatment for EE-induced cholestasis.
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Affiliation(s)
- Xinyu Li
- State Key Laboratory of Natural Medicines, New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Xiaojing Liang
- State Key Laboratory of Natural Medicines, New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Xiaoxia Gu
- Department of Obstetrics and Gynecology, Zhongda Hospital, Southeast University, Nanjing 210009, China
| | - Mengzhi Zou
- State Key Laboratory of Natural Medicines, New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China
| | - Weiping Cao
- Departments of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang 212001, China.
| | - Chunhui Liu
- Physics and Chemistry Test Center of Jiangsu Province, 210042 Nanjing, China.
| | - Xinzhi Wang
- State Key Laboratory of Natural Medicines, New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, 210009, China.
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Obiegbusi CN, Dong XJ, Obiegbusi SC, Jin X, Okoene IK. Predictors of Adverse Fetal Outcomes in Intrahepatic Cholestasis of Pregnancy (ICP): a Narrative Review. Reprod Sci 2024; 31:341-351. [PMID: 37626275 DOI: 10.1007/s43032-023-01329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023]
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a hepatic disorder in pregnancy linked with adverse fetal outcomes, which primarily manifests in the late second and third trimesters of pregnancy. This review aims to recapitulate the existing evidence on factors that can predict detrimental perinatal outcomes in pregnant women diagnosed with intrahepatic cholestasis of pregnancy. We searched PubMed, Web of Science, Cochrane Library, Scopus, Medline, and Embase databases and selected studies related to predictors of fetal outcome in intrahepatic cholestasis of pregnancy. Studies of the articles showed that predictors of an adverse fetal outcome include in vitro fertilization (IVF) pregnancy, multifetal pregnancy, biochemical markers, gestational age of ICP onset, presence of comorbidities (preeclampsia and gestational diabetes mellitus), maternal history of ICP, and hepatobiliary disease.Intrahepatic cholestasis of pregnancy (ICP) complicates the pregnancy. Hence, early assessment of low-risk and high-risk groups will help to administer definite management protocols and strategies to prevent adverse neonatal outcomes. Further research should concentrate on the number of conditions/factors and the predictive power of different factors to determine the most reliable predictors and biomarkers that can predict adverse fetal outcomes and improve the assessment of risk in pregnancy complicated with ICP.
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Affiliation(s)
- Chidera Nneji Obiegbusi
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Jing Dong
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Samuel Chigbo Obiegbusi
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Jin
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Huang L, Li X, Liu T, Wei L, Fan C, Tang D, Xiong W, Li Y, Wei S, Xiong Z. Effect of intrahepatic cholestasis of pregnancy on infantile food allergy: A retrospective longitudinal study cohort in Southwest China. Eur J Obstet Gynecol Reprod Biol 2022; 272:110-115. [PMID: 35303672 DOI: 10.1016/j.ejogrb.2022.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/14/2022] [Accepted: 03/11/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Intrahepatic cholestasis of pregnancy has been consistently associated with a higher incidence of adverse pregnancy outcomes. Previous studies mainly focused on the effects of intrahepatic cholestasis of pregnancy on pregnant mothers and fetuses, and few studies reported the postpartum growth and development of fetuses in pregnant women with intrahepatic cholestasis of pregnancy. The aim of this study was to investigate impact of maternal serum total bile acid levels on maternal and neonatal outcomes as well as child growth and food allergy. MATERIAL AND METHODS A retrospective longitudinal cohort investigation was carried out among 751 pregnant women with intrahepatic cholestasis of pregnancy at 30-32 weeks of gestation from the Longitudinal Intrahepatic Cholestasis of Pregnancy Study (LoICPS). Data on the characteristics of the mothers and neonates were collected. Infant growth data and food sensitivities were also collected. RESULTS In our cohort, the average maternal serum total bile acid level was 35.09±30.02 μmol/L, with 58.8% of mothers suffering from mild intrahepatic cholestasis of pregnancy and 29.2% suffering from severe intrahepatic cholestasis of pregnancy. Positive correlations were found between maternal serum total bile acid levels and twin pregnancy (beta-value: 11.55, 95% CI: 2.89 - 20.20. P = 0.009) and meconium stained amniotic fluid (beta-value: 14.64, 95% CI: 9.41 - 19.87. P < 0.001). In addition, the infants of mothers with severe intrahepatic cholestasis of pregnancy were more likely to be allergic to foods at 6 months. CONCLUSIONS This study suggested that despite pregnant women with intrahepatic cholestasis of pregnancy taking ursodeoxycholic acid tablets and cesarean section before expected date of childbirth, the perinatal outcome of newborns partially improving, the incidence of infantile food allergy was still increased.
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Affiliation(s)
- Liqiong Huang
- The Second Affiliated Hospital of Chongqing Medical University, Chongqing 610000, China; Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, China
| | - Xin Li
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, China
| | - Tianjiao Liu
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, China
| | - Lu Wei
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, China
| | - Conghong Fan
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, China
| | - Dongmei Tang
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, China
| | - Wen Xiong
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, China
| | - Yalan Li
- The Fourth People's Hospital of Chengdu, School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, China.
| | - Sumei Wei
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, China.
| | - Zhengai Xiong
- The Second Affiliated Hospital of Chongqing Medical University, Chongqing 610000, China.
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Dick MH, Brotman M. Placental Abruption and Partial Placental Prolapse During Induction of Labor in a 31-Year-Old Female With Intrahepatic Cholestasis of Pregnancy: A Case Report. Cureus 2022; 14:e23995. [PMID: 35547439 PMCID: PMC9085450 DOI: 10.7759/cureus.23995] [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] [Accepted: 04/09/2022] [Indexed: 11/13/2022] Open
Abstract
Placental abruption during induction of labor in females with intrahepatic cholestasis of pregnancy is not exceptionally common and there are no documented reports of placental prolapse following abruption in the literature. The aim of this study is to discuss the possibility of placental abruption and partial prolapse of a low-lying placenta during a prolonged induction of labor in a female with recurrent intrahepatic cholestasis of pregnancy following a cholecystectomy. We describe a 31-year-old G4P3003 female with recurrent intrahepatic cholestasis of pregnancy, with no family history of the condition and surgical history of cholecystectomy, whose induction of labor at 37+3/7 gestational weeks for intrahepatic cholestasis of pregnancy was complicated by placental abruption and partial prolapse of the low-lying placenta. Emergency cesarean section was required for the delivery of her healthy baby. Postpartum was complicated by severe postpartum hemorrhage, post-hemorrhagic anemia, hypotension, blood transfusion reaction, endometritis, and pneumonia. The pathophysiology of intrahepatic cholestasis of pregnancy is not fully understood. Intrahepatic cholestasis of pregnancy increases maternal morbidity, may reoccur in subsequent pregnancies, and is associated with adverse perinatal outcomes. Timely intervention at 37-38 gestational weeks can reduce adverse fetal and maternal outcomes. This case report supports the possibility of 1) a correlation between cholecystectomy and the continued recurrence of intrahepatic cholestasis of pregnancy, 2) placental abruption, and 3) partial prolapse of a low-lying placenta, related to the induction of labor in females with intrahepatic cholestasis of pregnancy. Thus, encouraging further studies to facilitate a greater level of understanding.
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Blumenfeld J, Koo K. Navigating Uncertainty: A Case Study of Intrahepatic Cholestasis of Pregnancy. J Midwifery Womens Health 2022; 67:398-402. [PMID: 35373493 PMCID: PMC9321066 DOI: 10.1111/jmwh.13362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/06/2022] [Accepted: 02/18/2022] [Indexed: 11/07/2022]
Abstract
Intrahepatic cholestasis of pregnancy (ICP), the most common liver disorder of pregnancy, is associated with complications for both a pregnant person and their fetus. The underlying cause is not well understood. The pruritus associated with ICP is uncomfortable for pregnant people; however, the primary concern is the fetal risk. Fetal risks include preterm labor and birth and intrauterine fetal demise. This is particularly significant for certain populations because of the disparities in incidence of ICP; in the United States, it disproportionately affects Latinx people, the largest and fastest‐growing minority population. Diagnosis, monitoring, and treatment of ICP are vital to reduce discomfort from pruritis and avoid potential fetal demise. However, diagnosis and treatment are complicated by the lack of definitive diagnostic criteria, the frequent delay in laboratory analysis, and the cost of treatment. This case report aims to improve midwives’ familiarity with ICP and discusses the epidemiology, risk factors, presentation, diagnostic criteria, and available management strategies for this disease as well as the importance of anticipatory guidance regarding increased lifetime risk of ICP in future pregnancies and hepatobiliary disease. Additionally, it discusses the challenges involved in diagnosis and access to treatment. Prompt diagnosis and initiation of treatment may reduce fetal morbidity and mortality.
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Affiliation(s)
- Julie Blumenfeld
- Midwifery Program, Division of Advanced Nursing PracticeRutgers School of NursingNewarkNew Jersey
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Mohan M, Prabhu SS, Pullattayil AK, Lindow S. A meta-analysis of the prevalence of gestational diabetes in patients diagnosed with obstetrical cholestasis. AJOG GLOBAL REPORTS 2021; 1:100013. [PMID: 36277255 PMCID: PMC9563540 DOI: 10.1016/j.xagr.2021.100013] [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] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Gestational diabetes and obstetrical cholestasis are common clinical conditions seen in clinical practice. There is evidence suggesting a coexisting relationship that could have a potential clinical implication related to stillbirth outcomes. OBJECTIVE This study aimed to determine the prevalence of gestational diabetes in women with obstetrical cholestasis. STUDY DESIGN A predefined protocol with a literature search was used to obtain all possible articles. A systematic review and meta-analysis of observational studies with quantifiable data published since 2010 were performed. Articles were evaluated and included in the study with specified criteria for the risk of bias using the Newcastle-Ottawa Scale. A meta-analysis was performed using Meta-analysis of Observational Studies in Epidemiology specifications to determine the prevalence of gestational diabetes in women with obstetrical cholestasis. RESULTS A total of 16,748 patients with obstetrical cholestasis from 21 studies were included. The prevalence of gestational diabetes in women with obstetrical cholestasis was 13.9% (20 studies analyzed). Gestational diabetes was more common in women with obstetrical cholestasis than in women without obstetrical cholestasis (odds ratio, 2.129; 95% confidence interval, 1.697–2.670;10 studies). Gestational diabetes is twice more common in women with severe cholestasis than in women with mild cholestasis (odds ratio, 2.168; 95% confidence interval, 1.429–3.289; 4 studies). CONCLUSION There is an increase in the prevalence of gestational diabetes among women diagnosed with obstetrical cholestasis. Compared with women with mild cholestasis, the increased risk of gestational diabetes in women with severe cholestatis is more than doubled. This suggests that the 2 conditions may have some biological similarities that affect clinical outcomes.
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