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Misra D, Singh N, Faruqi M, Tiwari V, Kumar V, Zafar F. Evaluating the Utility of Liver Transaminases as Predictors of Feto-Maternal Outcome in Lieu of Serum Bile Acids in Intrahepatic Cholestasis of Pregnancy: A Prospective Observational Study. J Obstet Gynaecol India 2024; 74:113-118. [PMID: 38707884 PMCID: PMC11065801 DOI: 10.1007/s13224-023-01881-6] [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] [Accepted: 10/08/2023] [Indexed: 05/07/2024] Open
Abstract
Introduction Intrahepatic Cholestasis of Pregnancy (ICP) is a disorder of the second half of pregnancy causing pruritus and abnormal liver function tests (LFT). Incidence in India is 1.2-1.5%. ICP leads to adverse feto-maternal outcomes with early delivery indicated before serum bile acids (SBA) (gold standard) and hepatic transaminases are critically high. With paucity of evidence these levels are not well defined. Objectives To determine the association of liver transaminases with pregnancy outcomes in ICP and evaluate critical levels for prediction of adverse outcomes. Material and Methods A prospective observational study was conducted comprising 88 pregnant women with pruritus not associated with rash. After history and examination, LFT and SBA levels were done, treatment given and followed till pregnancy termination to determine the feto-maternal outcome. Results The mean age of participants was 26.43 ± 3.35 years. The mean SBA, ALT and AST levels were 18.97 ± 10.320 μmol/L, 206.06 ± 45.71units/litre and 175.37 ± 101.088 units/litre respectively. 39.7% of participants were symptomatic for ICP while 38.6% responded to treatment. 34.1% underwent LSCS majorly (43.3%) formeconiumand 23.3% had foetal distress. 33% had preterm delivery. 5.68% of the neonates needed NICU admission and 6.8% had respiratory distress syndrome. The cut off for ALT on ROC curve analysis was 151.5 units/litre with AUC as 0.905, sensitivity and specificity of 89.7 and 70% respectively. Conclusion ICP leads to adverse pregnancy outcomes. ALT is a promising predictor of adverse outcome and termination of pregnancy can be planned accordingly.
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Affiliation(s)
- Devyani Misra
- AssiocProfessor Junior Grade, Department of Obstetrics & Gynaecology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh India
| | - Neetu Singh
- Professor Junior Grade, Department of Obstetrics & Gynaecology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh India
| | - Mariyam Faruqi
- Ex Senior Resident, Department of Obstetrics & Gynaecology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh India
| | - Vandana Tiwari
- Professor Junior Grade, Department of Biochemistry, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh India
| | - Vandana Kumar
- Assistant Professor, Department of Obstetrics & Gynaecology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh India
| | - Farah Zafar
- Ex Junior Resident, Department of Obstetrics & Gynaecology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh India
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Liu LW, Chen Y, Zhu LJ, Xu QX, Xu S, Ding Y, Yin B. A study on the relationship between gut microbiota and intrahepatic cholestasis of pregnancy. Heliyon 2024; 10:e25861. [PMID: 38384504 PMCID: PMC10878930 DOI: 10.1016/j.heliyon.2024.e25861] [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: 10/30/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/23/2024] Open
Abstract
Objective Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disease associated with a high incidence of complications in the mid and late stages of gestation. This study investigates differences in the composition of intestinal flora among pregnant women diagnosed with ICP, employing Illumina MiSeq high-throughput sequencing technology. Methods This case-control study obtained patient data from the hospital information system (HIS) and the laboratory information system (LIS). Fecal samples were collected from 25 pregnant women who did not undergo intestinal preparation before delivery between December 2020 and March 2021. Whole-genome analysis was performed. PCR was used to amplify the 16S rRNA V3-V4 variable region, which was then sequenced. Alpha and beta diversity were computed, and the maternal intestinal flora's abundance and composition characteristics were analyzed. Differences in intestinal flora between the two sample groups were examined. Results Bacteroides and Proteobacteria exhibited positive correlations with TBIL and IBIL. Betaproteobacteria, Gammaproteobacteria, and Erysipeiotrichi showed positive correlations with TBIL, IBIL, and DBIL, while Lactobacillus, Delftia, and Odoribacter demonstrated positive correlations with ALT. Conclusion The ICP group displayed significantly higher levels of total bile acid and ALT compared to the control group. The intestinal flora composition comprised four primary phyla: Firmicutes, Actinobacteria, Bacteroidetes, and Proteobacteria. ICP patients exhibited a lower relative abundance of intestinal flora across different levels of community composition when compared to the control group. Specific correlations between certain intestinal flora and clinical liver parameters were identified.
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Affiliation(s)
- Li-wen Liu
- Department of Anesthesia, The Reproductive Hospital of Guangxi Zhuang Autonomous Region, Nanning City, 530000, China
| | - Yan Chen
- Department of Obstetrical, Guangzhou Women and Children's Hospital Liuzhou Hospital, Liuzhou City, 545000, China
| | - Liu-jing Zhu
- Department of Obstetrical, Guangzhou Women and Children's Hospital Liuzhou Hospital, Liuzhou City, 545000, China
| | - Qun-xiang Xu
- Department of Breast, Guangzhou Women and Children's Hospital Liuzhou Hospital, Liuzhou City, 545000, China
| | - Shaolin Xu
- Department of Laboratory, Guangzhou Women and Children's Hospital Liuzhou Hospital, Liuzhou City, 545000, China
| | - Yanling Ding
- Department of Laboratory, Guangzhou Women and Children's Hospital Liuzhou Hospital, Liuzhou City, 545000, China
| | - Biao Yin
- Department of Eugenic Genetics, The Reproductive Hospital of Guangxi Zhuang Autonomous Region, Nanning City, 530000, China
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Regiroli G, La Malfa G, Loi B, Vivanti A, Centorrino R, De Luca D. Ultrasound-assessed lung aeration, oxygenation and respiratory care in neonatal bile acid pneumonia: A nested case-control study. Acta Paediatr 2023; 112:1898-1904. [PMID: 37265415 DOI: 10.1111/apa.16865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/03/2023]
Abstract
AIM Neonatal bile acid pneumonia (NBAP) occurs in neonates following obstetric cholestasis. We aimed to study the lung aeration and respiratory support of NBAP. METHODS Nested, case/control study enrolling age-matched neonates with NBAP, respiratory distress syndrome (RDS) or transient tachypnoea (TTN). Lung aeration and oxygenation were assessed with lung ultrasound score, oxygenation index and SpO2 /FiO2 . RESULTS Nineteen, 22 and 25 neonates with NBAP, RDS and TTN, respectively were studied (mean gestational age = 33 (2.2) weeks, 30 (45.5%) males). Upon admission, RDS patients had the worst lung ultrasound score (p = 0.022) and oxygenation index (p = 0.001), while NBAP and TTN neonates had similar values. At the worst time-point, NBAP and RDS patients showed similar oxygenation index (NBAP: 4.6 [2], RDS: 5.7 [3]) and SpO2 /FiO2 (NBAP: 3.1 [1.1], RDS: 2.7 [1]) which were worse than those of TTN patients (oxygenation index: p = 0.015, SpO2 /FiO2 : p = 0.001). RDS neonates needed the longest continuous positive airway pressure and highest mean airway pressure, but NBAP neonates needed invasive ventilation (26.3%, p = 0.01) and surfactant (31.6%, p = 0.003) more often than TTN patients who never needed these. CONCLUSION NBAP was a mild disorder in the first hours of life but subsequently worsened and became similar to RDS.
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Affiliation(s)
- Giulia Regiroli
- Division of Paediatrics and Neonatal Critical Care, "A.Beclere" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Giulia La Malfa
- Division of Paediatrics and Neonatal Critical Care, "A.Beclere" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Barbara Loi
- Division of Paediatrics and Neonatal Critical Care, "A.Beclere" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Alexandre Vivanti
- Division of Obstetrics and Gynaecology, "A.Beclere" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Roberta Centorrino
- Division of Paediatrics and Neonatal Critical Care, "A.Beclere" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, "A.Beclere" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
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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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Zheng L, Jing H, Liu L, Wang L. Feasibility of ultrasound in the diagnosis of neonatal respiratory distress syndrome in preterm infants. J Trop Pediatr 2023; 69:7028467. [PMID: 36744917 PMCID: PMC9901274 DOI: 10.1093/tropej/fmad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to investigate the feasibility of lung ultrasound in the diagnosis of neonatal respiratory distress syndrome (NRDS) in preterm infants. METHODS One hundred and nine preterm infants were prospectively recruited. Three ultrasound diagnostic criteria were developed to diagnose preterm infants with NRDS: (A) thickened or not smooth pleural line, part of the lung field shows diffuse 'B-line' sign or alveolar-interstitial syndrome (AIS); (B) thickened or not smooth pleural line, all lung fields show AIS, signifying the 'white lung' sign; (C) thickened or rough pleural line, 'white lung' sign and 'lung consolidation' sign can be observed in any lung field. RESULTS The sensitivity and negative predictive value of NRDS in preterm infants with diagnostic criteria A were 100%, but the specificity and positive predictive value were 67.95 and 55.36%, respectively. The specificity and positive predictive value of diagnostic criteria B and C were 100%, while the 95% CI of diagnostic criteria B was narrower than diagnostic criteria C. The sensitivity and negative predictive value of diagnostic criteria B were higher than that of diagnostic criteria C. Of the 31 NRDS cases, 15 cases had severe NRDS and the other 16 did not have severe NRDS. CONCLUSION Thickened or rough pleural line with white lung sign is an important characteristic for the diagnosis of NRDS by lung ultrasound. White lung sign combined with the lung consolidation sign had high diagnostic efficacy when distinguishing severe NRDS from not severe NRDS.
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Affiliation(s)
- Lei Zheng
- Department of Ultrasonography, First Hospital of Tsinghua University, Beijing 100016, PR China
| | - Hongyan Jing
- Operating Room, First Hospital of Tsinghua University, Beijing 100016, PR China
| | - Lihong Liu
- Department of Ultrasonography, First Hospital of Tsinghua University, Beijing 100016, PR China
| | - Lianyi Wang
- Department of Ultrasonography, First Hospital of Tsinghua University, Beijing 100016, PR China
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The impact of intrahepatic cholestasis on pregnancy outcomes: a retrospective cohort study. BMC Gastroenterol 2023; 23:16. [PMID: 36653757 PMCID: PMC9847161 DOI: 10.1186/s12876-023-02652-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 01/12/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This study analyzed the pregnancy outcomes of patients with intrahepatic cholestasis of pregnancy (ICP) in Hangzhou, China. METHODS Cases of pregnant women monitored by antepartum testing at Hangzhou Women's Hospital from January 2018 to December 2020 were reviewed. Subjects were classified into two groups according to whether they had ICP: 688 cases of ICP were assigned to an exposure group while 38,556 cases of non-ICP were assigned to a non-exposed group. Univariate analysis was performed on qualitative or quantitative data using the Chi-Squared test or Mann-Whitney U test, and the adjusted odds ratio (aOR) and 95% confidence interval (CI) of the two groups of related variables were calculated by multivariate binary logistic regression analysis. RESULTS The incidence rate of ICP was 1.75%. Pregnant women with hepatitis B virus were correlated with ICP. Hepatitis B carriers (aOR = 3.873), preeclampsia (PE, aOR = 3.712), thrombocytopenia (aOR = 1.992), gestational hypertension (GH, aOR = 1.627), hyperlipidemia (aOR = 1.602) and gestational diabetes mellitus (GDM, aOR = 1.265) were all risk factors for ICP. In contrast, Body Mass Index (BMI) ≥ 30 kg/m2 (aOR = 0.446), 25 m2 < maternal BMI < 29.9 kg/m2 (aOR = 0.699) and parity ≥ 1 (aOR = 0.722) were protective factors for ICP. Pregnant women in the ICP group had an increased risk of gestation days < 259 days (aOR = 4.574) and cesarean delivery (aOR = 1.930) after ICP, and a decreased risk of longer gestational days (aOR = 0.105), premature rupture of membranes (aOR = 0.384) and fetal macrosomia (aOR = 0.551). CONCLUSIONS By analyzing a Chinese population with ICP, we identified that pregnant women who are hepatitis B carriers or with PE, thrombocytopenia, GH, hyperlipidemia, and GDM are at higher risk of ICP. Moreover, ICP is associated with adverse pregnancy outcomes; in particular, ICP may increase the incidence of shorter gestational days and non-vaginal delivery methods such as cesarean section but reduce the incidence of premature rupture of membranes and fetal macrosomia.
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Chen L, Li J, Shi Y. Clinical characteristics and outcomes in neonates with perinatal acute respiratory distress syndrome in China: A national, multicentre, cross-sectional study. EClinicalMedicine 2023; 55:101739. [PMID: 36386029 PMCID: PMC9661498 DOI: 10.1016/j.eclinm.2022.101739] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Neonatal acute respiratory distress syndrome (NARDS) was defined in 2017 and the epidemiological data remain unknown. Our objective was to explore aetiological factors, clinical characteristics and outcomes in patients with perinatal NARDS. METHODS A multicentre, prospective, cross-sectional study was performed in 58 tertiary neonatal intensive care units in China from Jan 1, 2018 to June 30, 2019. Neonates diagnosed with NARDS were included. Primary outcomes were aetiological factors, clinical characteristics and outcomes. Binary logistic regression and multivariate cox proportional regression were performed to identify independent predictors for bronchopulmonary dysplasia (BPD) and/or death or single death. This study was registered with ClinicalTrials.Gov, NCT03311165. FINDINGS Among 70,013 admitted neonates, the incidence of NARDS was 1.44% (1005). The cumulative incidences were 65.6%, 86.7%, 94.1% within one, two and three days after birth. The median gestational age and birth weight were 36.4 weeks and 2700 g. Three main aetiological triggers included pneumonia (58.1%), asphyxia (24.3%) and early-onset sepsis (EOS) (21.3%). BPD and/or death was observed in 213 (21.2%) infants, consisting 104 (10.3%) BPD and 126 (12.6%) deaths. The numbers of mild, moderate and severe NARDS were 537 (53.4%), 286 (28.4%) and 182 (18.2%). Two or more doses of surfactant was associated with increased mortality as compared with one or less doses of surfactant (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.20-3.10, P = 0.006). Similarity also appeared in the comparison between EOS and non-EOS triggers (OR 1.57, 95% CI 1.06-2.33, P = 0.023). INTERPRETATION NARDS incidence was 1.44% and the three main aetiologies were pneumonia, asphyxia and EOS. The cumulative incidences were 65.6%, 86.7%, and 94.1% within one, two and three days after birth. Our results suggested that two or more doses of surfactant increased mortality compared with one or less doses of surfactant. FUNDING The National Clinical Research Center of China and Clinical Medical Study Program of Children's Hospital of Chongqing Medical University (NCRC-2019-GP-13) and Natural Science Foundation of Chongqing (cstc2020jcyj-msxmX0197).
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Key Words
- ARDS, acute respiratory distress syndrome
- Acute respiratory distress syndrome
- BIPAP, bi-level positive airway pressure
- BPD, bronchopulmonary dysplasia
- Bronchopulmonary dysplasia
- CI, confidence interval
- CMV, conventional mechanical ventiation
- Epidemiology
- GA, gestational age
- GDM, gestational diabetes mellitus
- HDCP, hypertensive disorder complicating pregnancy
- HFOV, high-frequency oscillatory ventilation
- ICP, intrahepatic cholestasis of pregnancy
- IQR, interquartile range
- IV, invasive ventilation
- IVF, in vitro fertilization
- MAS, meconium aspiration syndrome
- Mortality
- NARDS, neonatalacute respiratory distress syndrome
- NCPAP, nasal continuous positive airway pressure
- NHFOV, nasal high-frequency oscillatory ventilation
- NIPPV, nasal intermittent positive pressure ventilation
- NIV, noninvasive ventilation
- NIV-I, intubation after NIV failure
- Neonate
- OR, odds ratio
- PH, pulmonary hemorrhage
- PPHN, persistent pulmonary hypertension of newborn
- PROM, premature rupture of the membrane
- iNO, inhaled nitric oxide
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Affiliation(s)
- Long Chen
- Department of Neonatology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation Base of Child Development and Critical Disorders; Chongqing Key Laboratory of Pediatrics; Chongqing, 400014, China
| | - Jie Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation Base of Child Development and Critical Disorders; Chongqing Key Laboratory of Pediatrics; Chongqing, 400014, China
- Corresponding author.
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Wu K, Yin B, Li S, Zhu X, Zhu B. Prevalence, risk factors and adverse perinatal outcomes for Chinese women with intrahepatic cholestasis of pregnancy: a large cross-sectional retrospective study. Ann Med 2022; 54:2966-2974. [PMID: 36271887 PMCID: PMC9624205 DOI: 10.1080/07853890.2022.2136400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-related liver disorder and may cause adverse perinatal outcomes. This large cross-sectional retrospective study aimed to evaluate the prevalence and related risk factors of ICP and determine the adverse perinatal outcomes. METHODS This large cohort study from 1 January 2018 to 31 December 2019, included 39,742 eligible pregnant women. Data were extracted from the institutional electronic medical record database and analyzed using univariate and multivariate logistic regression models to determine the risk factors and adverse perinatal outcomes of ICP. RESULTS The overall prevalence of ICP was 3.81%. It was significantly higher in hepatitis B surface antigen (HBsAg) positive than negative women in all age groups, and in women with pre-pregnancy BMI underweight and obesity aged <25 years and ≥35 years than the other age groups. Multivariate logistic regression models showed an increased risk of ICP associated with maternal age <25 years and ≥35 years, pre-pregnancy underweight and obesity, HBsAg positive status, twin pregnancies, low maternal education, inadequate gestational weight gain, multiparous, in vitro fertilization, caesarean section history and the number of abortions ≥2. The presence of ICP was associated with increased risk of maternal outcomes of caesarean section and preterm birth, and neonatal outcomes of low birth weight and neonatal unit admission in singleton and twin pregnancies. CONCLUSION This study identified the prevalence, possible risk factors, and associated adverse perinatal outcomes of ICP, which provides useful information for clinicians to identify, counsel, and provide timely management for women at risk.KEY MESSAGESMaternal age <25 and ≥35, pre-pregnancy BMI underweight and obesity, hepatitis B surface antigen-positive status, twin pregnancies, low maternal education, inadequate gestational weight gain, multiparous, in vitro fertilization, caesarean section history and the number of abortions ≥2 are associated with an increased risk of ICP.Further, pregnancies with ICP are associated with an increased risk of maternal outcomes of caesarean section and preterm birth and neonatal outcomes of low birth weight and neonatal unit admission in singleton and twin pregnancies.
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Affiliation(s)
- Kaiqi Wu
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Binin Yin
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuai Li
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaojun Zhu
- Department of Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bo Zhu
- Department of Clinical Laboratory, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Futterman ID, Minkoff H, Lee-Hwang G, Mays JC. Bile-acid levels and lung maturity test in patients with intrahepatic cholestasis of pregnancy. J Perinat Med 2022; 50:1215-1217. [PMID: 35716390 DOI: 10.1515/jpm-2022-0085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 05/28/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Prolonged fetal exposure to maternal bile acids have been linked to fetal lung injury, but it is not known if it affects production of surfactant or fetal lung maturity tests. We set out to determine if elevated total bile acid (TBA) levels predict delayed fetal lung maturity (FLM) in patients with intrahepatic cholestasis of pregnancy (ICP). METHODS A retrospective cohort study examining patients with ICP who underwent amniocentesis between 36+0 and 37+6 between 2005 and 2014. Primary goal was to identify if a relationship exists between TBA levels and FLM defined as Lecithin:Sphingomyelin >2.5, detectable Phosphatidylglycerol, or lamellar body count of >50,000. RESULTS Among the 113 patients, there was no statistically significant difference in TBA levels between women with FLM and those with immaturity (31.3 [21.6, 44.5] μmol/L and 34.9 [23.9, 62.3] μmol/L respectively; p=0.16). Logistic regression performed using predefined TBA levels of 20, 30, 40 and 50 μmol/L revealed that TBA levels did not predict a negative FLM test at time of amniocentesis. CONCLUSIONS TBA levels do no predict presence or absence of FLM between 36+0 and 37+6 weeks of gestation. Though certain pregnancy complications can affect FLM, we could not identify a correlation between TBA levels and an accelerated or delayed lung maturation process.
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Affiliation(s)
- Itamar D Futterman
- Department of OBGYN, New York Medical College, Valhalla, NY, USA.,Department of OBGYN, New York Health + Hospital/Metropolitan Hospital, New York, NY, USA.,Department of OBGYN, Division of Maternal Fetal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Howard Minkoff
- Department of OBGYN, Division of Maternal Fetal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Gladys Lee-Hwang
- Department of OBGYN, New York Medical College, Valhalla, NY, USA.,Department of OBGYN, New York Health + Hospital/Metropolitan Hospital, New York, NY, USA
| | - Jonathan C Mays
- Department of OBGYN, New York Medical College, Valhalla, NY, USA.,Department of OBGYN, New York Health + Hospital/Metropolitan Hospital, New York, NY, USA
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Futterman ID, Mays JC, Minkoff H. Reply: Neonatal lung injury with intrahepatic cholestasis of pregnancy. J Perinat Med 2022; 50:1276. [PMID: 35968828 DOI: 10.1515/jpm-2022-0350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Itamar D Futterman
- Department of OBGYN, New York Medical College, Valhalla, NY, USA.,Department of OBGYN, New York Health + Hospital/Metropolitan Hospital, New York, NY, USA.,Maimonides Medical Center, Department of OBGYN, Division of Maternal Fetal Medicine, Brooklyn, NY, USA
| | - Jonathan C Mays
- Department of OBGYN, New York Medical College, Valhalla, NY, USA.,Department of OBGYN, New York Health + Hospital/Metropolitan Hospital, New York, NY, USA
| | - Howard Minkoff
- Maimonides Medical Center, Department of OBGYN, Division of Maternal Fetal Medicine, Brooklyn, NY, USA
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Recognizing, Diagnosing, and Managing Pregnancy Dermatoses. Obstet Gynecol 2022; 140:679-695. [PMID: 36075066 DOI: 10.1097/aog.0000000000004938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/26/2022] [Indexed: 01/05/2023]
Abstract
Pregnancy dermatoses are inflammatory skin disorders that occur during pregnancy or immediately postpartum. This heterogenous group of disorders includes pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, atopic eruption of pregnancy, and pustular psoriasis of pregnancy. In this article, we provide a comprehensive literature review of each condition focusing on nomenclature, epidemiology, pathogenesis, clinical presentation, diagnosis, differential diagnosis, maternal risk, fetal risk, and treatment. We aim to increase awareness and help clinicians recognize, diagnose, and manage these unique conditions.
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De Luca D, Alonso A, Autilio C. Bile acids-induced lung injury: update of reverse translational biology. Am J Physiol Lung Cell Mol Physiol 2022; 323:L93-L106. [DOI: 10.1152/ajplung.00523.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The presence of bile acids in lung tissue is associated with some clinical features observed in various medical specialties, but it took time to understand that these are due to a "bile acid-induced lung injury" since specific translational studies and cross-disciplinary awareness were lacking. We used a reverse translational approach to update and summarize the current knowledge about the mechanisms of bile acid-induced lung injury. This has been done in a cross-disciplinary fashion since these conditions may occur in patients of various age and in different medical fields. We here define these clinical conditions, then we review the physiopathology of these conditions and the animal models used to mimic them and, finally, their pathobiology. Mechanisms of bile acid-induced lung injury have been partially clarified overtime and are represented by: 1) the interaction with secretory phospholipase A2 pathway, 2) the effect on surfactant function and structure, 3) the biological effects on inflammation and local immunity, 4) the direct cellular toxicity. These mechanisms are schematically illustrated and histological comparisons between ARDS induced by bile acids and other triggers are also provided. Based on these mechanisms we propose possible direct therapeutic applications and, finally, we discuss further research steps to improve the understanding of processes that generate pathological clinical conditions.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Paris Saclay University Hospital, Clamart, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Le Plessis Robinson, France
| | - Alejandro Alonso
- Department of Biochemistry and Molecular Biology, Faculty of Biology, and Research, Institut-Hospital, Complutense University, Madrid, Spain
| | - Chiara Autilio
- Department of Biochemistry and Molecular Biology, Faculty of Biology, and Research, Institut-Hospital, Complutense University, Madrid, Spain
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Madendağ Y, Sahin E, Col Madendag I, Eraslan Sahin M. Assessment of intrahepatic cholestasis in pregnancy and the effect of disease severity on transient tachypnea in the newborn in uncomplicated fetuses. J Perinat Med 2022; 50:87-92. [PMID: 34280960 DOI: 10.1515/jpm-2021-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/09/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Considering the effects of bile-acid levels on fetal lungs and pulmonary surfactants, we hypothesized that in the presence of intrahepatic pregnancy cholestasis (ICP), poor neonatal respiratory problems are observed in relation to the severity of the disease. Delivery timing with the presence of ICP is scheduled during late-preterm and early term gestational weeks. The aim of this study was to assess ICP and disease severity effects on transient tachypnea of the newborn (TTN) in uncomplicated fetuses. METHODS This study comprised 1,097 singleton pregnant women who were separated into three groups-control, mild ICP, and severe ICP. The pregnant women diagnosed with ICP between January 2010 and September 2020 was investigated using the hospital's database. For the control group, healthy pregnant women who met the same exclusion criteria and were similar in terms of maternal age, gestational age at delivery, and mode of delivery were analyzed. RESULTS The TTN rate was 14.5% in the severe ICP group, 6.5% in the mild ICP group, and 6.2% in the control group. The TTN rate in the severe ICP group was significantly higher than that in the other groups (p<0.001). Similarly, the rate of admission to the neonatal intensive care unit was significantly higher in the severe ICP group than in the other groups (p<0.001). According to Pearson correlation analyses, maternal serum bile-acid levels were positively correlated with TTN (r=0.082; p=0.002). CONCLUSIONS Severe ICP, but not mild ICP, and serum bile-acid levels were positively correlated with increased TTN risk and reduced pulmonary surfactant levels.
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Affiliation(s)
- Yusuf Madendağ
- Depertmant of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Erdem Sahin
- Depertmant of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Ilknur Col Madendag
- Department of Obstetrics and Gynecology, Kayseri City Hospital, Kayseri, Turkey
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14
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De Luca D, Autilio C. Strategies to protect surfactant and enhance its activity. Biomed J 2021; 44:654-662. [PMID: 34365021 PMCID: PMC8847817 DOI: 10.1016/j.bj.2021.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/21/2021] [Accepted: 07/29/2021] [Indexed: 11/22/2022] Open
Abstract
The knowledge about surfactant biology is now deeper and recent research has allowed to clarify its role in several human lung disorders. The balance between surfactant production and consumption is better known and the same applies to their regulatory mechanisms. This has allowed to hypothesize and investigate several new and original strategies to protect surfactant and enhance its activity. These interventions are potentially useful for several disorders and particularly for acute respiratory distress syndrome. We here highlight the mechanisms regulating surfactant consumption, encompassing surfactant catabolism but also surfactant injury due to other mechanisms, in a physiopathology-driven fashion. We then analyze each corresponding strategy to protect surfactant and enhance its activity. Some of these strategies are more advanced in terms of research & development pathway, some others are still investigational, but all are promising and deserve a joint effort from clinical-academic researchers and the industry.
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Affiliation(s)
- Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, "A.Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France; Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France.
| | - Chiara Autilio
- Dpt. of Biochemistry and Molecular Biology and Research Institute "Hospital 12 de Octubre", Complutense University, Madrid, Spain
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Hagenbeck C, Hamza A, Kehl S, Maul H, Lammert F, Keitel V, Hütten MC, Pecks U. Management of Intrahepatic Cholestasis of Pregnancy: Recommendations of the Working Group on Obstetrics and Prenatal Medicine - Section on Maternal Disorders. Geburtshilfe Frauenheilkd 2021; 81:922-939. [PMID: 34393256 PMCID: PMC8354365 DOI: 10.1055/a-1386-3912] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/05/2021] [Indexed: 02/07/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease specific to pregnancy. The cardinal symptom of pruritus and a concomitant elevated level of bile acids in the serum and/or alanine aminotransferase (ALT) are suggestive for the diagnosis. Overall, the maternal prognosis is good. The fetal outcome depends on the bile acid level. ICP is associated with increased risks for adverse perinatal outcomes, including preterm delivery, meconium-stained amniotic fluid, and stillbirth. Acute fetal asphyxia and not chronic uteroplacental dysfunction leads to stillbirth. Therefore, predictive fetal monitoring is not possible. While medication with ursodeoxycholic acid (UDCA) improves pruritus, it has not been shown to affect fetal outcome. The indication for induction of labour depends on bile acid levels and gestational age. There is a high risk of recurrence in subsequent pregnancies.
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Affiliation(s)
| | - Amr Hamza
- Universitätsklinikum des Saarlandes, Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Homburg, Germany
- Kantonsspital Baden AG, Baden, Switzerland
| | - Sven Kehl
- Frauenklinik, Friedrich Alexander University Erlangen Nuremberg, Faculty of Medicine, Erlangen, Germany
| | - Holger Maul
- Section of Prenatal Disgnostics and Therapy, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Frank Lammert
- Klinik für Innere Medizin II, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Verena Keitel
- Universitätsklinikum Düsseldorf, Klinik für Gastroenterologie, Hepatologie und Infektiologie, Düsseldorf, Germany
| | - Matthias C. Hütten
- Clinique E2 Neonatology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | - Ulrich Pecks
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Klinik für Gynäkologie und Geburtshilfe, Kiel, Germany
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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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18
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Wang Y, Zhu L, Xu D, Gao L, Li Y, Liang B, Zhang X, Yue Y. Intrahepatic Cholestasis of Pregnancy Is Associated with Reduced Nitric Oxide Synthase (iNOS) in Plasma and Placentas: A Pilot Study. Med Sci Monit 2021; 27:e930176. [PMID: 33846282 PMCID: PMC8052913 DOI: 10.12659/msm.930176] [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: 11/18/2022] Open
Abstract
Background Intrahepatic cholestasis of pregnancy (ICP) is a condition specific to pregnancy, leading to increased fetal morbidity and mortality. Nitric oxide synthase (iNOS) may be a factor regulating the vasodilation of blood vessels, which are relevant to ischemic-hypoxic conditions. We aimed to explore the potential relationship between iNOS and ICP. Material/Methods A prospective, case-control study was conducted including 77 pregnant women with ICP and 80 healthy pregnant women as controls. Enzyme-linked immunosorbent assays were used to investigate maternal plasma iNOS levels. The placenta mRNA levels and cell-specific localization of iNOS were determined by quantitative polymerase chain reaction, western blotting, and immunohistochemical analysis. A multivariate linear regression model was used to identify the independent factors of serum total biliary acids (TAB) in ICP. Results Compared with controls, the expression of iNOS was significantly lower in maternal serum and placentas with ICP (P<0.001). Maternal plasm iNOS levels were negatively correlated with TAB (r=−0.450, P<0.001), cholyglycine (r=−0.367, P<0.001), alanine aminotransferase (r=−.359, P<0.001), and aspartate aminotransferase (r=−0.329, P<0.001). iNOS level was an indicator for ICP by multivariate linear regression analysis (β=−0.505, P<0.001). The ROC curve indicated the optimal cut-off level for iNOS was 2865.43 pg/mL (sensitivity, 85.71%; specificity, 63.75%). The ROC curve area for iNOS was 0.793 (95% CI 0.722–0.864). Conclusions iNOS plays an important role in poor fetoplacental vascular perfusion and adverse pregnancy outcomes. iNOS can provide complementary information in predicting the extent and severity of ICP.
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Affiliation(s)
- Yun Wang
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Liping Zhu
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Duo Xu
- Department of Obstetrics and Gynecology, Shenzhen Maternity and Child Healthcare Hospital Affiliated with Southern Medical University, Shenzhen, Guangdong, China (mainland)
| | - Liying Gao
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Yongmei Li
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Baoquan Liang
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Xiaoqian Zhang
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Yongfei Yue
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
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Yule CS, Holcomb DS, Kraus AC, Brown CEL, McIntire DD, Nelson DB. Cholestasis: A Prospective Study of Perinatal Outcomes and Time to Symptom Improvement. Am J Perinatol 2021; 38:414-420. [PMID: 32971564 DOI: 10.1055/s-0040-1717076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Although intrahepatic cholestasis of pregnancy (ICP) remains poorly understood, there are several perinatal complications associated with this condition. This study aimed to examine perinatal outcomes of women with ICP, evaluate outcomes according to severity of disease, and monitor time to symptom improvement following diagnosis. STUDY DESIGN It involves a prospective, observational study of women with ICP at a single institution. Women with new-onset pruritus without rash were referred to a high-risk obstetrics clinic and evaluated with fasting total bile acids (TBA). Laboratory-confirmed ICP was defined as fasting TBA ≥10 µmol/L. Following diagnosis, a standardized protocol was utilized, including treatment with ursodeoxycholic acid (UDCA). Perinatal outcomes were compared amongst those with and without ICP, and to the general population. Women with ICP were further analyzed based on maximum TBA: 10 to 39, 40 to 99, and ≥100 µmol/L. A Kaplan-Meier survival curve was used to analyze time to symptom improvement. RESULTS A total of 404 patients were evaluated and 212 (52%) were diagnosed with ICP. The mean gestational age at diagnosis was 34.1 ± 3.3 weeks. When comparing those with ICP to those not confirmed, and to the general population, there were no differences in age, parity, mode of delivery, preeclampsia, or stillbirth (p > 0.05). Preterm birth was significantly associated with ICP (p < 0.01). This relationship was significant across increasing severity of TBA (p < 0.01) and persisted when examining rates of spontaneous preterm birth (p < 0.01). All women with fasting TBA ≥40 µmol/L delivered preterm due to premature rupture of membranes or spontaneous labor. Time to symptom improvement after diagnosis was over 2 weeks on average; however, this time increased with worsening severity of disease. CONCLUSION Despite treatment with UDCA, women with ICP are at increased risk for spontaneous preterm birth, and this risk significantly increased with severity of disease. Although not significant, a trend exists between increasing time to symptom improvement and worsening severity of disease. KEY POINTS · Preterm birth is significantly increased in patients diagnosed with intrahepatic cholestasis of pregnancy.. · The risk of preterm birth in women with ICP increases across increasing strata of disease.. · Following initiation of treatment in patients with ICP, symptom improvement takes more than 2 weeks..
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Affiliation(s)
- Casey S Yule
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Denisse S Holcomb
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alexandria C Kraus
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Charles E L Brown
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Donald D McIntire
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David B Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
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Li GH, Huang SJ, Li X, Liu XS, Du QL. Response of gut microbiota to serum metabolome changes in intrahepatic cholestasis of pregnant patients. World J Gastroenterol 2020; 26:7338-7351. [PMID: 33362388 PMCID: PMC7739160 DOI: 10.3748/wjg.v26.i46.7338] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 11/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intrahepatic cholestasis in pregnancy (ICP) is the most common liver disease during pregnancy, and its exact etiology and course of progression are still poorly understood.
AIM To investigate the link between the gut microbiota and serum metabolome in ICP patients.
METHODS In this study, a total of 30 patients were recruited, including 15 patients with ICP (disease group) and 15 healthy pregnant patients (healthy group). The serum nontarget metabolomes from both groups were determined. Amplification of the 16S rRNA V3-V4 region was performed using fecal samples from the disease and healthy groups. By comparing the differences in the microbiota and metabolite compositions between the two groups, the relationship between the gut microbiota and serum metabolites was also investigated.
RESULTS The Kyoto Encyclopedia of Genes and Genomes analysis results showed that the primary bile acid biosynthesis, bile secretion and taurine and hypotaurine metabolism pathways were enriched in the ICP patients compared with the healthy controls. In addition, some pathways related to protein metabolism were also enriched in the ICP patients. The principal coordination analysis results showed that there was a distinct difference in the gut microbiota composition (beta diversity) between the ICP patients and healthy controls. At the phylum level, we observed that the relative abundance of Firmicutes was higher in the healthy group, while Bacteroidetes were enriched in the disease group. At the genus level, most of the bacteria depleted in ICP are able to produce short-chain fatty acids (e.g., Faecalibacterium, Blautia and Eubacterium hallii), while the bacteria enriched in ICP are associated with bile acid metabolism (e.g., Parabacteroides and Bilophila). Our results also showed that specific genera were associated with the serum metabolome.
CONCLUSION Our study showed that the serum metabolome was altered in ICP patients compared to healthy controls, with significant differences in the bile, taurine and hypotaurine metabolite pathways. Alterations in the metabolization of these pathways may lead to disturbances in the gut microbiota, which may further affect the course of progression of ICP.
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Affiliation(s)
- Guo-Hua Li
- Department of Reproductive Immunology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 200040, China
| | - Shi-Jia Huang
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 200040, China
| | - Xiang Li
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 200040, China
| | - Xiao-Song Liu
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 200040, China
| | - Qiao-Ling Du
- Department of Obstetrics, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 200040, China
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21
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Li R, Chen X, Liu Z, Chen Y, Liu C, Ye L, Xiao L, Yang Z, He J, Wang WJ, Qi H. Characterization of gut microbiota associated with clinical parameters in intrahepatic cholestasis of pregnancy. BMC Gastroenterol 2020; 20:395. [PMID: 33225888 PMCID: PMC7682054 DOI: 10.1186/s12876-020-01510-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 10/21/2020] [Indexed: 12/20/2022] Open
Abstract
Background Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that specifically occurs in pregnancy. Elevated levels of liver transaminases aspartate aminotransferase, alanine aminotransferase and serum bilirubin levels are common biochemical characteristics in ICP. The disorder is associated with an increased risk of premature delivery and stillbirth. The characterization of the potential microbiota in ICP could go a long way in the prevention and treatment of this pregnancy disease. Methods A total of 58 patients were recruited for our study: 27 ICP patients and 31 healthy pregnant subjects with no ICP. The V3 and V4 regions of the 16S rDNA collected from fecal samples of both diseased and control groups were amplified. 16S rRNA gene amplicon sequencing was then performed on gut microbiota. Sequencing data were analyzed and the correlation between components of microbiota and patient ICP status was found. Related metabolic pathways, relative abundance and significantly different operational taxonomic units (OTUs) between ICP and controls were also identified. Results Elevated levels of total bile acid, ALT, AST, Dbil and Tbil were recorded or observed in ICP subjects as compared to the control. Gut microbiota in pregnant women was dominated by four major phyla and 27 core genera. PCoA analysis results indicated that there was no significant clustering in Bray–Curtis distance matrices. Our results showed that there was a correlation between specific OTUs and measured clinical parameters of pregnant women. Comparison at the different taxonomy levels revealed high levels of abundance of Blautia and Citrobacter in ICP patients. At the family level, Enterobacteriaceae and Leuconostocaceae were higher in ICP patients. 638 KEGG Orthologs and 138 pathways significantly differed in the two groups. PLS-DA model with VIP plots indicated a total of eight genera and seven species were key taxa in ICP and control groups. Conclusions Our research indicated that although there was no significant clustering by PCoA analysis, patients with ICP have increased rare bacteria at different phylogenetic levels. Our results also illustrated that all 638 KEGG Orthologs and 136 in 138 KEGG pathways were less abundant in ICP patients compared to the controls.
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Affiliation(s)
- Rong Li
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing, 400016, People's Republic of China.,International Collaborative Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Xuehai Chen
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing, 400016, People's Republic of China.,International Collaborative Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Zhongzhen Liu
- BGI-Shenzhen, Build 11, Beishan Industrial Zone, Yantian District, Shenzhen, 518000, People's Republic of China.,China National GeneBank, BGI-Shenzhen, Shenzhen, 518000, People's Republic of China
| | - Yan Chen
- BGI-Shenzhen, Build 11, Beishan Industrial Zone, Yantian District, Shenzhen, 518000, People's Republic of China.,China National GeneBank, BGI-Shenzhen, Shenzhen, 518000, People's Republic of China
| | - Chuan Liu
- BGI-Shenzhen, Build 11, Beishan Industrial Zone, Yantian District, Shenzhen, 518000, People's Republic of China.,China National GeneBank, BGI-Shenzhen, Shenzhen, 518000, People's Republic of China
| | - Lingfei Ye
- BGI-Shenzhen, Build 11, Beishan Industrial Zone, Yantian District, Shenzhen, 518000, People's Republic of China.,China National GeneBank, BGI-Shenzhen, Shenzhen, 518000, People's Republic of China
| | - Liang Xiao
- BGI-Shenzhen, Build 11, Beishan Industrial Zone, Yantian District, Shenzhen, 518000, People's Republic of China.,China National GeneBank, BGI-Shenzhen, Shenzhen, 518000, People's Republic of China
| | - Zhenjun Yang
- BGI-Shenzhen, Build 11, Beishan Industrial Zone, Yantian District, Shenzhen, 518000, People's Republic of China.,China National GeneBank, BGI-Shenzhen, Shenzhen, 518000, People's Republic of China
| | - Jian He
- BGI-Chongqing Clinical Laboratory, BGI-Shenzhen, Chongqing, 401120, People's Republic of China
| | - Wen-Jing Wang
- BGI-Shenzhen, Build 11, Beishan Industrial Zone, Yantian District, Shenzhen, 518000, People's Republic of China. .,China National GeneBank, BGI-Shenzhen, Shenzhen, 518000, People's Republic of China.
| | - Hongbo Qi
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China. .,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing, 400016, People's Republic of China. .,International Collaborative Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, Chongqing, 400016, People's Republic of China.
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Hilscher MB, Kamath PS, Eaton JE. Cholestatic Liver Diseases: A Primer for Generalists and Subspecialists. Mayo Clin Proc 2020; 95:2263-2279. [PMID: 33012354 DOI: 10.1016/j.mayocp.2020.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 01/03/2020] [Accepted: 01/16/2020] [Indexed: 02/08/2023]
Abstract
Cholestasis describes impairment in bile formation or flow which can manifest clinically with fatigue, pruritus, and jaundice. The differential diagnosis of cholestatic liver diseases is broad, and the etiologies of cholestasis vary in the anatomical location of the defect and acuity of presentation. Cholestasis may occur in a variety of clinical scenarios. Therefore, it is important for a diverse audience with varied clinical practices to have a basic understanding of manifestations of cholestatic liver diseases.
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Affiliation(s)
- Moira B Hilscher
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John E Eaton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Walker KF, Chappell LC, Hague WM, Middleton P, Thornton JG. Pharmacological interventions for treating intrahepatic cholestasis of pregnancy. Cochrane Database Syst Rev 2020; 7:CD000493. [PMID: 32716060 PMCID: PMC7389072 DOI: 10.1002/14651858.cd000493.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that can develop in pregnancy. It occurs when there is a build-up of bile acids in the maternal blood. It has been linked to adverse maternal and fetal/neonatal outcomes. As the pathophysiology is poorly understood, therapies have been largely empiric. As ICP is an uncommon condition (incidence less than 2% a year), many trials have been small. Synthesis, including recent larger trials, will provide more evidence to guide clinical practice. This review is an update of a review first published in 2001 and last updated in 2013. OBJECTIVES To assess the effects of pharmacological interventions to treat women with intrahepatic cholestasis of pregnancy, on maternal, fetal and neonatal outcomes. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (13 December 2019), and reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials, including cluster-randomised trials and trials published in abstract form only, that compared any drug with placebo or no treatment, or two drug intervention strategies, for women with a clinical diagnosis of intrahepatic cholestasis of pregnancy. DATA COLLECTION AND ANALYSIS The review authors independently assessed trials for eligibility and risks of bias. We independently extracted data and checked these for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 26 trials involving 2007 women. They were mostly at unclear to high risk of bias. They assessed nine different pharmacological interventions, resulting in 14 different comparisons. We judged two placebo-controlled trials of ursodeoxycholic acid (UDCA) in 715 women to be at low risk of bias. The ten different pharmacological interventions were: agents believed to detoxify bile acids (UCDA) and S-adenosylmethionine (SAMe); agents used to bind bile acids in the intestine (activated charcoal, guar gum, cholestyramine); Chinese herbal medicines (yinchenghao decoction (YCHD), salvia, Yiganling and Danxioling pill (DXLP)), and agents aimed to reduce bile acid production (dexamethasone) Compared with placebo, UDCA probably results in a small improvement in pruritus score measured on a 100 mm visual analogue scale (VAS) (mean difference (MD) -7.64 points, 95% confidence interval (CI) -9.69 to -5.60 points; 2 trials, 715 women; GRADE moderate certainty), where a score of zero indicates no itch and a score of 100 indicates severe itching. The evidence for fetal distress and stillbirth were uncertain, due to serious limitations in study design and imprecision (risk ratio (RR) 0.70, 95% CI 0.35 to 1.40; 6 trials, 944 women; RR 0.33, 95% CI 0.08 to 1.37; 6 trials, 955 women; GRADE very low certainty). We found very few differences for the other comparisons included in this review. There is insufficient evidence to indicate if SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, Salvia, Yinchenghao decoction, Danxioling and Yiganling, or Yiganling alone or in combination are effective in treating women with intrahepatic cholestasis of pregnancy. AUTHORS' CONCLUSIONS When compared with placebo, UDCA administered to women with ICP probably shows a reduction in pruritus. However the size of the effect is small and for most pregnant women and clinicians, the reduction may fall below the minimum clinically worthwhile effect. The evidence was unclear for other adverse fetal outcomes, due to very low-certainty evidence. There is insufficient evidence to indicate that SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, YCHD, DXLP, Salvia, Yiganling alone or in combination are effective in treating women with cholestasis of pregnancy. There are no trials of the efficacy of topical emollients. Further high-quality trials of other interventions are needed in order to identify effective treatments for maternal itching and preventing adverse perinatal outcomes. It would also be helpful to identify those women who are mostly likely to respond to UDCA (for example, whether bile acid concentrations affect how women with ICP respond to treatment with UDCA).
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Affiliation(s)
- Kate F Walker
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
| | - William M Hague
- Women's and Children's Hospital, North Adelaide, Australia
- Robinson Research Institute, The University of Adelaide, North Adelaide, Australia
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
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Arthuis C, Diguisto C, Lorphelin H, Dochez V, Simon E, Perrotin F, Winer N. Perinatal outcomes of intrahepatic cholestasis during pregnancy: An 8-year case-control study. PLoS One 2020; 15:e0228213. [PMID: 32074108 PMCID: PMC7029845 DOI: 10.1371/journal.pone.0228213] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/10/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Previous studies of fetal effects have suggested that intrahepatic cholestasis of pregnancy is associated with a higher rate of adverse neonatal outcomes including preterm birth, neonatal respiratory distress syndrome, meconium-stained amniotic fluid, neonatal intensive care unit admission, and stillbirth. The objective was to compare the neonatal and maternal consequences in pregnancies affected by intrahepatic cholestasis and normal pregnancies. MATERIAL AND METHODS This case-control study compares pregnancies affected by intrahepatic cholestasis (pruritus and bile acid ≥ 10 μmol/L) with low-risk pregnancies managed between December 2006 and December 2014 at a French university hospital center. RESULTS There were 83 (59.3%) cases of mild cholestasis (10≤ BA ≤39 μmol/L), 46 (32.8%) of moderate cholestasis (40≤ BA ≤99 μmol/L), and 11 (7.9%) of severe cholestasis (BA ≥100 μmol/L). No in utero fetal deaths occurred in the 140 women with cholestasis or the 560 controls analyzed. The rate of respiratory distress syndrome was higher in neonates of women with intrahepatic cholestasis (17.1% vs. 4.6%, P<0.001; crude OR 4.46 (CI95% 2.49-8.03)). This risk was also significant after adjustment for gestational age at birth and mode of delivery, adjusted OR 2.56 (CI95%1.26-5.18). The postpartum hemorrhage rate was twice as high among the case mothers (25% versus 14.1% for controls, P = 0.002). CONCLUSION After adjustment on the confounding factors we found a higher rate of respiratory distress syndrome and neonatal morbidity among neonates of the cholestasis group.
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Affiliation(s)
- Chloé Arthuis
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
- Department of Gynecology and Obstetrics, University Hospital Center Nantes, Nantes, France
- * E-mail:
| | - Caroline Diguisto
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
| | - Henri Lorphelin
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
| | - Vincent Dochez
- Department of Gynecology and Obstetrics, University Hospital Center Nantes, Nantes, France
| | - Emmanuel Simon
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
| | - Franck Perrotin
- Department of Gynecology and Obstetrics, University Hospital Regional Center Tours, Tours, France
| | - Norbert Winer
- Department of Gynecology and Obstetrics, University Hospital Center Nantes, Nantes, France
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Raschetti R, Yousef N, Vigo G, Marseglia G, Centorrino R, Ben-Ammar R, Shankar-Aguilera S, De Luca D. Echography-Guided Surfactant Therapy to Improve Timeliness of Surfactant Replacement: A Quality Improvement Project. J Pediatr 2019; 212:137-143.e1. [PMID: 31079857 DOI: 10.1016/j.jpeds.2019.04.020] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/20/2019] [Accepted: 04/10/2019] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To improve time of surfactant administration with a surfactant replacement protocol based on semiquantitative lung ultrasound score (LUS) thresholds. STUDY DESIGN Quality improvement (QI), prospective, before-after, pilot study. In a 6-month period surfactant replacement was based only on inspired oxygen fraction (FiO2) thresholds. In the second 6-month period, surfactant was given when either the FiO2 or LUS exceeded the limits. The main QI measures were the proportion of neonates receiving surfactant within the first 3 hours of life and maximal FiO2 reached before surfactant replacement. Secondary QI measures were the duration of respiratory support and ventilator-free days. Data were also collected for 1 year after the study to verify sustainability. RESULTS Echography-guided Surfactant THERapy (ESTHER) increased the proportion of neonates receiving surfactant within the first 3 hours of life (71.4%-90%; P < .0001) and reduced the maximal FiO2 reached before surfactant replacement (0.33 [0.26-0.5]) vs 0.4 [0.4-0.55]; P = .005). The global need for surfactant did not significantly change. ESTHER also resulted in a significant decrease in duration of invasive ventilation and ventilator-free days. CONCLUSIONS ESTHER improved the timeliness of surfactant administration and secondary QI indicators related to surfactant replacement.
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Affiliation(s)
- Roberto Raschetti
- Division of Pediatrics and Neonatal Critical Care, A. Béclère Medical Center, South Paris University Hospitals, AP-HP, Paris, France; Medical School, South Paris-Saclay University, Paris, France; School of Pediatrics, University of Pavia, Pavia, Italy
| | - Nadya Yousef
- Division of Pediatrics and Neonatal Critical Care, A. Béclère Medical Center, South Paris University Hospitals, AP-HP, Paris, France
| | - Giulia Vigo
- Division of Pediatrics and Neonatal Critical Care, A. Béclère Medical Center, South Paris University Hospitals, AP-HP, Paris, France
| | | | - Roberta Centorrino
- Division of Pediatrics and Neonatal Critical Care, A. Béclère Medical Center, South Paris University Hospitals, AP-HP, Paris, France
| | - Rafik Ben-Ammar
- Division of Pediatrics and Neonatal Critical Care, A. Béclère Medical Center, South Paris University Hospitals, AP-HP, Paris, France
| | - Shivani Shankar-Aguilera
- Division of Pediatrics and Neonatal Critical Care, A. Béclère Medical Center, South Paris University Hospitals, AP-HP, Paris, France
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, A. Béclère Medical Center, South Paris University Hospitals, AP-HP, Paris, France; Medical School, South Paris-Saclay University, Paris, France.
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Vivanti AJ, Voican C, De Luca D, Benachi A. Intrahepatic cholestasis: suggested future investigations. Lancet 2019; 394:e17. [PMID: 31272691 DOI: 10.1016/s0140-6736(19)31391-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/05/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Alexandre J Vivanti
- Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, AP-HP, 92140 Clamart, France; Université Paris-Sud, Orsay, France.
| | - Cosmin Voican
- Service d'Hépato-Gastro-Entérologie, Hôpital Antoine Béclère, AP-HP, 92140 Clamart, France; Université Paris-Sud, Orsay, France
| | - Daniele De Luca
- Service de Réanimation Néonatale, Hôpital Antoine Béclère, AP-HP, 92140 Clamart, France; Université Paris-Sud, Orsay, France
| | - Alexandra Benachi
- Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, AP-HP, 92140 Clamart, France; Université Paris-Sud, Orsay, France
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Intrahepatic Cholestasis of Pregnancy: A Case Study of the Rare Onset in the First Trimester. ACTA ACUST UNITED AC 2019; 55:medicina55080454. [PMID: 31404990 PMCID: PMC6723234 DOI: 10.3390/medicina55080454] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 12/27/2022]
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a gestation-specific liver disorder, defined most often as the onset of pruritus, usually from the third trimester of pregnancy, associated with abnormal liver test results and/or increased total serum bile acids and spontaneous relief after delivery. The 21-year-old patient was admitted to our ward in the 11th week of pregnancy due to raised liver enzymes. The first onset of pruritus and jaundice appeared a month before hospitalization. Immunology tests and Toxoplasma gondii were negative. We excluded viral etiology, while alpha-1-antitrypsin, serum and urine copper levels, and thyroid hormones were within the reference values. The patient denied she had taken any medicines and herbal preparations before and during pregnancy. Total bile acids in the serum were significantly elevated (242 μmol/L). The abdominal ultrasound revealed a regular finding. Liver biopsy suggested a cholestatic liver disorder. After a presentation of all risks, the patient decided to stop the pregnancy. After a month, the hepatogram was within the reference values. Very rarely an ICP can occur in early pregnancy (first trimester), which calls for close monitoring. The risk of serious adverse fetal outcomes and spontaneous preterm delivery is proportional with increased levels of maternal serum bile acid.
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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: 19] [Impact Index Per Article: 3.8] [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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Manzotti C, Casazza G, Stimac T, Nikolova D, Gluud C. Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy. Cochrane Database Syst Rev 2019; 7:CD012546. [PMID: 31283001 PMCID: PMC6613619 DOI: 10.1002/14651858.cd012546.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy is a pregnancy-specific liver disorder, possibly associated with an increased risk of severe fetal adverse events. Total serum bile acids (TSBA) concentration, alone or in combination with serum aminotransferases, have been the most often used biomarkers for the diagnosis of intrahepatic cholestasis of pregnancy in clinical practice. Serum bile acid profile, composed of primary or secondary, conjugated or non-conjugated bile acids, may provide more specific disease information. OBJECTIVES To assess and compare, independently or in combination, the diagnostic accuracy of total serum bile acids or serum bile acids profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women, presenting with pruritus. To define the optimal cut-off values for components of serum bile acid profile; to investigate possible sources of heterogeneity. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register, the Cochrane Library, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, BIOSIS, CINAHL, two Chinese databases (CKNI, VIP), Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Evidence Search: Health and Social Care by the National Institute for Health and Care Excellence (NICE), the World Health Organization (WHO) Reproductive Health Library (RHL), and the Turning Research into Practice database (TRIP). The most recent date of search was 6 May 2019. We identified additional references by handsearching the references of articles, meta-analyses, and evidence-based guidelines retrieved from the computerised databases, on-line trial registries, and grey literature through OpenSIGLE, National Technical Information Service (NTIS), ProQuest Dissertations & Thesis Database, and Index to Theses in Great Britain and Ireland. SELECTION CRITERIA Prospective or retrospective diagnostic case-control or cross-sectional studies, irrespective of publication date, format, and language, which evaluated the diagnostic accuracy of total serum bile acids (TSBA) or components of serum bile acid profile for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women of any age or ethnicity, in any clinical setting, symptomatic for pruritus. DATA COLLECTION AND ANALYSIS We selected studies by reading titles, abstracts, or full texts, and assessing their fulfilment of our inclusion criteria. We emailed primary authors to request missing data or individual participant data. Having extracted data from each included study, we built the two-by-two tables for each primary study and for all the index tests considered. We estimated sensitivity and specificity with their 95% confidence intervals (CI). We presented data in coupled forest plots, showing sensitivities and specificities of each study, and we plotted the studies in the Receiver Operating Characteristic (ROC) space. We performed meta-analyses adopting the hierarchical summary ROC model (HSROC) or the bivariate model to meta-analyse the data. We made indirect comparisons of the considered index tests by adding the index tests as covariates to the bivariate or HSROC models. We performed heterogeneity analysis and sensitivity analysis on studies assessing TSBA accuracy. We used Review Manager 5 (RevMan 5) and SAS statistical software, release 9.4 (SAS Institute Inc., Cary, NC, USA), to perform all statistical analyses. We used QUADAS-2 domains to assess the risk of bias of the included studies. MAIN RESULTS Our search yielded 5073 references, but at the end of our selection process, only 16 studies fulfilled the review inclusion criteria. Nine of these provided individual participant data. We analysed only data concerning TSBA, cholic acid (CA), glycocholic acid (GCA), chenodeoxycholic acid (CDCA), and CA/CDCA because the remaining planned index tests were assessed in few studies. Only one study had low risk of bias in all four QUADAS-2 domains. The most biased domains were the patient sampling and the reference standard domains. When considering all studies with a cut-off of 10 μmol/L, TSBA overall sensitivity ranged from 0.72 to 0.98 and specificity ranged from 0.81 to 0.97. After a sensitivity analysis excluding case-control studies, TSBA sensitivity ranged from 0.48 to 0.66 and specificity from 0.52 to 0.99. After a sensitivity analysis excluding studies in which TSBA was part of the reference standard, TSBA sensitivity ranged from 0.49 to 0.65 and specificity from 0.53 to 0.99. We found the estimates of the overall accuracy for some serum bile acid components (CA, GCA, CDCA, and CA/CDCA) to be imprecise, with the CI for sensitivity and specificity very wide or impossible to calculate. Indirect comparisons between serum bile acid profile components and TSBA were not statistically significant. None of the heterogeneity analysis performed was statistically significant, except for the timing of assessment of TSBA (onset of symptoms, peak value among multiple assessments, delivery) but without clinically relevant results. We could not analyse the diagnostic accuracy of combinations of index tests because none of the included studies carried them out, and because of the small number of included studies. AUTHORS' CONCLUSIONS The overall high risk of bias, the existing concern regarding applicability of the results in clinical practice, and the great heterogeneity of the results in the included studies prevents us from making recommendations and reaching definitive conclusions at the present time. Thus, we do not find any compelling evidence to recommend or refute the routine use of any of these tests in clinical practice. So far, the diagnostic accuracy of TSBA for intrahepatic cholestasis of pregnancy might have been overestimated. There were too few studies to permit a precise estimate of the accuracy of serum bile acid profile components. Further primary clinical research is mandatory. We need both further phase II and phase III diagnostic studies.
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Affiliation(s)
- Cristina Manzotti
- Fondazione IRCCS Ca' Granda ‐ Ospedale Maggiore Policlinico, Università degli Studi di MilanoObstetrics and Gynecology DepartmentVia Commenda 12 ‐ Clinica Mangiagalli, piano terraMilanMilanItaly20122
- Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
- Fondazione IRCCS Ca' Granda ‐ Ospedale Maggiore Policlinico, Università degli Studi di MilanoGastro‐Intestinal UnitVia Commenda 12 ‐ Clinica Mangiagalli, 1° piano, scala AMilanMilanItaly20122
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
| | - Tea Stimac
- Clinical Hospital Centre RijekaObstetrics and GynecologyCambierieva 17RijekaCroatia51000
| | - Dimitrinka Nikolova
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Mohan M, Antonios A, Konje J, Lindow S, Ahmed Syed M, Akobeng A. Stillbirth and associated perinatal outcomes in obstetric cholestasis: a systematic review and meta-analysis of observational studies. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100026. [PMID: 31403117 PMCID: PMC6687374 DOI: 10.1016/j.eurox.2019.100026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/06/2019] [Accepted: 04/16/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Obstetric cholestasis is a condition occurring in pregnancy with suspected adverse perinatal outcomes. Stillbirth is a significant adverse event associated with obstetric cholestasis and considered for intervention in pregnancy. OBJECTIVES There are multiple studies with epidemiological data with regards to the outcomes of obstetric cholestasis. Our hypothesis is to the test the association of stillbirth and related outcomes in obstetric cholestasis. SEARCH STRATEGY & SELECTION CRITERIA Two independent reviewers did independent searches and selection with a standardized design as outlined in the PRISMA statement. ANALYSIS The retrieved relevant literature was subjected to a rigorous quality assessment and followed by standardized interpretable results. RESULTS The pooled estimate in this study showed that there was no significant difference in the stillbirth rates in the obstetric (OC) population when compared to the non-obstetric cholestasis (reference) population. However, there was an increased risk of preterm birth in the OC population compared to the reference population; however, the cesarean section and induction of labor results were directly related. DISCUSSION This study provides an epidemiological data related to the perinatal outcomes associated with obstetric cholestasis, specifically stillbirth. This result is likely to produce a benchmark for current evidence-based practice and to assist future research in understanding the implication of associated stillbirth risk and related outcomes with OC.
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Affiliation(s)
- Manoj Mohan
- Women’s Clinical Management Group (WCMG), Sidra Medicine, Doha, Qatar
| | | | | | | | | | - Anthony Akobeng
- Gastro intestinal Hepatology & Nutritional Unit, Sidra Medicine, Doha, Qatar
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Raschetti R, Centorrino R, Letamendia E, Benachi A, Marfaing-Koka A, De Luca D. Estimation of early life endogenous surfactant pool and CPAP failure in preterm neonates with RDS. Respir Res 2019; 20:75. [PMID: 30992006 PMCID: PMC6469148 DOI: 10.1186/s12931-019-1040-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/02/2019] [Indexed: 11/20/2022] Open
Abstract
Background It is not known if the endogenous surfactant pool available early in life is associated with the RDS clinical course in preterm neonates treated with CPAP. We aim to clarify the clinical factors affecting surfactant pool in preterm neonates and study its association with CPAP failure. Methods Prospective, pragmatic, blind, cohort study. Gastric aspirates were obtained (within the first 6 h of life and before the first feeding) from 125 preterm neonates with RDS. Surfactant pool was measured by postnatal automated lamellar body count based on impedancemetry, without any pre-analytical treatment. A formal respiratory care protocol based on European guidelines was applied. Clinical data and perinatal risk factors influencing RDS severity or lamellar body count were real-time recorded. Investigators performing lamellar body count were blind to the clinical data and LBC was not used in clinical practice. Results Multivariate analysis showed gestational age to be the only factor significantly associated with lamellar body count (standardized β:0.233;p = 0.023). Lamellar body count was significantly higher in neonates with CPAP success (43.500 [23.750–93.750]bodies/μL), than in those failing CPAP (20.500 [12.250–49.750] bodies/μL;p = 0.0003).LBC had a moderate reliability to detect CPAP failure (AUC: 0.703 (0.615–0.781);p < 0.0001; best cut-off: ≤30,000 bodies/μL). Upon adjustment for possible confounders, neither lamellar body count, nor its interaction factor with gestational age resulted associated with CPAP failure. Conclusions Early postnatal lamellar body count on gastric aspirates in CPAP-treated preterm neonates with RDS is significantly influenced only by gestational age. Lamellar bodies are not associated with CPAP failure. Thus, the endogenous surfactant pool available early in life only has a moderate reliability to predict CPAP failure.
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Affiliation(s)
- Roberto Raschetti
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A.Béclère", South Paris University Hospitals, AP-HP, Paris, France
| | - Roberta Centorrino
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A.Béclère", South Paris University Hospitals, AP-HP, Paris, France
| | - Emmanuelle Letamendia
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A.Béclère", South Paris University Hospitals, AP-HP, Paris, France.,Division of Obstetrics and Gynecology, Medical Center "A.Béclère", South Paris University Hospitals, AP-HP, Paris, France.,Division of Hematology, Medical Center "A.Béclère", South Paris University Hospitals, AP-HP, Paris, France
| | - Alexandra Benachi
- Division of Obstetrics and Gynecology, Medical Center "A.Béclère", South Paris University Hospitals, AP-HP, Paris, France
| | - Anne Marfaing-Koka
- Division of Hematology, Medical Center "A.Béclère", South Paris University Hospitals, AP-HP, Paris, France
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A.Béclère", South Paris University Hospitals, AP-HP, Paris, France. .,Physiopathology and Therapeutic Innovation Unit-UNSERM U999, South Paris-Saclay University, Paris, France.
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Autilio C, Shankar-Aguilera S, Minucci A, Touqui L, De Luca D. Effect of cooling on lung secretory phospholipase A2 activity in vitro, ex vivo, and in vivo. Am J Physiol Lung Cell Mol Physiol 2019; 316:L498-L505. [DOI: 10.1152/ajplung.00201.2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hypothermia can modify surfactant composition and function. Secretory phospholipase A2 (sPLA2) hydrolyses surfactant phospholipids and is important in the pathobiology of several critical respiratory disorders. We hypothesize that sPLA2 activity might be influenced by the temperature partially explaining surfactant changes. This study aims to evaluate comprehensively the effect of hypothermia on sPLA2 activity. We measured sPLA2 activity at different temperatures, alone or combined with bile acids, in vitro (incubating human recombinant sPLA2-IIA and porcine sPLA2-IB), ex vivo (by cooling bronchoalveolar lavage samples from neonates with respiratory distress syndrome or no lung disease), and in vivo (using lavage samples obtained before and after 72 h of whole body cooling in neonates with hypoxic-ischemic encephalopathy). We also measured concentrations of various sPLA2 subtypes and natural sPLA2 inhibitors in in vivo cooled samples. Results were corrected for protein content and dilution. In vitro cooling did not show any effect of hypothermia on sPLA2. Ex vivo cooling did not alter total sPLA2 activity, and the addition of bile acids increased sPLA2 activity irrespective of the temperature and the type of sampled patient. In vivo hypothermia reduced median sPLA2 activity from 16.6 [15.2–106.7] IU/mg to 3.3 [2.7–8.5] IU/mg ( P = 0.026) and mean sPLA2-IIA from 1.1 (0.8) pg/μg to 0.6 (0.4) pg/μg ( P = 0.047), whereas dioleylphosphatidylglycerol increased from 8.3 (3.9)% to 12.8 (5.1)% ( P = 0.02). Whole body hypothermia decreases in vivo global sPLA2 activity in bronchoalveolar lavage fluids through the reduction of sPLA2-IIA and increment of dioleylphosphatidylglycerol. This effect is absent during in vitro or ex vivo hypothermia.
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Affiliation(s)
- Chiara Autilio
- Laboratory of Clinical Molecular Biology, Department of Laboratory Medicine, University Hospital “A.Gemelli,” Catholic University of the Sacred Heart, Rome, Italy
- Dept of Biochemistry and Molecular Biology, Faculty of Biology, Complutense University, Madrid, Spain
| | - Shivani Shankar-Aguilera
- Division of Pediatrics and Neonatal Critical Care, Medical Center “A.Béclère,” South Paris University Hospitals, Assistance Publique-Hopitaux de Paris, Paris, France
- Respiratory Physiopathology Unit, Institut Pasteur, Paris, France
| | - Angelo Minucci
- Laboratory of Clinical Molecular Biology, Department of Laboratory Medicine, University Hospital “A.Gemelli,” Catholic University of the Sacred Heart, Rome, Italy
| | | | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Medical Center “A.Béclère,” South Paris University Hospitals, Assistance Publique-Hopitaux de Paris, Paris, France
- Physiopathology and Therapeutic Innovation Unit, South Paris-Saclay University, Paris, France
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Hegyi P, Maléth J, Walters JR, Hofmann AF, Keely SJ. Guts and Gall: Bile Acids in Regulation of Intestinal Epithelial Function in Health and Disease. Physiol Rev 2019; 98:1983-2023. [PMID: 30067158 DOI: 10.1152/physrev.00054.2017] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Epithelial cells line the entire surface of the gastrointestinal tract and its accessory organs where they primarily function in transporting digestive enzymes, nutrients, electrolytes, and fluid to and from the luminal contents. At the same time, epithelial cells are responsible for forming a physical and biochemical barrier that prevents the entry into the body of harmful agents, such as bacteria and their toxins. Dysregulation of epithelial transport and barrier function is associated with the pathogenesis of a number of conditions throughout the intestine, such as inflammatory bowel disease, chronic diarrhea, pancreatitis, reflux esophagitis, and cancer. Driven by discovery of specific receptors on intestinal epithelial cells, new insights into mechanisms that control their synthesis and enterohepatic circulation, and a growing appreciation of their roles as bioactive bacterial metabolites, bile acids are currently receiving a great deal of interest as critical regulators of epithelial function in health and disease. This review aims to summarize recent advances in this field and to highlight how bile acids are now emerging as exciting new targets for disease intervention.
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Affiliation(s)
- Peter Hegyi
- Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged , Szeged , Hungary ; Institute for Translational Medicine, Medical School, University of Pécs , Pécs , Hungary ; Momentum Epithelial Cell Signalling and Secretion Research Group and First Department of Medicine, University of Szeged , Szeged , Hungary ; Division of Digestive Diseases, Department of Gastroenterology, Hammersmith Hospital, Imperial College London , London , United Kingdom ; Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California ; and Department of Molecular Medicine, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital , Dublin , Ireland
| | - Joszef Maléth
- Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged , Szeged , Hungary ; Institute for Translational Medicine, Medical School, University of Pécs , Pécs , Hungary ; Momentum Epithelial Cell Signalling and Secretion Research Group and First Department of Medicine, University of Szeged , Szeged , Hungary ; Division of Digestive Diseases, Department of Gastroenterology, Hammersmith Hospital, Imperial College London , London , United Kingdom ; Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California ; and Department of Molecular Medicine, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital , Dublin , Ireland
| | - Julian R Walters
- Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged , Szeged , Hungary ; Institute for Translational Medicine, Medical School, University of Pécs , Pécs , Hungary ; Momentum Epithelial Cell Signalling and Secretion Research Group and First Department of Medicine, University of Szeged , Szeged , Hungary ; Division of Digestive Diseases, Department of Gastroenterology, Hammersmith Hospital, Imperial College London , London , United Kingdom ; Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California ; and Department of Molecular Medicine, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital , Dublin , Ireland
| | - Alan F Hofmann
- Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged , Szeged , Hungary ; Institute for Translational Medicine, Medical School, University of Pécs , Pécs , Hungary ; Momentum Epithelial Cell Signalling and Secretion Research Group and First Department of Medicine, University of Szeged , Szeged , Hungary ; Division of Digestive Diseases, Department of Gastroenterology, Hammersmith Hospital, Imperial College London , London , United Kingdom ; Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California ; and Department of Molecular Medicine, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital , Dublin , Ireland
| | - Stephen J Keely
- Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences-University of Szeged , Szeged , Hungary ; Institute for Translational Medicine, Medical School, University of Pécs , Pécs , Hungary ; Momentum Epithelial Cell Signalling and Secretion Research Group and First Department of Medicine, University of Szeged , Szeged , Hungary ; Division of Digestive Diseases, Department of Gastroenterology, Hammersmith Hospital, Imperial College London , London , United Kingdom ; Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California ; and Department of Molecular Medicine, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital , Dublin , Ireland
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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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Mei Y, Lin Y, Luo D, Gao L, He L. Perinatal outcomes in intrahepatic cholestasis of pregnancy with monochorionic diamniotic twin pregnancy. BMC Pregnancy Childbirth 2018; 18:291. [PMID: 29980184 PMCID: PMC6035470 DOI: 10.1186/s12884-018-1913-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 06/22/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The primary aim of the study is to investigate the perinatal outcomes in intrahepatic cholestasis of pregnancy (ICP) with monochorionic diamniotic (MCDA) twin pregnancy. METHODS This study is a retrospective observational study for women with ICP and MCDA twin pregnancy. Included cases were divided into mild ICP group (10-39 mmol/L) and severe ICP group (> = 40 mmol/L), whose perinatal outcomes were compared between this two groups and whose predictors of adverse perinatal outcomes were evaluated. RESULTS 37 cases and 21 cases are in mild and severe ICP group respectively, of which, the incidence of gestational diabetes mellitus (GDM) and iatrogenic preterm delivery in severe ICP group are higher than those in mild ICP group. Gestational age (GA) at diagnosis of ICP < 32 weeks is an independent risk factor for GA at delivery < 35 weeks and for composite adverse neonatal outcome. Total bile acids (TBA) > 40 mmol/l is an independent risk factor for meconium-stained amniotic fluid. CONCLUSION For women with ICP and MCDA twin pregnancy, GA at diagnosis of ICP < 32 weeks and TBA > 40umol/L are associated with adverse perinatal outcomes.
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MESH Headings
- Adult
- China/epidemiology
- Cholestasis, Intrahepatic/diagnosis
- Cholestasis, Intrahepatic/epidemiology
- Female
- Gestational Age
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/epidemiology
- Parturition
- Pregnancy
- Pregnancy Complications/diagnosis
- Pregnancy Complications/epidemiology
- Pregnancy Outcome/epidemiology
- Pregnancy, Twin/physiology
- Pregnancy, Twin/statistics & numerical data
- Premature Birth/diagnosis
- Premature Birth/epidemiology
- Premature Birth/prevention & control
- Prognosis
- Retrospective Studies
- Risk Factors
- Severity of Illness Index
- Twins, Monozygotic
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Affiliation(s)
- Youwen Mei
- Department of Obstetrics and Gynecology, Chengdu Women and Children’s Central Hospital, Chengdu City, Sichuan Province China
| | - Yonghong Lin
- Department of Obstetrics and Gynecology, Chengdu Women and Children’s Central Hospital, Chengdu City, Sichuan Province China
| | - Dan Luo
- Department of Obstetrics and Gynecology, Chengdu Women and Children’s Central Hospital, Chengdu City, Sichuan Province China
| | - Lan Gao
- Department of Obstetrics and Gynecology, Chengdu Women and Children’s Central Hospital, Chengdu City, Sichuan Province China
| | - Li He
- Department of Obstetrics and Gynecology, Chengdu Women and Children’s Central Hospital, Chengdu City, Sichuan Province China
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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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Cholestases intrahepatiques gravidiques (CIG) précoces et tardives : étude des complications materno-fœtales. ACTA ACUST UNITED AC 2018; 46:388-394. [DOI: 10.1016/j.gofs.2018.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Indexed: 12/27/2022]
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Manzotti C, Casazza G, Stimac T, Nikolova D, Gluud C. Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2017. [DOI: 10.1002/14651858.cd012546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Cristina Manzotti
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano; Obstetrics and Gynecology Department; Via Commenda 12 - Clinica Mangiagalli, piano terra Milan Milan Italy 20122
- Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano; Gastro-Intestinal Unit; Via Commenda 12 - Clinica Mangiagalli, 1° piano, scala A Milan Milan Italy 20122
| | - Giovanni Casazza
- Università degli Studi di Milano; Dipartimento di Scienze Biomediche e Cliniche "L. Sacco"; via GB Grassi 74 Milan Italy 20157
| | - Tea Stimac
- Clinical Hospital Centre Rijeka; Obstetrics and Gynecology; Cambierieva 17 Rijeka Croatia 51000
| | - Dimitrinka Nikolova
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
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Morphologic Damage of Rat Alveolar Epithelial Type II Cells Induced by Bile Acids Could Be Ameliorated by Farnesoid X Receptor Inhibitor Z-Guggulsterone In Vitro. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9283204. [PMID: 27340672 PMCID: PMC4908247 DOI: 10.1155/2016/9283204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/05/2016] [Accepted: 04/11/2016] [Indexed: 12/16/2022]
Abstract
Objective. To determine whether bile acids (BAs) affect respiratory functions through the farnesoid X receptor (FXR) expressed in the lungs and to explore the possible mechanisms of BAs-induced respiratory disorder. Methods. Primary cultured alveolar epithelial type II cells (AECIIs) of rat were treated with different concentrations of chenodeoxycholic acid (CDCA) in the presence or absence of FXR inhibitor Z-guggulsterone (GS). Then, expression of FXR in nuclei of AECIIs was assessed by immunofluorescence microscopy. And ultrastructural changes of the cells were observed under transmission electron microscope and analyzed by Image-Pro Plus software. Results. Morphologic damage of AECIIs was exhibited in high BAs group in vitro, with high-level expression of FXR, while FXR inhibitor GS could attenuate the cytotoxicity of BAs to AECIIs. Conclusions. FXR expression was related to the morphologic damage of AECIIs induced by BAs, thus influencing respiratory functions.
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Abstract
OBJECTIVE To verify if preterm neonates transferred between tertiary referral centers have worse outcomes than matched untransferred infants. DESIGN Cohort study with a historically matched control group. SETTING Two tertiary-level neonatal ICUs. PATIENTS Seventy-five neonates per group. INTERVENTIONS Transfer between tertiary-level neonatal ICUs carried out by a fully equipped transportation team. MEASUREMENTS AND MAIN RESULTS We measured in-hospital mortality, frequency of intraventricular hemorrhage greater than 2nd grade, periventricular leukomalacia, necrotizing enterocolitis greater than or equal to grade 2, bronchopulmonary dysplasia, composite outcomes (in-hospital mortality/bronchopulmonary dysplasia, in-hospital mortality/intraventricular hemorrhage > 2nd grade, and bronchopulmonary dysplasia/periventricular leukomalacia/intraventricular hemorrhage > 2nd grade), length of neonatal ICU stay, weight at discharge, and time spent on ventilatory support. Seventy-five similar (except for antenatal steroids administration) neonates were enrolled in each cohort. Cohorts did not differ in mortality, bronchopulmonary dysplasia, intraventricular hemorrhage greater than 2nd grade, periventricular leukomalacia, necrotizing enterocolitis greater than or equal to grade 2, any composite outcomes, neonatal ICU stay, weight at discharge, and duration of respiratory support. Results were unchanged adjusting for antenatal steroids. CONCLUSIONS Neonatal transfer between tertiary-level centers does not impact on clinical outcomes, if performed under optimal conditions.
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Abstract
Determining the optimal timing for induction of labor is critical in minimizing the risks to maternal and fetal health. While data are available to guide us in some clinical situations, such as hypertension and diabetes, many gaps in knowledge still exist in others, including cholestasis of pregnancy, fetal anomalies, and placental abruption. This review of the currently available literature assesses the risks and benefits of preterm and early term induction in a wide variety of maternal and fetal conditions.
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Affiliation(s)
- Stephen J Bacak
- Department of Obstetrics and Gynecology, University of Rochester, Elmwood Ave, Box 668, Rochester, NY 14642
| | - Courtney Olson-Chen
- Department of Obstetrics and Gynecology, University of Rochester, Elmwood Ave, Box 668, Rochester, NY 14642
| | - Eva Pressman
- Department of Obstetrics and Gynecology, University of Rochester, Elmwood Ave, Box 668, Rochester, NY 14642.
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Kawakita T, Parikh LI, Ramsey PS, Huang CC, Zeymo A, Fernandez M, Smith S, Iqbal SN. Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol 2015; 213:570.e1-8. [PMID: 26071912 PMCID: PMC5199141 DOI: 10.1016/j.ajog.2015.06.021] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/26/2015] [Accepted: 06/03/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We sought to determine predictors of adverse neonatal outcomes in women with intrahepatic cholestasis of pregnancy (ICP). STUDY DESIGN This study was a multicenter retrospective cohort study of all women diagnosed with ICP across 5 hospital facilities from January 2009 through December 2014. Obstetric and neonatal complications were evaluated according to total bile acid (TBA) level. Multivariable logistic regression models were developed to evaluate predictors of composite neonatal outcome (neonatal intensive care unit admission, hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, transient tachypnea of the newborn, mechanical ventilation use, oxygen by nasal cannula, pneumonia, and stillbirth). Predictors including TBA level, hepatic transaminase level, gestational age at diagnosis, underlying liver disease, and use of ursodeoxycholic acid were evaluated. RESULTS Of 233 women with ICP, 152 women had TBA levels 10-39.9 μmol/L, 55 had TBA 40-99.9 μmol/L, and 26 had TBA ≥100 μmol/L. There was no difference in maternal age, ethnicity, or prepregnancy body mass index according to TBA level. Increasing TBA level was associated with higher hepatic transaminase and total bilirubin level (P < .05). TBA levels ≥100 μmol/L were associated with increased risk of stillbirth (P < .01). Increasing TBA level was also associated with earlier gestational age at diagnosis (P < .01) and ursodeoxycholic acid use (P = .02). After adjusting for confounders, no predictors were associated with composite neonatal morbidity. TBA 40-99.9 μmol/L and TBA ≥100 μmol/L were associated with increased risk of meconium-stained amniotic fluid (adjusted odds ratio, 3.55; 95% confidence interval, 1.45-8.68 and adjusted odds ratio, 4.55; 95% confidence interval, 1.47-14.08, respectively). CONCLUSION In women with ICP, TBA level ≥100 μmol/L was associated with increased risk of stillbirth. TBA ≥40 μmol/L was associated with increased risk of meconium-stained amniotic fluid.
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Affiliation(s)
- Tetsuya Kawakita
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC.
| | - Laura I Parikh
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC
| | - Patrick S Ramsey
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Chun-Chih Huang
- Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, MD
| | - Alexander Zeymo
- Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, MD
| | - Miguel Fernandez
- Department of Obstetrics and Gynecology, Virginia Hospital Center, Arlington, VA
| | - Samuel Smith
- Department of Obstetrics and Gynecology, MedStar Franklin Square Medical Center, Baltimore, MD
| | - Sara N Iqbal
- Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC
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Zhang Y, Li F, Wang Y, Pitre A, Fang ZZ, Frank MW, Calabrese C, Krausz KW, Neale G, Frase S, Vogel P, Rock CO, Gonzalez FJ, Schuetz JD. Maternal bile acid transporter deficiency promotes neonatal demise. Nat Commun 2015; 6:8186. [PMID: 26416771 PMCID: PMC4598356 DOI: 10.1038/ncomms9186] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 07/28/2015] [Indexed: 12/27/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is associated with adverse neonatal survival and is estimated to impact between 0.4 and 5% of pregnancies worldwide. Here we show that maternal cholestasis (due to Abcb11 deficiency) produces neonatal death among all offspring within 24 h of birth due to atelectasis-producing pulmonary hypoxia, which recapitulates the neonatal respiratory distress of human ICP. Neonates of Abcb11-deficient mothers have elevated pulmonary bile acids and altered pulmonary surfactant structure. Maternal absence of Nr1i2 superimposed on Abcb11 deficiency strongly reduces maternal serum bile acid concentrations and increases neonatal survival. We identify pulmonary bile acids as a key factor in the disruption of the structure of pulmonary surfactant in neonates of ICP. These findings have important implications for neonatal respiratory failure, especially when maternal bile acids are elevated during pregnancy, and highlight potential pathways and targets amenable to therapeutic intervention to ameliorate this condition.
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Affiliation(s)
- Yuanyuan Zhang
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
| | - Fei Li
- Laboratory of Metabolism, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Yao Wang
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
| | - Aaron Pitre
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
| | - Zhong-Ze Fang
- Laboratory of Metabolism, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Matthew W Frank
- Department of Infectious Diseases, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
| | - Christopher Calabrese
- Small Animal Imaging Core, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
| | - Kristopher W Krausz
- Laboratory of Metabolism, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Geoffrey Neale
- Hartwell Center, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
| | - Sharon Frase
- Cellular Imaging Shared Resource, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
| | - Peter Vogel
- Department of Pathology, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
| | - Charles O Rock
- Department of Infectious Diseases, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
| | - Frank J Gonzalez
- Laboratory of Metabolism, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - John D Schuetz
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, USA
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Joutsiniemi T, Timonen S, Linden M, Suvitie P, Ekblad U. Intrahepatic cholestasis of pregnancy: observational study of the treatment with low-dose ursodeoxycholic acid. BMC Gastroenterol 2015; 15:92. [PMID: 26215400 PMCID: PMC4517361 DOI: 10.1186/s12876-015-0324-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 07/20/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To exam the biochemical, obstetric management and pregnancy outcome in women with intrahepatic cholestasis of pregnancy (ICP) and treatment with ursodeoxycholic acid (UDCA). METHODS Pregnancy outcome in patients with ICP (N = 307) was studied and patients treated with UDCA (N = 208) vs. no UDCA were compared. The data of the antenatal visits, deliveries and neonatal outcome of 307 pregnancies with ICP was collected from the hospital computerized delivery room log book. UDCA was used in 208 pregnancies. The diagnosis was made by maternal pruritus and elevation of total fasting bile acid (BA) (>6 μmol/l) and elevation of serum alanine aminotransferases (ALT) (>45 U/l). Maternal and neonatal data was analysed and data of the patients who used UDCA during pregnancy was analysed separately and compared with the data from patients without medication. RESULTS UDCA was well tolerated. Mothers receiving UDCA had ICP diagnosed five weeks earlier than mothers without medication. At the diagnosis, levels of total BA and ALT were higher in the group using UDCA compared to the group without medication. Most deliveries were induced and perinatal outcome was good. Apgar scores at 5 min were significantly lower in UDCA group (p < 0.05), but fetal umbilical artery pH values were similar in both groups (p > 0.05). There were 30 patients with total BA > 40 μmol/l at diagnosis, 24 with UDCA and 6 without medication and those deliveries were induced soon after diagnosis. The preterm labour was also more common in these patents (p < 0.05). Women with preterm babies had significantly early onset pruritus and ICP was diagnosed earlier. Serum ALT and total BA levels were significantly higher in those pregnancies at diagnosis and also at first control. CONCLUSIONS Preterm labour was associated in severe ICP (total BA > 40 μmol/l), ALT levels were also significantly higher and ICP was diagnosed earlier (p < 0.05). Apgar scores were lower in preterm babies (p < 0.05), but umbilical artery pHvalues were not significantly lower. UDCA was well tolerated by pregnant women. With low-dose UDCA treatment the obstetric outcome was good. We still recommend careful obstetrical follow-up.
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Affiliation(s)
- Titta Joutsiniemi
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Susanna Timonen
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Maria Linden
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Pia Suvitie
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Ulla Ekblad
- Department of Obstetrics and Gynaecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
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Garcia-Flores J, Cañamares M, Cruceyra M, Garicano A, Espada M, Lopez A, Tamarit I. Clinical value of maternal bile Acid quantification in intrahepatic cholestasis of pregnancy as an adverse perinatal outcome predictor. Gynecol Obstet Invest 2015; 79:222-8. [PMID: 25720981 DOI: 10.1159/000370003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 11/18/2014] [Indexed: 11/19/2022]
Abstract
AIMS To evaluate the correlation between perinatal outcome and bile acid levels in intrahepatic cholestasis of pregnancy (ICP), and to evaluate variations in the mean bile acid level when stratifying by maternal and perinatal factors. A comparison between mild and severe ICP was made. METHODS A prospective observational study was performed in pregnant patients who underwent blood tests for bile acids due to persistent pruritus. Based on bile acid levels, maternal and neonatal data were obtained and were compared between patients presenting with ICP and gestational pruritus (normal bile acid level). RESULTS A total of 145 patients were included, 47 of whom were diagnosed as ICP (52 newborns) and 98 as gestational pruritus (102 newborns). The ICP group had a higher rate of NICU admission (14/42 vs. 6/98, p < 0.001) and global neonatal morbidity (13/42 vs. 9/98, p = 0.002), but these differences were no longer seen after adjusting for gestational age, singleton pregnancies and induction of labour. Patients presenting with severe ICP (maximum bile acids levels above 40 µmol/l) showed a higher rate of meconium-stained amniotic fluid (0/28 vs. 4/14, p = 0.009), NICU admission (9/34 vs. 11/17, p = 0.01) and neonatal global morbidity (5/32 vs. 8/17, p = 0.02). CONCLUSIONS ICP patients have higher rates of adverse neonatal outcomes when compared to those with gestational pruritus. Some of this neonatal morbidity may be secondary to late spontaneous preterm deliveries, multiple gestation and a policy of elective induction of labour after 37 weeks of gestation. A comparison of outcomes among patients with mild and severe ICP shows that the severely affected group has higher rates of meconium-stained amniotic fluid and neonatal morbidity.
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Affiliation(s)
- Jose Garcia-Flores
- Obstetrics and Gynecology Department, Hospital Universitario Quiron Madrid, Madrid, Spain
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Ding YL, Zhang LJ, Wang X, Zhou QC, Li N, Wang CX, Zhang XQ. Fetal lung surfactant and development alterations in intrahepatic cholestasis of pregnancy. World J Obstet Gynecol 2014; 3:78-84. [DOI: 10.5317/wjog.v3.i2.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 11/07/2013] [Accepted: 01/14/2014] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate the association between total bile acid (TBA) level during intrahepatic cholestasis of pregnancy (ICP) and fetal lung surfactant alteration.
METHODS: We recruited 42 ICP and 32 normal pregnancy women in this study. The maternal blood, fetal blood and amniotic fluid TBA level were detected using a circulating enzymatic method. Umbilical blood pulmonary surfactant protein A (SP-A) was evaluated with enzyme-linked immunosorbent assay. High performance liquid chromatography was used for the determination of phosphatidyl choline (PC), phosphatidyl inositol (PI), lysolecithin (LPC) and sphingomyelin (SM). Amniotic fluid lamellar body was counted with a fully automatic blood cell counter. Fetal lung area and fetal body weight were calculated from data obtained with an iu22 color supersonic diagnostic set. Clinical information of a nonstress test, amniotic fluid properties and neonatal Apgar score, and birth weight were recorded for review.
RESULTS: The TBA level in maternal blood, fetal blood and amniotic fluid in the ICP group were significantly higher than that in the control group (maternal blood: 34.11 ± 6.75 mmol/L vs 4.55 ± 1.72 mmol/L, P < 0.05; fetal blood: 11.9 ± 2.23 mmol/L vs 3.52 ± 1.56 mmol/L, P < 0.05; amniotic fluid: 3.89 ± 1.99 mmol/L vs 1.43 ± 1.14 mmol/L, P < 0.05). Amniotic fluid PC and PI in the ICP group were significantly lower than that in the control group (PC: 65.71 ± 7.23 μg/mL vs 69.70 ± 6.68 μg/mL, P < 0.05; PI: 3.87 ± 0.65 μg/mL vs 4.28 ± 0.74 μg/mL, P < 0.05). PC/LPC ratio of the ICP group was lower than that of the control group (14.40 ± 3.14 vs 16.90 ± 2.52, P < 0.05). Amniotic LB in the ICP group was significantly lower than that of the control group ((74.13 ± 4.37) × 109/L vs (103.0 ± 26.82) × 109/L, P < 0.05). Fetal umbilical blood SP-A level in the ICP group was significantly higher than that of the control group (30.26 ± 7.01 ng/mL vs 22.63 ± 7.42 ng/mL, P < 0.05). Fetal lung area/body weight ratio of the ICP group was significantly lower than that of the control group (5.76 ± 0.63 cm2/kg vs 6.89 ± 0.48 cm2/kg, P < 0.05). In the ICP group, umbilical cord blood TBA concentration was positively correlated to the maternal blood TBA concentration (r = 0.746, P < 0.05) and umbilical blood SP-A (r = 0.422, P < 0.05), but it was negatively correlated to the amniotic fluid lamellar corpuscle (r = 0.810, P < 0.05) and fetal lung area/body weight ratio (r = 0.769, P < 0.05). Furthermore, umbilical blood TBA showed a negative correlation to PC, SM and PI (rpc = 0.536, rsm = 0.438, rpi = 0.387 respectively, P < 0.05). The neonatal asphyxia, neonatal respiratory distress syndrome, fetal distress and perinatal death rates in the ICP group are higher than that of the control group.
CONCLUSION: ICP has higher TBA in maternal and fetal blood and amniotic fluid. The high concentration of TBA may affect fetal pulmonary surfactant production and fetal lung maturation.
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Kroumpouzos G. Specific dermatoses of pregnancy: advances and controversies. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.10.59] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Yu L, Ding Y, Huang T, Huang X. Effect of bile Acid on fetal lung in rat model of intrahepatic cholestasis of pregnancy. Int J Endocrinol 2014; 2014:308274. [PMID: 24778648 PMCID: PMC3980923 DOI: 10.1155/2014/308274] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 12/27/2022] Open
Abstract
Objective. To determine the correlation between maternal bile acid (BA) level and fetal pulmonary surfactant in rats and study the effects of BA on fetal lung in rat model of intrahepatic cholestasis of pregnancy. Methods. Forty pregnant rats were treated with (A) 5.5 mg/kg BA, (B) 1.4 mg/kg BA, and (C) 1 ml physiological saline. Levels of total bile acid (TBA), ALT, AST, TBIL, DBIL, and SP-A were determined and the lungs of fetal rats were analyzed for pathological changes. Results. Groups A and B intervened with BA showed significant higher level of TBA in both maternal and fetal serum, more mortality rate of fetal rats, more concentration of SP-A in fetal serum, and wider alveolus mesenchyme of fetal rats than the control Group C. Higher level of BA associated with increased fetal risk and lower numerical density of mitochondria in type II alveolar epithelial cells. The levels of TBA in maternal serum were found to have significant positive correlation with those in fetal serum and SP-A level but negatively with the area of alveolus and the numerical density of lamellar body. Conclusions. The TBA level in maternal serum showed significant association with lung pathological changes in fetal rats.
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Affiliation(s)
- Ling Yu
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital of Central South University, 139 Renmin Zhong Lu, Changsha, Hunan 410011, China
| | - Yiling Ding
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital of Central South University, 139 Renmin Zhong Lu, Changsha, Hunan 410011, China
- *Yiling Ding:
| | - Ting Huang
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital of Central South University, 139 Renmin Zhong Lu, Changsha, Hunan 410011, China
| | - Xiaoxia Huang
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital of Central South University, 139 Renmin Zhong Lu, Changsha, Hunan 410011, China
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Role of macrophages in bile acid-induced inflammatory response of fetal lung during maternal cholestasis. J Mol Med (Berl) 2013; 92:359-72. [DOI: 10.1007/s00109-013-1106-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 09/17/2013] [Accepted: 11/14/2013] [Indexed: 01/14/2023]
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Joutsiniemi T, Timonen S, Leino R, Palo P, Ekblad U. Ursodeoxycholic acid in the treatment of intrahepatic cholestasis of pregnancy: a randomized controlled trial. Arch Gynecol Obstet 2013; 289:541-7. [PMID: 23978872 DOI: 10.1007/s00404-013-2995-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 07/29/2013] [Indexed: 12/17/2022]
Abstract
PURPOSE To test the efficacy and safety of ursodeoxycholic acid (UDCA) in the treatment of patients with intrahepatic cholestasis of pregnancy (ICP). METHODS In the randomized (double-blind, placebo-controlled) study 20 pregnant women with ICP received (random allocation of) either 450 mg/day UDCA or placebo for 14 days during the third trimester of pregnancy. The severity of pruritus was registered and itching scores were assessed before the treatment and weekly thereafter. The effects of UDCA on liver function and fetoplacental hormone production were measured with covering laboratory testing: serum levels of alanine aminotransferase (ALAT), total bile acids (TBA), estradiol, progesterone, prolactin, cholesterol, HDL-cholesterol, triglycerides, activated partial thromboplastin time, fibrinogen D-dimers (FIDD) and platelet count were assessed before the treatment and weekly thereafter. Data on pregnancy and delivery outcome were recorded and analyzed. RESULTS UDCA was well tolerated. A significant improvement in itching scores was detected in 2 weeks in the group receiving UDCA. Serum levels of ALAT and TBA fell after 2 weeks treatment. The other laboratory values were not modified by the treatment. CONCLUSIONS UDCA improves maternal itching scores and liver function tests without interfering with the fetoplacental estrogen production in patients with ICP. UDCA is well tolerated by pregnant women. No fetal or neonatal side-effects could be detected.
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Affiliation(s)
- Titta Joutsiniemi
- Department of Obstetrics and Gynecology, Turku University Central Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland,
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