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Dumančić S, Mikuš M, Palčić Z, Habek D, Tešanović M, Mimica MD, Marušić J. Severe Early-Onset Intrahepatic Cholestasis of Pregnancy Following Ovarian Hyperstimulation Syndrome with Pulmonary Presentation after In Vitro Fertilization: Case Report and Systematic Review of Case Reports. Life (Basel) 2024; 14:129. [PMID: 38255744 PMCID: PMC10820620 DOI: 10.3390/life14010129] [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: 11/23/2023] [Revised: 01/03/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-related liver disease, usually presented in the third trimester with pruritus, elevated transaminase, and serum total bile acids. Evidence shows that it can be developed in the first trimester, more commonly after in vitro fertilization (IVF) procedures, with the presence of ovarian hyperstimulation syndrome (OHSS). METHODS A literature search was conducted in the PubMed/MEDLINE database of case reports/studies reporting early-onset ICP in spontaneous and IVF pregnancies published until July 2023. RESULTS Thirty articles on early-onset ICP were included in the review analysis, with 19 patients who developed ICP in spontaneous pregnancy and 15 patients who developed ICP in IVF pregnancies with or without OHSS. Cases of 1st and 2nd trimester ICP in terms of "early-onset" ICP were pooled to gather additional findings. CONCLUSIONS Proper monitoring should be applied even before expected pregnancy and during IVF procedures in patients with known risk factors for OHSS and ICP development (patient and family history), with proper progesterone supplementation dosage and genetic testing in case of ICP recurrence.
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Affiliation(s)
- Stipe Dumančić
- Department of Obstetrics and Gynecology, Clinical Hospital Center Split, 21 000 Split, Croatia; (S.D.); (M.D.M.)
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, 10 000 Zagreb, Croatia
| | - Zdenka Palčić
- Department of Obstetrics and Gynecology, Clinical Hospital Center Split, 21 000 Split, Croatia; (S.D.); (M.D.M.)
| | - Dubravko Habek
- School of Medicine, Catholic University of Croatia, Ilica 242, 10 000 Zagreb, Croatia;
| | - Mara Tešanović
- Department of Obstetrics and Gynecology, General Hospital Dubrovnik, 20 000 Dubrovnik, Croatia;
| | - Marko Dražen Mimica
- Department of Obstetrics and Gynecology, Clinical Hospital Center Split, 21 000 Split, Croatia; (S.D.); (M.D.M.)
| | - Jelena Marušić
- Department of Obstetrics and Gynecology, Clinical Hospital Center Split, 21 000 Split, Croatia; (S.D.); (M.D.M.)
- School of Medicine, University of Split, Soltanska 2, 21 000 Split, Croatia
- University Department of Health Studies, University of Split, R. Boskovica 35, 21 000 Split, Croatia
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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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Jurk SM, Kremer AE, Schleussner E. Intrahepatic Cholestasis of Pregnancy. Geburtshilfe Frauenheilkd 2021; 81:940-947. [PMID: 34393257 PMCID: PMC8354350 DOI: 10.1055/a-1522-5178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/02/2021] [Indexed: 12/29/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a rare but potentially serious complication of pregnancy, the main symptom of which is intense pruritus with elevated serum levels of bile acids. The elevated serum bile acid concentration is regarded as a predictor for poor perinatal outcome including intrauterine death. Ursodeoxycholic acid (UDCA) has become established as the treatment of choice in clinical management to achieve a significant improvement in symptoms and reduce the cholestasis. Pregnant women with severe intrahepatic cholestasis should always be managed in a perinatal centre with close interdisciplinary monitoring and treatment involving perinatologists and hepatologists to minimise the markedly increased perinatal morbidity and mortality as well as maternal symptoms.
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Affiliation(s)
| | - Andreas E Kremer
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Erlangen, Germany.,Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Switzerland
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Koh K, Kathirvel R, Mathur M. Rare case of obstetric cholestasis presenting in the first trimester following in vitro fertilisation. BMJ Case Rep 2021; 14:14/7/e244254. [PMID: 34233868 DOI: 10.1136/bcr-2021-244254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) generally presents in the third trimester with pruritus without a rash, characterised by elevated bile acids, with or without transaminitis and hyperbilirubinaemia. Risk factors include a family history of cholestasis, South Asian ethnicity, multifetal gestation, in vitro fertilisation (IVF) and history of hepatitis or biliary disorders.IVF involves the use of high dose gonadotropin stimulation and human chorionic gonadotropin trigger. High doses of progesterone supplementation are additionally given after embryo transfer. The increase in oestrogen and progesterone levels early on in the pregnancy is a possible explanation for the development of ICP in IVF pregnancies at earlier gestations.We present a rare case of iatrogenic ICP presenting in the first trimester in a pregnancy conceived by IVF. Unlike other cases reported, our patient did not have recurrence of ICP in the third trimester, and also had no history of ICP in her first pregnancy.
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Affiliation(s)
- Krystal Koh
- Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | - Rajeswari Kathirvel
- Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore.,NUS Yong Loo Lin School of Medicine, Singapore
| | - Manisha Mathur
- Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore.,NUS Yong Loo Lin School of Medicine, Singapore
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Tian X, Niu K, Cao H, Zhan G, Zhang Y, Xu F, Shangguan W, Gao Y. Pruritus after continuous administration of epidural morphine for post-cesarean delivery analgesia: a case control study. BMC Pregnancy Childbirth 2021; 21:60. [PMID: 33451285 PMCID: PMC7811233 DOI: 10.1186/s12884-020-03522-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 12/22/2020] [Indexed: 02/08/2023] Open
Abstract
Background Pruritus is one of the most common side effects of epidural morphine administered for post-surgery analgesia, and pregnant women tend to be highly susceptible. The relative contributions of morphine concentration, local anesthetics, and level of pain to pruritus after epidural morphine for post-cesarean delivery analgesia remain unclear. Accordingly, the present study aimed to identify risk factors for pruritus after continuous administration of epidural morphine for post-cesarean delivery analgesia. Methods This case control study was based on routinely collected clinical data. Participants included women who had undergone cesarean section and adopted a patient-controlled analgesia pump for postoperative analgesia. A series of logistic regression analyses were performed. Interaction terms were added to explore the moderation effects of combined local anesthetics and pain level on associations between morphine concentration and pruritus. Robustness of the results was checked through sensitivity analysis using propensity scores matching approach. Results Higher morphine concentration, assisted reproductive treatment, and multipara and cesarean section history were significantly more prevalent in the pruritus group than in the control group. The probabilities of pruritus at morphine concentrations of 10, 15, 20, 25, 30 and 40 μg/mL increased sequentially from 0.05, 0.1, 0.2, 0.35, 0.54 to 0.84, respectively. The trend remained steep in the ropivacaine stratum and became flatter when combined with levobupivacaine. At mild pain combined with levobupivacaine, the incidence of pruritus increased from 0.33 (95% confidence interval [CI] 0.1–0.68) in the 10 μg/mL morphine group to 0.48 (95% CI 0.1–0.88) in the 40 μg/mL morphine group. In the stratum of moderate pain combined with levobupivacaine, the incidence increased from 0.4 (95% CI 0.04–0.92) to 0.56 (95% CI 0.03–0.98). The results in the sensitivity analysis were in consistent with above findings. Conclusions Higher concentrations of morphine, multipara, and assisted reproductive treatment were factors associated with a higher probability of pruritus. Pain level or combined local anesthetics could moderate the association between morphine concentration and pruritus.
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Affiliation(s)
- Xinyi Tian
- Department of Anesthesia, Pain and Critical Care Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Kaifan Niu
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China
| | - Hong Cao
- Department of Anesthesia, Pain and Critical Care Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Gonghao Zhan
- Department of Anesthesia, Pain and Critical Care Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Yan Zhang
- School of Public Health, Fudan University, Shanghai, China.,NHC Key Lab. of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Fudan University, Shanghai, China
| | - Feng Xu
- Department of Anesthesia, Pain and Critical Care Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Wangning Shangguan
- Department of Anesthesia, Pain and Critical Care Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China.
| | - Ye Gao
- Department of Anesthesia, Pain and Critical Care Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, China.
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Malherbe JAJ, Garas G, Khor TS, MacQuillan GC. Delayed Fulminant Hepatic Failure from Dydrogesterone-Related In Vitro Fertilization Therapy Requiring Liver Transplantation During Pregnancy. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925690. [PMID: 32938902 PMCID: PMC7520868 DOI: 10.12659/ajcr.925690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patient: Female, 35-year-old Final Diagnosis: Fulminant liver failure Symptoms: Coagulopathy • hepatic encephalopathy • jaundice Medication:— Clinical Procedure: Liver transplantation Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Jacques A J Malherbe
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Medical School, University of Western Australia, Crawley, WA, Australia
| | - George Garas
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Medical School, University of Western Australia, Crawley, WA, Australia.,Western Australia Liver Transplantation Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Tze S Khor
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Nedlands, WA, Australia
| | - Gerry C MacQuillan
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Medical School, University of Western Australia, Crawley, WA, Australia.,Western Australia Liver Transplantation Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Alemdaroğlu S, Yılmaz Baran Ş, Durdağ GD, Yuksel Şimşek S, Yetkinel S, Alkaş Yağınç D, Kalaycı H, Şimşek E. Intrahepatic cholestasis of pregnancy: are in vitro fertilization pregnancies at risk? J Matern Fetal Neonatal Med 2020; 34:2548-2553. [PMID: 32419565 DOI: 10.1080/14767058.2020.1765331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIM Single pregnancy patients with intrahepatic cholestasis of pregnancy (ICP) were divided into two groups according to the conception method, as spontaneous and in vitro fertilization (IVF). We aim to compare the maternal, laboratory and perinatal characteristics of both groups. MATERIALS AND METHOD The records of 10,929 patients who gave birth in the center between October 2011 and July 2019 were analyzed retrospectively from the data processing system records. Maternal, laboratory and perinatal characteristics of 109 single pregnancies (spontaneous n: 91; IVF n: 18) diagnosed with ICP were compared. FINDINGS The maternal demographic data of both groups were similar (p: .05). In both groups, gestational week, gestational age at birth, birth weight, neonatal intensive care admission rate, meconium-stained amniotic fluid, umbilical cord pH, the 5-minute APGAR score, and the presence of pregnancy complications were similar (p > .05). RESULT Although ICP is reported with a higher incidence in IVF pregnancies, ICP findings and prognosis are similar to those of spontaneous pregnancies.
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Affiliation(s)
- Songül Alemdaroğlu
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Şafak Yılmaz Baran
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | | | - Seda Yuksel Şimşek
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Selçuk Yetkinel
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Didem Alkaş Yağınç
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Hakan Kalaycı
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
| | - Erhan Şimşek
- Department of Obstetrics and Gynecology, Baskent University, Adana, Turkey
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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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