Intrahepatic cholestasis of pregnancy - Diagnosis and management: A consensus statement of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ): Executive summary

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy liver disease, characterised by pruritus and increased total serum bile acids (TSBA), Australian incidence 0.6-0.7%. ICP is diagnosed by non-fasting TSBA ≥19 μmol/L in a pregnant woman with pruritus without rash without a known pre-existing liver disorder. Peak TSBA ≥40 and ≥100 μmol/L identify severe and very severe disease respectively, associated with spontaneous preterm birth when severe, and with stillbirth, when very severe. Benefit-vs-risk for iatrogenic preterm birth in ICP remains uncertain. Ursodeoxycholic acid remains the best pharmacotherapy preterm, improving perinatal outcome and reducing pruritus, although it has not been shown to reduce stillbirth.

Total serum bile acids predict therapy for HBeAg-negative chronic hepatitis B patients with borderline ALT and high HBV DNA

INTRODUCTION

The introduction of antiviral therapy in chronic hepatitis B (CHB) infection depends on precise evaluation of hepatic lesions. Total serum bile acids (TSBAs) are highly sensitive in monitoring liver dysfunction. We evaluated the predictive role of TSBAs for hepatic lesions in CHB patients with borderline alanine aminotransferase (ALT) and high level of hepatitis B virus (HBV) DNA copies.

METHODOLOGY

328 CHB patients were enrolled, 241 were hepatitis B e antigen (HBeAg)-positive and 87 were HBeAg-negative. Patients were further divided into two entities according to inflammation/fibrosis evaluated by liver biopsy, low-grade (inflammation grade < 2 and fibrosis stage < 2) and high-grade (inflammation grade ≥ 2 or/and fibrosis stage ≥ 2) cohorts. TSBAs were compared with noninvasive tools including aspartate aminnotransferase (AST)-to-platelet ratio index (APRI), fibrosis-4 (FIB-4) and red cell distribution width (RDW)-to-platelet ratio (RPR) to predict high-grade hepatic lesions in CHB subgroups.

RESULTS

TSBAs, APRI, FIB-4 and RPR were statistically different between low- and high-grade patients in HBeAg-positive cohort. Only TSBAs showed significant difference between low and high grade in HBeAg-negative patients. Similarly, APRI, FIB-4 and RPR were correlated with different division of inflammation/fibrosis only in HBeAg-positive while TSBAs were correlated with inflammation/fibrosis levels in both HBeAg-positive and HBeAg-negative groups. Of the four indicators, the receiver operating characteristic (ROC) curve analysis showed that TSBAs have the maximum AUC (area under the curve) in HBeAg-negative group but the minimum in HBeAg-positive cohort.

CONCLUSIONS

TSBAs can be used for predicting antiviral therapy in CHB patients with HBeAg-negative, borderline ALT and high HBV DNA.

Intrahepatic cholestasis of pregnancy - Time to redefine the reference range of total serum bile acids: A cross-sectional study

Objective

To establish pregnancy‐specific reference ranges for fasting and postprandial total serum bile acid (TSBA) concentrations.

Design

Cross‐sectional study.

Setting

Tertiary‐care university hospital.

Population

Healthy pregnant women at term admitted to the Obstetrics Department over a period of 1 year. Exclusion criteria were an established diagnosis of intrahepatic cholestasis of pregnancy (ICP) or any coexisting condition of increased risk for ICP.

Methods

Both fasting (after 8–14 h of fasting) and postprandial (2 h after meal) TSBA concentrations were measured in 612 women (with 528 fasting samples and 377 postprandial samples) by automated enzymatic spectrophotometric assay.

Main outcome measures

Fasting and postprandial TSBA concentrations in 612 women.

Results

Reference intervals of 4.4–14.1 μmol/L for fasting TSBA and 4.7–20.2 μmol/L for postprandial TSBA were established. The postprandial values were significantly higher than the fasting values, with a median increase of 1.0 μmol/L (p < 0.0001). A correlation between fasting TSBA concentrations and postprandial concentrations was found, as well as correlations with fetal sex, parity and assisted reproductive technologies. A seasonal pattern was noticed for both fasting and postprandial TSBA, with the highest values measured in the winter season (p < 0.01 and 0.02, respectively)

Conclusions

Normal pregnancy is associated with mild hypercholanaemia, and therefore a higher threshold should be considered for the diagnosis of ICP. We suggest using the upper reference limits observed in our healthy pregnant population (14 μmol/L for fasting TSBA and 20 μmol/L for postprandial TSBA). As the fasting measurement is more specific for the diagnosis, and the postprandial measurement is essential for the assessment of severity, it is recommended to measure both values rather than use random sampling.

Tweetable abstract

Normal pregnancy is associated with mild hypercholanaemia, a higher threshold should be considered for the diagnosis of ICP.

Normal pregnancy is associated with mild hypercholanaemia, a higher threshold should be considered for the diagnosis of ICP.

Linked article: This article is commented on by Ovadia et al., pp. 1897–1898. in this issue. To view this minicommentary visit https://doi.org/10.1111/1471‐0528.17171

Myocardial Infarction and Coronary Artery Disease in Menopausal Women With Type 2 Diabetes Mellitus Negatively Correlate With Total Serum Bile Acids

BACKGROUND

As metabolic molecules, bile acids (BAs) not only promote the absorption of fat-soluble nutrients, but they also regulate many metabolic processes, including the homeostasis of glucose and lipids. Although total serum BA (TBA) measurement is a readily available clinical test related to coronary artery disease (CAD), myocardial infarction (MI), and type 2 diabetes mellitus (T2DM), the relationship between TBA and these pathological conditions remain unclear, and research on this topic is inconclusive.

METHODS

This study enrolled 20,255 menopausal women aged over 50 years, including 6,421 T2DM patients. The study population was divided into different groups according to the median TBA level in order to explore the clinical characteristics of menopausal women with different TBA levels. Spline analyses, generalized additive model (GAM) model and regression analyses based on TBA level were used to explore the relationship between TBA and different diseases independently, including CAD and MI, or in combination with T2DM.

RESULTS

Both in the general population and in the T2DM subgroup, the TBA level was significantly lower in CAD patients than in non-CAD patients. Spline analyses indicated that within normal clinical range of TBA concentration (0-10 µmol/L), the presence of CAD and MI showed similar trends in total and T2DM population. Similarly, the GAM model indicated that within the 0-10 μmol/L clinical range, the predicted probability for CAD and MI alone and in combination with T2DM was negatively correlated with TBA concentration. Multivariate regression analysis suggested that low TBA level was positively associated with the occurrence of CAD combined with T2DM (OR: 1.451; 95%CI: 1.141-1.847).

CONCLUSIONS

In menopausal women, TBA may represent a valuable clinical serum marker with negative correlation for CAD and MI in patients with T2DM.

Erratum: Myocardial Infarction and Coronary Artery Disease in Menopausal Women With Type 2 Diabetes Mellitus Negatively Correlate With Total Serum Bile Acids

[This corrects the article DOI: 10.3389/fendo.2021.754006.].

Intrahepatic Cholestasis of Pregnancy: A Case Study of the Rare Onset in the First Trimester

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.

The biochemical diagnosis of intrahepatic cholestasis of pregnancy

BACKGROUND

Bile acid levels and liver function tests may be normal at presentation in women with intrahepatic cholestasis of pregnancy. The biochemical results of patients presenting with pruritus typical for intrahepatic cholestasis of pregnancy were reviewed.

METHODS

A retrospective audit of women coded as having intrahepatic cholestasis of pregnancy over a three-year period.

RESULTS

One hundred and ninety-three women (1.1% of the obstetric population) presented with pruritus typical of intrahepatic cholestasis of pregnancy. Forty (21%) of these women had normal biochemistry at presentation, half subsequently developing abnormal results. Women with a history of allergic reactions were more likely to develop intrahepatic cholestasis of pregnancy.

CONCLUSIONS

Normal biochemistry should not preclude a trial of ursodeoxycholic acid in women with distressing pruritus typical for intrahepatic cholestasis of pregnancy. Biochemical tests which are more sensitive and specific in the diagnosis of intrahepatic cholestasis of pregnancy would be valuable. Investigation of other populations with intrahepatic cholestasis of pregnancy regarding a possible association with atopy/allergy would be interesting.

Environmental Working Conditions, Lung Function and Total Serum Bile Acids of Spray Painters Exposed to Organic Solvents in Ile-Ife, Nigeria

BACKGROUND

Nigeria has a growing spray painting industry, however, the burden of occupational health problems related to organic solvent exposure among spray painters in Nigeria is under-studied.

OBJECTIVES

This study aimed to assess workshop characteristics and ambient concentration of total volatile organic compounds (VOCs) in spray painting workshops and to compare lung function status and total serum bile acid levels of spray painters and controls.

METHODS

A cross-sectional study design was employed to survey 120 spray painters and 120 controls (electronic technicians). A semi-structured questionnaire was used to obtain data on socio-demographics characteristics of the respondents. Weight, height and lung function of respondents were measured. In addition, a checklist was used to survey the spray painting workshops. Total VOC levels were determined in 37 spray painting and 31 electronic workshops. Data were analyzed using Statistical Program for the Social Sciences (SPSS) version 20 and a p-value of <0.05 was considered to be statistically significant.

RESULTS

Windows were present in only 5 (13.5%) spray painting workshops and 23 (62%) workshops had a retractable tarpaulin at the entrance. Only 9 (24%) workshops had changing rooms, while fire extinguishers and first aid kits were not present in any of the surveyed workshops. A respirator with filter was sighted in only 1 (3%) workshop. The 8-hour time weighted average concentration of total VOCs in spray painting workshops was 13.4 ppm, which is above the national permissible exposure limits of 1.9 ppm. Forced vital capacity (FVC) percent predicted was significantly lower in spray painters (93.9 ±10.8%) than controls (96.7± 8.2%) (t = -2.326, df=238 p< 0.001). In addition, forced expiratory volume in the first second (FEV1) percent predicted was lower in spray painters (94.6±12.2%) than controls (100.3±9.1%) (t=-4.058, df=238, p=0.002). FEV1/FVC% was significantly lower among spray painters (85.48±8.70%) compared with controls (87.88±6.22%) (t=-2.861 df=238, p= 0.005). Total serum bile acids was significantly elevated in painters (8.71±3.39 mmol/l) compared to controls (4.67 ±2.15 mmol/l) (t=10.358, df=213, p<0.05).

CONCLUSIONS

Spray painters in the present study conduct their activities in hazardous work settings. More needs to be done concerning workplace regulation and enforcements to ensure that spray painters comply with minimum standards of occupational safety, workplace hygiene and sanitation.

PATIENT CONSENT

Obtained.

ETHICS APPROVAL

Ethical approval was granted by the Health Research and Ethics Committee of the Institute of Public Health, Obafemi Awolowo University.