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El Jamaly H, Eslick GD, Weltman M. Primary biliary cholangitis in pregnancy: A systematic review with meta-analysis. Hepatobiliary Pancreat Dis Int 2022; 21:218-225. [PMID: 35361530 DOI: 10.1016/j.hbpd.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 03/01/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The outcomes and disease associations in pregnant women with primary biliary cholangitis (PBC) have not been largely explored. This study aimed to determine the level of evidence associated with maternal and fetal outcomes and other disease associations in female patients with PBC. DATA SOURCES A comprehensive literature search was conducted. Maternal and fetal outcomes were obtained from patients with a previous, current or subsequent diagnosis of PBC. A random-effects model was employed, using odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS Eleven studies, with 2179 female PBC patients were included. Pregnant women with PBC were significantly more likely to have a miscarriage (OR = 1.27, 95% CI: 1.02-1.58; P = 0.03), and a history of abortion (OR = 1.50, 95% CI: 1.09-2.07; P = 0.01), with absent heterogeneity (I2 = 0%). PBC pregnant women were significantly more likely to deliver via vaginal birth (OR = 1.69, 95% CI: 1.33-2.14; P < 0.001) with low level heterogeneity (I2 < 0.001%). Patients had a statistically significant increased likelihood of lifetime smoking (OR = 1.95, 95% CI: 1.17-3.23; P = 0.01). Egger's regression revealed no evidence of publication bias. CONCLUSIONS This meta-analysis provides pooled evidence that a PBC pregnancy is associated with fetal morbidity and maternal lifestyle associations that may influence pregnancy outcomes. More studies are needed to establish disease associations that may directly affect pregnancy outcomes. These data are essential for clinicians managing these patients before, during or after pregnancy.
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Affiliation(s)
- Hydar El Jamaly
- Department of Gastroenterology and Hepatology, Nepean Hospital, Penrith, New South Wales, Australia; Nepean Clinical School, The University of Sydney, Penrith, New South Wales, Australia.
| | - Guy D Eslick
- NHMRC Centre for Research Excellence in Digestive Health, Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Martin Weltman
- Department of Gastroenterology and Hepatology, Nepean Hospital, Penrith, New South Wales, Australia; Nepean Clinical School, The University of Sydney, Penrith, New South Wales, Australia
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Ferrigno B, Barba R, Medina-Morales E, Trivedi H, Patwardhan V, Bonder A. Cholestatic Liver Disease and Pregnancy: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:1068. [PMID: 35207342 PMCID: PMC8875982 DOI: 10.3390/jcm11041068] [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: 01/21/2022] [Revised: 02/08/2022] [Accepted: 02/16/2022] [Indexed: 02/01/2023] Open
Abstract
Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are two types of chronic cholestatic liver disease (CCLD). Little is known regarding the relationship between these conditions and pregnancy. We performed a systematic review and meta-analysis regarding the maternal and fetal outcomes amongst patients with a known diagnosis of PBC and PSC undergoing pregnancy. Our analysis shows that patients with PBC and PSC who undergo pregnancy are at an increased risk of pre-term delivery, as well as the development of new or worsening pruritus during pregnancy. Additionally, patients with PBC are at higher risk of undergoing a biochemical disease flare during the postpartum period compared to during pregnancy. However, there were no documented cases of maternal mortality or development of decompensated cirrhosis during pregnancy or the postpartum period.
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Affiliation(s)
- Bryan Ferrigno
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA;
| | - Romelia Barba
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.); (E.M.-M.); (H.T.); (V.P.)
| | - Esli Medina-Morales
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.); (E.M.-M.); (H.T.); (V.P.)
| | - Hirsh Trivedi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.); (E.M.-M.); (H.T.); (V.P.)
| | - Vilas Patwardhan
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.); (E.M.-M.); (H.T.); (V.P.)
| | - Alan Bonder
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (R.B.); (E.M.-M.); (H.T.); (V.P.)
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Sun Y, Haapanen K, Li B, Zhang W, Van de Water J, Gershwin ME. Women and primary biliary cirrhosis. Clin Rev Allergy Immunol 2016; 48:285-300. [PMID: 25241227 DOI: 10.1007/s12016-014-8449-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Primary biliary cirrhosis occurs more frequently in women, and previous studies indicated that the average age of primary biliary cirrhosis (PBC) onset makes pregnancy in PBC patients uncommon. However, more recently, improved diagnostic testing has enabled detection of PBC in younger women, including those of childbearing age. This has led investigators to become increasingly interested in the relationship between the ontogeny of PBC and pregnancy. Published cases indicate that the typical age for pregnant women to be diagnosed with PBC is in the early 30s, and that during gestation, pruritus and jaundice are the most common symptoms. During gestation, susceptible women may experience onset of PBC resulting from the drastic changes in female hormones; this would include not only the mitochondrial damage due to accumulation of bile acids but also changes in the immune response during the different stages of pregnancy that might play an important role in the breakdown of self-tolerance. The mechanisms underlying the potential relationship between PBC and pregnancy warrant further investigation. For women first diagnosed with PBC during gestation, or those for whom first appearance of a flare up occurs during and postpartum, investigation of the immune response throughout gestation could provide new avenues for immunologic therapeutic intervention and the discovery of new treatment strategies for PBC.
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Affiliation(s)
- Ying Sun
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA
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Good maternal and fetal outcomes for pregnant women with primary biliary cirrhosis. Clin Gastroenterol Hepatol 2014; 12:1179-1185.e1. [PMID: 24321209 DOI: 10.1016/j.cgh.2013.11.030] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 10/25/2013] [Accepted: 11/13/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Up to 25% of patients diagnosed with primary biliary cirrhosis (PBC) are of childbearing age. However, little is known about disease course during pregnancy. METHODS We performed a retrospective analysis of women with PBC during pregnancy using a representative large cohort of patients attending the Liver Center at Toronto Western hospital from January 1979 through June 2009 (n = 306). Statistical analysis was performed by using R statistical software. RESULTS We identified 32 women (50 pregnancies) who either became pregnant after a diagnosis of PBC or in whom pregnancy led to diagnosis. Liver biochemistry remained stable in most patients (70%) throughout pregnancy. However, 23 of 32 patients (72%) had a flare in biochemical disease activity post partum, which was unrelated to biochemical disease activity before conception (P = .53), or during the gestational period (P = .14). No adverse maternal events were observed during pregnancy or post partum, and only 2 of 32 of women (6%) developed progressive disease after delivery. De novo pruritus developed during pregnancy in 17 of 32 women (53%), whereas itch that existed before conception worsened for 4 patients. Fifteen of 21 women (71%) with pregnancy-related pruritus required symptom-specific therapy. Twenty-nine of 32 women (91%) had at least 1 successful live birth; adverse fetal outcome was not influenced by biochemical disease activity before conception (P = .24) or during pregnancy (P = 1.00). CONCLUSION Pregnancy in women with PBC is frequently symptomatic but mostly uneventful. The majority of women maintain stable liver biochemistry during pregnancy, although postpartum biochemical exacerbations are common.
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Efe C, Kahramanoğlu-Aksoy E, Yilmaz B, Ozseker B, Takci S, Roach EC, Purnak T, Kav T, Ozaslan E, Wahlin S. Pregnancy in women with primary biliary cirrhosis. Autoimmun Rev 2014; 13:931-5. [PMID: 24879082 DOI: 10.1016/j.autrev.2014.05.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/20/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Primary biliary cirrhosis (PBC) may present in all decades of life, also in childbearing age. Data on maternal and fetal outcome is limited. We aimed to investigate the impact of pregnancy and childbirth on the disease course and possible effects of PBC on fetal outcome. METHODS Retrospective study of local cases and a compact review of published reports between 1950 and 2014. RESULTS Our cases along with literature review provided 98 pregnancies in 72 PBC patients. PBC was diagnosed during pregnancy in 26 (36%) patients and 46 (64%) had the diagnosis before conception. Twenty-four (30%) of the pregnancies were associated with biochemical flares and 55 (70%) with clinical improvement or stabilization. De novo onset or worsening of pruritus was seen in 49% (45/92). No maternal deaths were reported. Post-partum disease activation was observed in 60% (53/88). One patient was referred for liver transplantation after delivery. A miscarriage rate of 24% and three stillbirths were reported. Most patients were treated with ursodeoxycholic acid (UDCA) during breastfeeding and 12 patients also received UDCA during the first trimester without any identified side effects. CONCLUSION Most women with PBC maintain a stable disease during pregnancy, but post-partum biochemical flares are common. Symptomatic pruritus may be challenging in pregnant PBC patients. UDCA appears to be safe during pregnancy and breastfeeding. A successful pregnancy outcome is a realistic expectation for women with PBC.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey.
| | | | - Bülent Yilmaz
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Burak Ozseker
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Sahin Takci
- Department of Neonatology, Gaziosmanpaşa University, Tokat, Turkey
| | | | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Taylan Kav
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| | - Staffan Wahlin
- Department of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Monoe K, Takahashi A, Katsushima F, Kanno Y, Saito H, Abe K, Yokokawa J, Ohira H. Case of primary biliary cirrhosis-autoimmune hepatitis overlap which manifested after delivery. Intern Med 2011; 50:1299-301. [PMID: 21673465 DOI: 10.2169/internalmedicine.50.5022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 34-year-old woman showed liver dysfunction for the first time at 3 months after delivery. Two years later, she was referred to our department with continued liver dysfunction. She fulfilled the criteria for primary biliary cirrhosis (PBC)-autoimmune hepatitis (AIH) overlap. Liver dysfunction improved after administration of ursodeoxycholic acid and bezafibrate. To the best of our knowledge this represents the second report of PBC-AIH overlap after delivery and we discuss immunological changes during the perinatal period.
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Affiliation(s)
- Kyoko Monoe
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine, Japan
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Abstract
Most care of liver disease is in the ambulatory setting, and therefore the clinical needs of patients represent those of any other chronic illness. Emphasis must be given to preventative strategies such that liver lifetime (including pre-emptive strategies related to potential allograft survival) is maximised through timely intervention and avoidance of side effects. This review addresses the pertinent practical clinical concerns faced by clinicians as they manage adult patients with chronic liver disease, with an emphasis on preventing and managing symptoms and complications directly and indirectly related to the underlying disease.
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Affiliation(s)
- Gideon M Hirschfield
- Toronto Western Hospital, University Health Network, University of Toronto, ON, Canada.
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Poupon R, Chrétien Y, Chazouillères O, Poupon RE. Pregnancy in women with ursodeoxycholic acid-treated primary biliary cirrhosis. J Hepatol 2005; 42:418-9. [PMID: 15710226 DOI: 10.1016/j.jhep.2004.08.029] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2004] [Revised: 07/27/2004] [Accepted: 08/23/2004] [Indexed: 02/09/2023]
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Heathcote EJ. Management of primary biliary cirrhosis. The American Association for the Study of Liver Diseases practice guidelines. Hepatology 2000; 31:1005-13. [PMID: 10733559 DOI: 10.1053/he.2000.5984] [Citation(s) in RCA: 320] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Primary biliary cirrhosis (PBC) is a presumed autoimmune disease of the liver, which predominantly affects women once over the age of 20 years. Most cases are diagnosed when asymptomatic (60%). The antimitochondrial antibody is present in serum in most, but not in all, patients with PBC. The disease generally progresses slowly but survival is less than an age- and gender-matched general population. The symptomatic patient may have fatigue, generalized pruritus, portal hypertension, osteoporosis, skin xanthomata, fat soluble vitamin deficiencies, and/or recurrent asymptomatic urinary tract infections. Many nonhepatic autoimmune diseases are found in association with PBC and may prompt initial presentation. To date, immunosuppressive therapy has not been shown to prolong survival in PBC. The hydrophilic bile acid, ursodeoxycholic acid (UDCA), has been shown when given in a dose of 13 to 15 mg/kg daily for up to 4 years to delay the time to liver transplantation or death. This therapy also causes a significant improvement of all the biochemical markers of cholestasis but has no beneficial effects on any of the symptoms or associated disorders. Treatment with UDCA does not obviate the need for liver transplantation. Therapies to prevent complications arising from malabsorption, portal hypertension, and/or osteoporosis are required as well. Good control of pruritus can be achieved in most patients. PBC is diagnosed with increasing frequency, but the agent(s) responsible for this slowly progressive destruction of the interlobular bile ducts remains elusive and hence a specific therapy remains unavailable.
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Affiliation(s)
- E J Heathcote
- Division of Gastroenterology, University of Toronto, The Toronto Hospital, Toronto, Ontario, Canada.
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Janczewska I, Olsson R, Hultcrantz R, Broomé U. Pregnancy in patients with primary sclerosing cholangitis. LIVER 1996; 16:326-30. [PMID: 8938634 DOI: 10.1111/j.1600-0676.1996.tb00754.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A deterioration of liver function may occur during pregnancy in patients with chronic liver disorder. Primary sclerosing cholangitis (PSC) is a chronic progressive liver disorder with a highly variable and fluctuating course. This study aims at investigating the outcome of pregnancy in patients with PSC and, conversely, the effect of pregnancy on the disease. Thirteen pregnancies in 10 patients with PSC (4 with liver cirrhosis, 6 with mild liver disease) were observed. Seven patients had PSC before pregnancy, 2 developed the disease during pregnancy, and one patient developed PSC 2 months after a normal pregnancy with a normal delivery. Clinical symptoms and biochemical analyses were routinely evaluated during the pregnancy. No gastrointestinal haemorrhage was observed during the pregnancy. Two patients had pruritus and 2 abdominal pain before pregnancy, and these symptoms continued during pregnancy. Abdominal pain was noted in 3 patients lacking this symptom before pregnancy. Four patients without pruritus prior to pregnancy developed this symptom during the pregnancy. In two patients, pruritus was so intense as to bring on premature delivery. Liver tests did not indicate any deterioration during pregnancy. No fetal loss occurred. The outcome for all babies was normal. In patients with PSC pregnancy does not seem to have a negative effect on the disease process, neither mothers nor babies showed any ill effects. PSC has not worsened during the pregnancy in our patients.
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Affiliation(s)
- I Janczewska
- Department of Gastroenterology, Huddinge University Hospital, Sweden
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Rabinovitz M, Appasamy R, Finkelstein S. Primary biliary cirrhosis diagnosed during pregnancy. Does it have a different outcome? Dig Dis Sci 1995; 40:571-4. [PMID: 7895546 DOI: 10.1007/bf02064371] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Pregnancy in women with primary biliary cirrhosis (PBC) is uncommon, and once it occurs it usually does not worsen the liver disease. First manifestation of PBC during pregnancy in women with no known liver disease at the time of conception is very rare, and the natural history of this disease in such cases is yet unknown. Herein we describe a woman who had been diagnosed with PBC during the third trimester of pregnancy and, while she gave birth to a normal healthy child, her disease rapidly deteriorated and she has been listed for liver transplantation. It appears that PBC that is first noted during pregnancy might have a different course than that of PBC diagnosed before pregnancy.
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Affiliation(s)
- M Rabinovitz
- Department of Medicine, University of Pittsburgh, School of Medicine, Pennsylvania 15213
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