Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy

Performance evaluation of enzymatic total bile acid (TBA) routine assays: systematic comparison of five fifth-generation TBA cycling methods and their individual bile acid recovery from HPLC-MS/MS reference

OBJECTIVES

Serum total bile acid (TBA) levels are frequently assessed in clinical routine for the early detection of hepatobiliary dysfunction. However, the comparability of current 5th-generation TBA cycle assays based on 3α-hydroxysteroid dehydrogenase (3α-HSD) and their ability to quantify individual bile acids has not been systematically addressed.

METHODS

Patient serum samples (n=60) across the diagnostically relevant TBA range (1-200 μmol/L) were analyzed using five TBA routine assays from Abbott, DiaSys, Diazyme, Beijing Strong (BSBE) and Randox on the same analyzer (BioMajesty® JCA-BM6010/C). The assays were compared using Passing-Bablok regression and the recovery of 11 individual BAs was evaluated against RP-HPLC-MS/MS as non-enzymatic reference method.

RESULTS

Despite excellent correlation (Spearman r ≥0.99), the assays showed proportional differences (slope) ranging from 0.99 (BSBE/Randox) to 1.24 (Abbott/DiaSys). The assays showed considerable deviation in the recovery of competitor's calibrators and controls, and large heterogeneity in the recovery of individual BAs, with mean deviations from reference value between 13 % (DiaSys) and 42 % (Abbott). CA and TCA were measured most accurately and consistently, whereas GCA, CDCA, DCA, UDCA, and conjugates were over- or undermeasured to varying degrees.

CONCLUSIONS

The linear relationship and constant proportional bias between all five routine assays enable the harmonization of TBA measurements up to 60 μmol/L. However, for patient samples with high TBA levels and disease-specific overrepresentation of individual BAs, harmonization will require: i) optimized reaction conditions to equalize substrate specificity, and ii) calibration to a common, commutable reference material with well-defined BA composition instead of internal standards spiked with different BAs.

Establishment and validation of a nomogram for predicting preterm birth in intrahepatic cholestasis during pregnancy: a retrospective study

OBJECTIVE

This study aimed to develop and evaluate a nomogram for predicting preterm birth in patients with intrahepatic cholestasis of pregnancy (ICP), with a view to assisting clinical management and intervention.

METHODS

This retrospective observational study included 257 pregnant women with ICP from Sichuan Provincial People's Hospital between January 1, 2022 and July 30, 2024. The routine clinical and laboratory information of these patients were also collected. We used the least absolute shrinkage and selection operator (LASSO) and multivariable logistic regression analysis to investigate the association between clinical and laboratory data and preterm birth in ICP patients. A nomogram was developed to predict the likelihood of preterm birth in ICP patients. The prediction accuracy of the model was evaluated by consistency index (C-index), receiver operating characteristic (ROC) curve, area under the curve (AUC), and calibration curve. Decision curve analysis (DCA) was used to evaluate its applicability in clinical practice.

RESULTS

Among the 257 ICP patients, 56 (21.79%) were diagnosed with preterm birth. Cases were randomly divided into a training set (154 cases) and a test set (103 cases). A nomogram was developed to predict preterm birth in ICP patients based on height, twin pregnancy (TP), gestational age at diagnosis (GA at diagnosis), and total bile acid level (TBA) at diagnosis. The calibration curve of the training set was close to the diagonal (C-index = 0.864), and the calibration curve of the test set was also close to the diagonal (C-index = 0.835). These results indicate that the model has a good consistency. The AUC of the training group and the test group were 0.864 and 0.836, respectively, indicating the good accuracy of the model. The DCA reveals that this nomogram could be applied to clinical practice.

CONCLUSION

The combination of TBA level, TP, height and GA at diagnosis is an effective model for identifying preterm birth in ICP patients. These results will help guide the clinical management and treatment of patients with ICP, thereby reducing maternal and infant safety issues caused by preterm birth.

A prospective multicenter birth cohort in China: pregnancy health atlas

The China Prospective Multi-Center Birth Cohort Study was launched in 2022. In collaboration with medical centers in 12 cities, it aims to establish a high-quality, multidimensional cohort comprising 20,000 natural pregnancy and assisted reproductive families. As of June 26, 2024, 12,911 pregnant women have participated in this study, and 161,122 biological samples have been collected. These samples cover four critical periods (early pregnancy, mid-pregnancy, late pregnancy, and postpartum) and comprise 10 different types such as serum, plasma, and urine. The study has collected comprehensive information from early pregnancy to newborns. The participants have an average age of 29.76 years, an average height of 160.46 cm, an average pre-pregnancy BMI of 23.11, and an average BMI of 27.25 before delivery. The cohort includes individuals from 26 ethnic groups, with 25 minority groups comprising 5.03% of the population. Guizhou Province exhibits the highest percentage of ethnic minorities at 24.96% and Guangdong Province owns the highest proportion (12.22%) of women with two or more children. The prevalence of thalassemia in Guangdong Province is seven times higher than in other provinces. Among pregnant women over 35 years old, the prevalence of gestational diabetes mellitus is twice that of women under 35. Additionally, the prevalence of preeclampsia in women with assisted reproductive pregnancies is more than twice that of those with natural pregnancies. The study extensively collected diverse data and biological samples, making this cohort an ideal candidate for DOHaD field and multi-omics research.

The utility of albumin-bilirubin score in patients with intrahepatic cholestasis of pregnancy: a retrospective comparative study

OBJECTIVE

The aim of this study was to examine the utility of the albumin-bilirubin score in cases of intrahepatic cholestasis of pregnancy.

METHODS

A total of 413 patients (182 intrahepatic cholestasis of pregnancy, 50 suspected intrahepatic cholestasis of pregnancy, 181 healthy controls) enrolled in this study. Patients with typical pruritus and bile acid levels >10 μmol/L are defined as the intrahepatic cholestasis of pregnancy group. Patients with pruritus have the same pattern as intrahepatic cholestasis of pregnancy, but who are ultimately diagnosed with other dermatoses of pregnancy are defined as suspected intrahepatic cholestasis of pregnancy. Demographic data, laboratory parameters, and albumin-bilirubin scores were compared between three groups. Correlation analysis was performed on the albumin-bilirubin score and bile acid levels. Also, receiver operating curve analyses were performed to evaluate the predictive performance of the albumin-bilirubin score for intrahepatic cholestasis of pregnancy diagnosis.

RESULTS

The albumin-bilirubin score of the intrahepatic cholestasis of pregnancy group was significantly higher than the other groups. A positive, weak correlation was found between the albumin-bilirubin score and bile acid levels in the intrahepatic cholestasis of pregnancy group. The receiver operating curve curve analyses showed albumin-bilirubin score has significant performance for the prediction of intrahepatic cholestasis of pregnancy in all subjects (area under the curve: 0.726, 95%CI 0.679-0.774, p<0.001) (sensitivity: 69%, specificity: 64%). The detection rate for albumin-bilirubin score was calculated as 67.3%. The positive predictive value was 3.95% (CI 2.9-5.3%), and the negative predictive value was 98.9% (CI 98.6-99.2%).

CONCLUSION

This study indicated higher albumin-bilirubin score levels in the intrahepatic cholestasis of pregnancy group and a positive relationship between serum bile acid levels and albumin-bilirubin score. Therefore, albumin-bilirubin score could be a cost-effective liver function test for pregnant women with intrahepatic cholestasis of pregnancy.

Effect of Maternal Ursodeoxycholic Acid Treatment on Fetal Atrioventricular Conduction in Patients with Intrahepatic Cholestasis of Pregnancy

INTRODUCTION

The aim of this study was, first, to investigate the difference in fetal atrioventricular conduction in patients with and without intrahepatic cholestasis of pregnancy (ICP) by measuring the fetal PR interval; second, to evaluate the altering effect of ursodeoxycholic acid (UDCA) treatment on the fetal PR interval in ICP patients.

METHODS

The study consisted of 42 ICP patients and 48 healthy pregnant women. Fetal echocardiography was performed to measure the mechanical PR interval. The fetal PR interval and the clinical characteristics were compared between the two groups. The effect of UDCA treatment on the fetal PR interval in ICP patients was evaluated.

RESULTS

In ICP patients, significantly longer fetal PR intervals were observed than in the control group (123.21 ± 8.54 vs. 115.13 ± 5.95 ms, p < 0.001). In the ICP group, there was a positive correlation between the fetal PR interval and maternal fasting total bile acid (TBA) levels (r = 0.514, p = 0.001). After 1 week of treatment with UDCA in patients with ICP, the PR interval was shorter than before, although the reduction was not statistically significant (120.98 ± 6.70 vs. 123.21 ± 8.54 ms, p = 0.095). In patients with severe ICP (TBA >40 mmol/L, n = 10), a significant reduction in the fetal PR interval was observed after treatment with UDCA (127.5 ms [IQR, 118.0-134.75] before vs. 122 ms [IQR, 109.5-126.5] after, p = 0.037).

CONCLUSION

Fetal PR interval increased in ICP patients in correlation with maternal serum TBA concentration. Treatment with UDCA may have limited positive effects on the fetal AV conduction system. The beneficial effects of UDCA on the fetal PR interval may be more pronounced in patients with higher bile acid levels.

The association between aspartate aminotransferase (AST) to platelets (PLT) ratio (APRI) and the development of intrahepatic cholestasis in pregnancy and other related complications

OBJECTIVE

To assess the association between aspartate aminotransferase (AST) to platelet count ratio index (APRI score), during the first and third trimesters of pregnancy and the development of intrahepatic cholestasis in pregnancy (ICP).

METHODS

Case-control study was conducted. The study included patients diagnosed with ICP by elevated bile acids (n = 118) and a control group of women with symptoms such as elevated liver enzymes or pruritus with normal level of bile acids (n = 127) who attended a large tertiary teaching medical center between the years 2014 and 2021. The groups were compared in terms of obstetrical characteristics, perinatal outcomes, first- and third-trimester laboratory tests, and APRI scores during the first and third trimester. A receiver operating characteristic (ROC) analysis was performed to determine the APRI score cutoff value that could predict ICP.

RESULTS

The third-trimester APRI scores of patients with ICP were significantly higher than those of the control group (P < 0.001). The ROC analysis revealed that the cutoff value for the APRI score was 0.42 with 65.3% sensitivity and 73.2% specificity.

CONCLUSION

Our results suggest that the third-trimester APRI score is positively associated with ICP.

The maternal hair metabolome is capable of discriminating intrahepatic cholestasis of pregnancy from uncomplicated pregnancy

Introduction

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disease associated with elevated bile acids in the blood. Diagnosis typically only occurs after the manifestation of clinical symptoms and the metabolic mechanisms underlying its development remain unclear. The aim of this study was to investigate potential specific metabolites and the underlying metabolic changes occurring during the development of ICP in the maternal plasma and hair metabolomes of women diagnosed with either ICP or having a healthy pregnancy.

Methods

A total of 35 Chinese women with ICP and 42 healthy pregnancies were enrolled in our study. Plasma and hair samples, total bile acid levels (TBA), alanine transaminase levels (ALT), aspartate aminotransferase levels (AST), and additional clinical information were collected during the third trimester. Metabolites from maternal plasma and hair segments collected pre-conception and analyzed using gas chromatography-mass spectrometry (GC-MS).

Results

Three plasma metabolites (p < 0.05, q < 0.38) and 21 hair metabolites (p < 0.05, q < 0.05) were significantly different between ICP and healthy pregnancies. A combination of the eight most significant hair metabolites in a multivariate receiver operating characteristic curve model showed the best area under the curve (AUC) was 0.885, whereas the highest AUC using metabolites from plasma samples was only 0.74. Metabolic pathway analysis revealed 32 pathways were significantly (p and q values < 0.05) affected in the hair samples of patients with ICP. Pathways associated with glutathione metabolism and ABC transporters were affected. No metabolic pathways were significantly affected in plasma.

Discussion

Overall, this study showed that the hair metabolome could be more useful than the plasma metabolome for distinguishing ICP from normal pregnancy.

Bile acid profiling as an effective biomarker for staging in pediatric inflammatory bowel disease

Rapid and accurate clinical staging of pediatric patients with inflammatory bowel disease (IBD) is crucial to determine the appropriate therapeutic approach. This study aimed to identify effective, convenient biomarkers for staging IBD in pediatric patients. We recruited cohorts of pediatric patients with varying severities of IBD to compare the features of the intestinal microbiota and metabolites between the active and remitting disease stages. Metabolites with potential for staging were targeted for further assessment in both patients and colitis model mice. The performance of these markers was determined using machine learning and was validated in a separate patient cohort. Pediatric patients with IBD exhibited distinct gut microbiota structures at different stages of disease activity. The enterotypes of patients with remitting and active disease were Bacteroides-dominant and Escherichia-Shigella-dominant, respectively. The bile secretion pathway showed the most significant differences between the two stages. Fecal and serum bile acid (BA) levels were strongly related to disease activity in both children and mice. The ratio of primary BAs to secondary BAs in serum was developed as a novel comprehensive index, showing excellent diagnostic performance in stratifying IBD activity (0.84 area under the receiver operating characteristic curve in the primary cohort; 77% accuracy in the validation cohort). In conclusion, we report profound insights into the interactions between the gut microbiota and metabolites in pediatric IBD. Serum BAs have potential as biomarkers for classifying disease activity, and may facilitate the personalization of treatment for IBD.

Identification and validation of diagnostic biomarkers for intrahepatic cholestasis of pregnancy based on untargeted and targeted metabolomics analyses of urine metabolite profiles

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is a prevalent pregnancy-specific complication that presents with maternal itching and elevated serum bile acid levels. ICP is associated with unfavorable pregnancy outcomes, severely decreasing the pregnant woman's quality of life. Timely identification of ICP is crucial for effective management and improved outcomes.

METHODS

We collected urine samples from 8 patients with ICP and 8 healthy individuals. We used Liquid Chromatography-Mass Spectrometry (LC-MS) to detect metabolite expression levels, then conducted a series of bioinformatic analyses to explore the potential biological meanings of differentially expressed metabolites, and preliminarily discovered several candidate biomarkers. To validate these candidate biomarkers, we performed Gas Chromatography-Mass Spectrometry (GC-MS) detection and analyzed their diagnostic values using receiver operating characteristic (ROC) curve.

RESULTS

Untargeted metabolomics data showed that 6129 positive peaks and 6218 negative peaks were extracted from each specimen. OPLS-DA analysis and the heat map for cluster analysis showed satisfactory capability in discriminating ICP specimens from controls. Subsequent analysis extracted 64 significantly differentially expressed metabolites, which could be potential biomarkers for diagnosis of ICP. Based on the KEGG enrichment analyses, six candidate biomarkers were preliminarily identified. Two most promising biomarkers (3-hydroxypropionic acid and uracil) were validated by targeted metabolomics analyses with the area under the curve (AUC) of 0.920 and 0.850 respectively.

CONCLUSION

Based on preliminary screening from untargeted metabolomics and subsequent validation through targeted metabolomics, 3-hydroxypropionic acid and uracil were identified as promising diagnostic biomarkers for ICP.

Secreted proteins in plasma and placenta as novel non-invasive biomarkers for intrahepatic cholestasis of pregnancy: A case-control study

Background

Intrahepatic cholestasis of pregnancy (ICP) is likely to lead to unfavorable consequences. Total bile acid (TBA) is thought to be the sole ICP indicator available as of now, but it comes with some kind of restrictions in terms of sensitivity and specificity. We were endeavoring to find potential diagnostic biomarkers for ICP in this investigation.

Methods

This case-control study with a prospective nature included 40 females in the stage of pregnancy who were diagnosed with ICP. It also included another 20 females who were also pregnant but with sound physical condition(control). Placental and plasma samples were collected from all females that were in the stage of pregnancy, except for 20 ICP patients, in which only plasma was collected. We used four-dimensional data-independent acquisition followed by enzyme-linked immunosorbent assay and immunohistochemistry to identify and validate plasma and placental profiles in ICP patients and controls. Bioinformatics was adopted in an effort to demonstrate the relevant biological processes and signalling pathways. Correlation analysis was used to analyse the consistency of tissue and plasma protein expression and the correlation between sequencing and experimental results.

Results

The expression levels of nectin-1 (NECTIN1), Kunitz-type protease inhibitor 1 (SPINT1), and inter-alpha-trypsin inhibitor heavy chain H3 (ITIH3) were remarkably higher in ICP patients than in controls. However, heparin cofactor 2 (SERPIND1) expression levels in female participants in the stage of pregnancy who were diagnosed with ICP were remarkably lower than those pregnant females with good physical fitness. In addition to the negative correlation between SERPIND1 and TBA, NECTIN1, SPINT1, and ITIH3 expression positively correlated with TBA. Area under the receiver operating characteristic curve (AUC) values of 0.7925, 0.8313, 0.8163, and 0.9025, respectively, were used to assess the diagnostic accuracies of NECTIN1, SPINT1, ITIH3, and SERPIND1. AUC (0.9438) was considerably greater when NECTIN1, SPINT1, and SERPIND1 were integrated, according to binary logistic regression. The AUC of the ROC curve for various combinations of SERPIND1 and other indicators was higher than itself, thus providing a more reliable ICP diagnosis. Furthermore, according to the bioinformatics analysis, the NECTIN1, SPINT1, ITIH3, and SERPIND1 were identified as secreted proteins because they were localized in the extracellular region.

Conclusions

This research discovered new non-invasive ICP indicators. On top of this, it sheds new light on the crucial diagnostic function of secreted proteins in ICP.

Rational use of drugs to alleviate adverse outcomes caused by COVID-19 quarantine in women with intrahepatic cholestasis of pregnancy

Purpose

This study aimed to investigate the impacts of home quarantine on pregnancy outcomes of women with intrahepatic cholestasis of pregnancy (ICP) during the COVID-19 outbreak and whether the rational use of drugs will change these impacts.

Methods

This multi-center study was conducted to compare the pregnancy outcomes in women with ICP between the home quarantine group and the non-home quarantine group in southwest China. Propensity score matching was performed to confirm the pregnancy outcomes of the medication group and the non-medication group in women with ICP during the epidemic period.

Results

A total of 3,161 women with ICP were enrolled in this study, including 816 in the home quarantine group and 2,345 in the non-home quarantine group. Women with ICP in the home quarantine group had worse pregnancy outcomes, such as a growing risk of gestational diabetes mellitus A1, fetal growth restriction, pre-eclampsia, preterm delivery, and even stillbirth. Drug therapy could alleviate some adverse pregnancy outcomes caused by home quarantine, including pre-eclampsia, preterm delivery, and meconium-stained amniotic fluid.

Conclusion

COVID-19 quarantine would increase the incidence of ICP and lead to adverse pregnancy outcomes in women with ICP. The rational use of drugs reduced some obstetrical complications and improved partial pregnancy outcomes. Our findings suggested that the government and hospitals should enhance their management and life guidance for women with ICP and speed up developing home quarantine guidelines.

Revisited role of the placenta in bile acid homeostasis

To date, the discussion concerning bile acids (BAs) during gestation is almost exclusively linked to pregnancy complications such as intrahepatic cholestasis of pregnancy (ICP) when maternal serum BA levels reach very high concentrations (>100 μM). Generally, the placenta is believed to serve as a protective barrier avoiding exposure of the growing fetus to excessive amounts of maternal BAs that might cause detrimental effects (e.g., intrauterine growth restriction and/or increased vulnerability to metabolic diseases). However, little is known about the precise role of the placenta in BA biosynthesis, transport, and metabolism in healthy pregnancies when serum BAs are at physiological levels (i.e., low maternal and high fetal BA concentrations). It is well known that primary BAs are synthesized from cholesterol in the liver and are later modified to secondary BA species by colonic bacteria. Besides the liver, BA synthesis in extrahepatic sites such as the brain elicits neuroprotective actions through inhibition of apoptosis as well as oxidative and endoplasmic reticulum stress. Even though historically BAs were thought to be only "detergent molecules" required for intestinal absorption of dietary fats, they are nowadays acknowledged as full signaling molecules. They modulate a myriad of signaling pathways with functional consequences on essential processes such as gluconeogenesis -one of the principal energy sources of the fetus- and cellular proliferation. The current manuscript discusses the potential multipotent roles of physiologically circulating BAs on developmental processes during gestation and provides a novel perspective in terms of the importance of the placenta as a previously unknown source of BAs. Since the principle "not too much, not too little" applicable to other signaling molecules may be also true for BAs, the risks associated with fetal exposure to excessive levels of BAs are discussed.

Unique microRNA expression profiles in plasmic exosomes from intrahepatic cholestasis of pregnancy

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is strongly associated with an increased risk of adverse perinatal outcomes. Total bile acid (TBA) levels in the late second or third trimester are a major factor in the diagnosis. Here, we sought to establish the miRNA expression profile of plasm exosomes of ICP and identify possible biomarkers for the diagnosis of ICP.

METHODS

This case-control study involved 14 ICP patients as the experimental group and 14 healthy pregnant women as the control group. Electron microscopy was used to observe the presence of exosomes in plasma. Nanosight and Western blotting of CD63 was used to assess exosome quality. Among them, three ICP patients and three controls were used for isolation plasmic exosome and preliminary miRNA array analysis. The Agilent miRNA array was utilized to dynamically monitor the miRNA expression in plasmic exosomes of included patients in the first trimester(T1), second trimester (T2), third trimester (T3), and delivery (T4). Then, Quantitative real-time Polymerase chain reaction was used to identify and validate differentially expressed miRNAs in plasma-derived exosomes.

RESULTS

The expression levels of hsa-miR-940, hsa-miR-636, and hsa-miR-767-3p in plasma-derived exosomes of ICP patients were significantly higher than those of healthy pregnant women. Besides, these three miRNAs were also significantly up-regulated at the plasma, placental, and cellular levels (P < 0.05). The diagnostic accuracy of hsa-miR-940, hsa-miR-636, and hsa-miR-767-3p was further evaluated by the ROC curve, the area under the curve (AUC) values for each were 0.7591, 0.7727, and 0.8955, respectively.

CONCLUSIONS

We identified three differentially expressed miRNAs in the plasma exosomes of ICP patients. Hence, hsa-miR-940, hsa-miR-636, and hsa-miR-767-3p may be potential biomarkers for enhancing the diagnosis and prognosis of ICP.

Swainsonine Induces Liver Inflammation in Mice via Disturbance of Gut Microbiota and Bile Acid Metabolism

Swainsonine induced liver inflammation in livestock; however, the underlying mechanisms, especially the role of bile acids (BAs), in the pathogenesis remained elusive. Here, our results showed that swainsonine induced hepatic inflammation via changing BA metabolism and gut microbiota in mice. Swainsonine significantly upregulated the levels of deoxycholic acid (DCA) and taurine-β-muricholic acid (T-β-MCA) in the serum and liver of mice due to the markedly increased genus Clostridium and the decreased genus Lactobacillus in the gut. As antagonists of the farnesoid X receptor (FXR), elevated DCA and T-β-MCA inhibited hepatic Fxr gene expression and thus suppressed FXR-SHP signaling and activated hepatic Cyp7a1 gene expression, which induced a significant upregulation of the total BA level in serum, contributing to liver inflammation. These findings offer new insights into the underlying mechanisms in which swainsonine induced liver inflammation in mice via the gut-liver axis and suggest that gut microbiota and its metabolite BAs may be underlying triggering factors.

Can first-trimester aspartate aminotransferase/platelet ratio index score predict intrahepatic cholestasis of pregnancy?

Background and Aim

The study aimed to investigate the effectiveness of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and platelet values in predicting intrahepatic cholestasis of pregnancy (ICP) in the first trimester, together with the aspartate aminotransferase/platelet ratio index (APRI) score.

Materials and Methods

This study consisted of a patient group diagnosed with ICP (n=49) and a control group (n=62). Laboratory tests of both groups were analyzed retrospectively.

Results

The first-trimester APRI score and AST and ALT values were found to be statistically significantly higher than those of the control group. The platelet value was found to be statistically significantly lower in the study group, even though it was within the normal reference range.

Conclusion

The first-trimester APRI score was found to be effective in predicting ICP. In addition, the first-trimester AST, ALT, and platelet values were found to be effective in predicting ICP diagnosed in the third trimester even though if not as much as the APRI score.

Bile Acids in Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is the most common, reversible, and closely related to pregnancy condition characterized by elevated levels of bile acids (BAs) in blood serum and an increased risk of adverse perinatal outcomes. Due to the complex interactions between the mother and the fetus in metabolism and transplacental BAs transport, ICP is classified as a fetal-maternal disease. The disease is usually mild in pregnant women, but it can be fatal to the fetus, leading to numerous complications, including intrauterine death. The pathophysiology of the disease is based on inflammatory mechanisms caused by elevated BA levels. Although ICP cannot be completely prevented, its early diagnosis and prompt management significantly reduce the risk of fetal complications, the most serious of which is unexpected intrauterine death. It is worth emphasizing that all diagnostics and management of ICP during pregnancy are based on BA levels. Therefore, it is important to standardize the criteria for diagnosis, as well as recommendations for management depending on the level of BAs, which undoubtedly determines the impact on the fetus. The purpose of this review is to present the potential and importance of BAs in the detection and rules of medical procedure in ICP.

Intrauterine growth retardation affects liver bile acid metabolism in growing pigs: effects associated with the changes of colonic bile acid derivatives

BACKGROUND

Intrauterine growth retardation (IUGR) is associated with severely impaired nutrient metabolism and intestinal development of pigs. Our previous study found that IUGR altered intestinal microbiota and metabolites in the colon. However, the consequences of IUGR on bile acid metabolism in pigs remained unclear. The present study aimed to investigate the bile acid metabolism in the liver and the profile of bile acid derivatives in the colon of growing pigs with IUGR using bile acid targeted metabolomics. Furthermore, we determined correlations between colonic microbiota composition and metabolites of IUGR and normal birth weight (NBW) pigs at different growth stages that were 7, 21, and 28-day-old, and the average body weight (BW) of 25, 50, and 100 kg of the NBW pigs.

RESULTS

The results showed that the plasma total bile acid concentration was higher (P < 0.05) at the 25 kg BW stage and tended to increase (P = 0.08) at 28-day-old in IUGR pigs. The hepatic gene expressions related to bile acid synthesis (CYP7A1, CYP27A1, and NTCP) were up-regulated (P < 0.05), and the genes related to glucose and lipid metabolism (ATGL, HSL, and PC) were down-regulated (P < 0.05) at the 25 kg BW stage in IUGR pigs when compared with the NBW group. Targeted metabolomics analysis showed that 29 bile acids and related compounds were detected in the colon of pigs. The colonic concentrations of dehydrolithocholic acid and apocholic acid were increased (P < 0.05), while isodeoxycholic acid and 6,7-diketolithocholic acid were decreased (P < 0.05) in IUGR pigs, when compared with the NBW pigs at the 25 kg BW stage. Moreover, Spearman's correlation analysis revealed that colonic Unclassified_[Mogibacteriaceae], Lachnospira, and Slackia abundances were negatively correlated (P < 0.05) with dehydrolithocholic acid, as well as the Unclassified_Clostridiaceae abundance with 6,7-diketolithocholic acid at the 25 kg BW stage.

CONCLUSIONS

These findings suggest that IUGR could affect bile acid and glucolipid metabolism in growing pigs, especially at the 25 kg BW stage, these effects being paralleled by a modification of bile acid derivatives concentrations in the colonic content. The plausible links between these modified parameters are discussed.

Complications of Hypertriglyceridemia in Pregnancy and Its Impact on Neonates: a Hospital-Based Study From Odisha

Objective

Hypertriglyceridemia (HTG) in pregnancy causes an increased risk for maternal and fetal complications. But, reports on the impact of HTG in pregnancy on maternal and fetal outcomes are scarce in developing countries. We aim to determine the maternal and neonatal complications of HTG in pregnancy.

Materials and methods

This prospective observational study was conducted on 150 pregnant women with HTG in the department of obstetrics and gynecology, KIMS, Bhubaneswar, from December 2019 to November 2020. Measurement of triglycerides during the first trimester, second trimester, and delivery was done. Maternal complications and neonatal outcomes in HTG mothers and mothers with normal triglyceride levels were compared.

Results

Out of 150 HTG cases, hypothyroidism, preeclampsia, acute pancreatitis, and sickle cell crisis occurred in 41 (27.3%), 22 (14.7%), six (4%), and three (2%) cases, respectively. The triglyceridemia (TG) levels raised from 133.7±48.2 mg/dl in the first trimester to 232.8±151.0 mg/dl in the third trimester. There is a significant increase in TG levels at the time of delivery compared to the first and second trimesters (p< .001). Out of 140 neonates, 30 (21.4%) were preterm, eight (5.7%) had intrauterine growth restriction (IUGR), and four (6.06%) were macrosomic. Intrauterine death, preterm, and macrosomia are significantly associated with maternal HTG compared to normal mothers (p < .032). All mortalities were due to acute pancreatitis (6; 4%) among mothers and four intrauterine fetal death.

Conclusion

There is a steady increase in TG levels in the successive trimesters of pregnancy. Gestational severe hypertriglyceridemia causes life-threatening complications. HTG-induced acute pancreatitis needs to be managed aggressively to prevent maternal death. Neonates of HTG mothers suffer from complications like prematurity, IUGR, and macrosomia.

Efficacy of fetal left ventricular modified myocardial performance index in predicting adverse perinatal outcomes in intrahepatic cholestasis of pregnancy

OBJECTIVE

This study aimed to evaluate the effectiveness of fetal left ventricular modified myocardial performance index in predicting adverse perinatal outcomes for intrahepatic cholestasis of pregnancy.

METHODS

A cross-sectional study was conducted, including 51 women with intrahepatic cholestasis of pregnancy and 80 healthy controls. Using Doppler ultrasonography, E-wave, A-wave, isovolumetric contraction time, isovolumetric relaxation time, and ejection time were recorded and the left ventricular modified myocardial performance index was measured.

RESULTS

Findings showed that the mean left ventricular modified myocardial performance index, isovolumetric contraction time, and isovolumetric relaxation time values were statistically significantly higher while the ejection time and E/A ratios were statistically significantly lower in the intrahepatic cholestasis of pregnancy group than the control group. In the intrahepatic cholestasis of pregnancy group, a statistically significant positive correlation was found between left ventricular modified myocardial performance index and adverse perinatal outcomes in the intrahepatic cholestasis of pregnancy group (r=0.478, p<0.001), while a statistically significant negative correlation was found between the E/A ratio and adverse perinatal outcomes (r=-0.701, p<0.001).

CONCLUSIONS

For intrahepatic cholestasis of pregnancy cases, high fetal left ventricular modified myocardial performance index values were an indicator of ventricular dysfunction, and this correlated with negative perinatal outcomes.

The alcohol dehydrogenase isoenzyme (ADH I) as a marker of intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is an important pregnancy liver disorder. The alterations of different enzymes activity in the hepatocytes in the course of liver diseases are reflected in an increase in the activity of the corresponding enzymes in the blood. In present study we assayed the activity of alcohol dehydrogenase (ADH) and its isoenzyme in the serum of patients with ICP. Serum were collected from 100 pregnancies with ICP in the second or third trimester of pregnancy. Serum samples were also taken from 100 healthy pregnant women. The activity of ADH I was measured by spectrofluorometric method, ADH total was measured by photometric method. There was significant increase in the activity of ADH I (2.79 mU/l vs. 1.72 mU/l) and total ADH activity (1103 mU/l vs. 682 mU/l) in the sera of women with ICP compared to the healthy pregnant women. Importantly, the sensitivity and specificity of ADH I for diagnosis of ICP were 85% and 91%, respectively. Area under the Receiver Operating Curve for ADH I in ICP was 0.81. The activity of ADH I in the sera of women with ICP is statistically significantly increased, which may have a diagnostic significance for ICP patients.

Deep Learning Algorithm-Based Magnetic Resonance Imaging Feature-Guided Serum Bile Acid Profile and Perinatal Outcomes in Intrahepatic Cholestasis of Pregnancy

This study was aimed to explore magnetic resonance imaging (MRI) based on deep learning belief network model in evaluating serum bile acid profile and adverse perinatal outcomes of intrahepatic cholestasis of pregnancy (ICP) patients. Fifty ICP pregnant women diagnosed in hospital were selected as the experimental group, 50 healthy pregnant women as the blank group, and 50 patients with cholelithiasis as the gallstone group. Deep learning belief network (DLBN) was built by stacking multiple restricted Boltzmann machines, which was compared with the recognition rate of convolutional neural network (CNN) and support vector machine (SVM), to determine the error rate of different recognition methods on the test set. It was found that the error rate of deep learning belief network (7.68%) was substantially lower than that of CNN (21.34%) and SVM (22.41%) (P < 0.05). The levels of glycoursodeoxycholic acid (GUDCA), glycochenodeoxycholic acid (GCDCA), and glycocholic acid (GCA) in the experimental group were dramatically superior to those in the blank group (P < 0.05). Both the experimental group and the blank group had notable clustering of serum bile acid profile, and the experimental group and the gallstone group could be better distinguished. In addition, the incidence of amniotic fluid contamination, asphyxia, and premature perinatal infants in the experimental group was dramatically superior to that in the blank group (P < 0.05). The deep learning confidence model had a low error rate, which can effectively extract the features of liver MRI images. In summary, the serum characteristic bile acid profiles of ICP were glycoursodeoxycholic acid, glycochenodeoxycholic acid, and glycocholic acid, which had a positive effect on clinical diagnosis. The toxic effects of high concentrations of serum bile acids were the main cause of adverse perinatal outcomes and sudden death.

Serum Exosomes MicroRNAs Are Novel Non-Invasive Biomarkers of Intrahepatic Cholestasis of Pregnancy

Background

Intrahepatic cholestasis of pregnancy (ICP) is closely related to the occurrence of adverse outcomes. Currently, total bile acids (TBAs) are the only diagnostic index for ICP, and its sensitivity and specificity have certain limitations. In this study, we aimed to develop potential biomarkers for the diagnosis of ICP.

Methods

Sixty pregnant women diagnosed with ICP and 48 healthy pregnant controls were enrolled in this study. We used the Agilent microRNA (miRNA) array followed by quantitative reverse transcriptase polymerase chain reaction assays to identify and validate the serum exosome miRNA profiles in ICP and healthy pregnant controls. We employed bioinformatics to identify metabolic processes associated with differentially expressed serum exosome miRNAs.

Results

The expression levels of hsa-miR-4271, hsa-miR-1275, and hsa-miR-6891-5p in maternal serum exosomes were significantly lower in ICP patients compared to controls; the diagnostic accuracy of hsa-miR-4271, hsa-miR-1275, and hsa-miR-6891-5p was evaluated with the area under the receiver operating characteristic curve (AUC) values of 0.861, 0.886, and 0.838, respectively. Multiple logistic regression analysis showed that a combination of the levels of hsa-miR-4271and hsa-miR-1275 afforded a significantly higher AUC (0.982). The non-error rate of a combination of all three exosome miRNAs was the highest (95%), thus more reliable ICP diagnosis. The expression levels of all three exosome miRNAs were negatively associated with TBAs. Furthermore, according to bioinformatics analysis, the three exosome miRNAs were related to lipid metabolism, apoptosis, oxidative stress, and the Mitogen Activated Protein Kinase (MAPK) signaling pathway.

Conclusions

This study may identify the novel non-invasive biomarkers for ICP and provided new insights into the important role of the exosome miRNA regulation in ICP.

Bile Acid Detection Techniques and Bile Acid-Related Diseases

Bile acid is a derivative of cholinergic acid (steroidal parent nucleus) that plays an important role in digestion, absorption, and metabolism. In recent years, bile acids have been identified as signaling molecules that regulate self-metabolism, lipid metabolism, energy balance, and glucose metabolism. The detection of fine changes in bile acids caused by metabolism, disease, or individual differences has become a research hotspot. At present, there are many related techniques, such as enzyme analysis, immunoassays, and chromatography, that are used for bile acid detection. These methods have been applied in clinical practice and laboratory research to varying degrees. However, mainstream detection technology is constantly updated and replaced with the passage of time, proffering new detection technologies. Previously, gas chromatography (GS) and gas chromatography-mass spectrometry (GC-MS) were the most commonly used for bile acid detection. In recent years, high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) has developed rapidly and has gradually become the mainstream bile acid sample separation and detection technology. In this review, the basic principles, development and progress of technology, applicability, advantages, and disadvantages of various detection techniques are discussed and the changes in bile acids caused by related diseases are summarized.

Assessment of intrahepatic cholestasis in pregnancy and the effect of disease severity on transient tachypnea in the newborn in uncomplicated fetuses

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.

Studies on Novel Diagnostic and Predictive Biomarkers of Intrahepatic Cholestasis of Pregnancy Through Metabolomics and Proteomics

Background

Intrahepatic cholestasis of pregnancy (ICP) usually occurs in the third trimester and is associated with increased risks in fetal complications. Currently, the exact mechanism of this disease is unknown. The purpose of this study was to develop potential biomarkers for the diagnosis and prediction of ICP.

Methods

We enrolled 40 pregnant women diagnosed with ICP and 40 healthy pregnant controls. The number of placental samples and serum samples between the two groups was 10 and 40 respectively. Ultra-performance liquid chromatography tandem high-resolution mass spectrometry was used to analyze placental metabolomics. Then, we verified the differentially expressed proteins and metabolites, both placental and blood serum, in the first, second, and third trimesters.

Results

Metabolomic analysis of placental tissue revealed that fatty acid metabolism and primary bile acid biosynthesis were enriched. In the integrated proteomic and metabolomic analysis of placental tissue, peroxisomal acyl-CoA oxidase 1 (ACOX1), L-palmitoylcarnitine, and glycocholic acid were found to be three potential biomarkers. In a follow–up analysis, expression levels of both placental and serum ACOX1, L-palmitoylcarnitine, and glycocholic acid in both placenta and serum were found to be significantly higher in third-trimester ICP patients; the areas under the ROC curves were 0.823, 0.896, and 0.985, respectively. Expression levels of serum ACOX1, L-palmitoylcarnitine, and glycocholic acid were also significantly higher in first- and second-trimester ICP patients; the areas under the ROC curves were 0.726, 0.657, and 0.686 in the first trimester and 0.718, 0.727, and 0.670 in the second trimester, respectively. Together, levels of the three aforementioned biomarkers increased the value for diagnosing and predicting ICP (AUC: 0.993 for the third, 0.891 for the second, and 0.932 for the first trimesters).

Conclusions

L-palmitoylcarnitine, ACOX1, and glycocholic acid levels taken together may serve as a new biomarker set for the diagnosis and prediction of ICP.

Use of bile acids as potential markers of liver dysfunction in humans: A systematic review

OBJECTIVE

This study aimed to determine the effectiveness of using total, individual serum, or urinary bile acids (BA) as potential markers of liver dysfunction.

METHODS

We searched the PubMed and Web of Science databases using the following keywords- "serum bile acids," "liver dysfunction," "liver injury," "liver disease," "traditional liver function tests," "Chronic liver disease," "acute liver injury". The search was complemented by manual screening of the list of references for relevant articles. We selected only English-language manuscripts for adult patients based on predetermined inclusion and exclusion criteria. Animal studies and studies on neonates and children were not included.

OUTCOME MEASURES

Changes in BA concentrations or ratios at or prior to changes in liver function tests.

RESULTS

A total of 547 studies were identified, of which 28 were included after reading the entire manuscript. These studies included 1630 patients and 836 controls published between 1990 and 2017. The methods used in BA assays varied significantly, and the studies did not agree. on specific individual BA or BA ratios as biomarkers of specific liver injury or dysfunction. Except for the prognostic value of BA in intrahepatic cholestasis of pregnancy (ICP), studies have failed to provide evidence for BA as a liver biomarker.

CONCLUSIONS

Despite the research conducted on BA for over 27 years, there are inconsistencies in the reported results and a lack of solid evidence to support the use of individual BA or BA ratios as biomarkers of liver injury. Adequately conducted studies needed to resolve this limitation in the literature.

Metabolic characteristics of plasma bile acids in patients with intrahepatic cholestasis of pregnancy-mass spectrometric study

INTRODUCTION

Intrahepatic cholestasis of pregnancy (ICP) is one of the more common complications in the middle and late stages of pregnancy, which requires early detection and intervention.

OBJECTIVE

The aim of the study is to investigate the changes in the metabolic profile of bile acids (BAs) in plasma of pregnant women with ICP and to look biomarkers for the diagnosis and grading of ICP, and to explore the disease mechanism.

METHODS

The targeted metabolomics based on high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) was used to analyze plasma BAs.

RESULTS

Twenty-seven BAs can be quantified in all participants. Among them, 22 BAs were identified as differential BAs between ICP and control groups. Five BAs include 3β-CA, 3β-DCA, CDCA-3Gln, NCA, and Tβ-MCA, were found to be associated with ICP for the first time. Nine BAs include NCA, GCA, GCDCA, GHCA, GUDCA, HCA, TCA, TCDCA and THCA, can be used as possible ICP diagnostic biomarkers. Four BAs, i.e., GLCA, THCA, GHCA and TLCA-3S may be used as potential biomarkers for ICP grading.

CONCLUSION

There were significant differences in plasma BA profiles between ICP patients and the control. The BA profiles of mild ICP group and severe ICP group partially overlapped. Potential diagnostic and grading BA markers were identified. A significant characteristic of ICP group was the increase of conjugated BAs. A mechanism to sustain the equilibrium of BA metabolism and adaptive response has been developed in ICP patients to accelerate excretion and detoxification.

Alpha-1 Antitrypsin Z Variant (AAT PI*Z) as a Risk Factor for Intrahepatic Cholestasis of Pregnancy

Background: Intrahepatic cholestasis of pregnancy (ICP; prevalence 0.2–15.6%) is the most common pregnancy-related liver disorder. It may have serious consequences for a pregnancy, including increased risk of preterm delivery, meconium staining of amniotic fluid, fetal bradycardia, distress, and fetal demise. In cases of high bile acids (>100μmol/L), patients have 10-fold increase in the risk of stillbirth. Biophysical methods of fetal monitoring, such as cardiotocography, ultrasonography, or Doppler have been proven unreliable for risk prediction in the course of intrahepatic cholestasis. Therefore, we believe extensive research for more specific, especially early, markers should be carried out. By analogy with cholestasis in children with inherited alpha-1 antitrypsin deficiency (AATD), we hypothesized the SERPINA1 Z pathogenic variant might be related to a higher risk of cholestasis in pregnancy. This study aimed to investigate the most common AATD variants (Z and S SERPINA1 alleles) in a group of cholestatic pregnant women.

Results: The Z carrier frequency was calculated to be 6.8%, which is much higher compared to the general population [2.3%; the Chi-squared test with Yates correction is 6.8774 (p=0.008)].

Conclusion: Increased prevalence of SERPINA1 PI*Z variant in a group of women with intrahepatic cholestasis may suggest a possible genetic origin of a higher risk of intrahepatic cholestasis in pregnancy.

Value of Serum Glycocholic Acid and Total Bile Acids in Predicting Maternal and Perinatal Outcomes in Intrahepatic Cholestasis of Pregnancy

Objective

To see whether serum glycocholic acid (CG) and total bile acids (TBA) can predict maternal and perinatal outcomes in pregnant women with intrahepatic cholestasis (ICP).

Method

The observation group consisted of 80 women with ICP who were treated in our hospital, whereas the control group consisted of 50 ordinary women who were also treated at our hospital at the same time. The levels of CG and TBA in the two groups were determined independently, and the differences in poor perinatal outcomes were compared. Finally, the predictive diagnostic value of CG and TBA for poor perinatal outcomes in ICP mothers was displayed using the Spearman correlation between CG and TBA and Apgar. The maternal CG and TBA levels in the observation group were substantially higher than in the control group (P0.05). The observation group had more significant maternal-fetal discomfort, neonatal asphyxia, preterm birth, and perinatal death than the control group (P0.05). The risk of poor perinatal outcomes in ICP mothers rose when TBA and CG levels increased (P0.05). Apgar ratings were inversely associated with CG and TBA (r = −0.8251 and r = −0.5969, respectively, P0.05). The CG and TBA diagnostic AUCs for unfavorable perinatal outcomes in ICP mothers were (P0.05).

Conclusion

CG and TBA have a high diagnostic value for ICP and may better predict and identify poor prenatal outcomes. It is suitable for clinical use.

Genetic variants associated with beta-cell function and insulin sensitivity potentially influence bile acid metabolites and gestational diabetes mellitus in a Chinese population

INTRODUCTION

To investigate associations between genetic variants related to beta-cell (BC) dysfunction or insulin resistance (IR) in type 2 diabetes (T2D) and bile acids (BAs), as well as the risk of gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

We organized a case-control study of 230 women with GDM and 217 without GDM nested in a large prospective cohort of 22 302 Chinese women in Tianjin, China. Two weighted genetic risk scores (GRSs), namely BC-GRS and IR-GRS, were established by combining 39 and 23 single nucleotide polymorphisms known to be associated with BC dysfunction and IR, respectively. Regression and mediation analyses were performed to evaluate the relationship of GRSs with BAs and GDM.

RESULTS

We found that the BC-GRS was inversely associated with taurodeoxycholic acid (TDCA) after adjustment for confounders (Beta (SE)=-0.177 (0.048); p=2.66×10^-4). The BC-GRS was also associated with the risk of GDM (OR (95% CI): 1.40 (1.10 to 1.77); p=0.005), but not mediated by TDCA. Compared with individuals in the low tertile of BC-GRS, the OR for GDM was 2.25 (95% CI 1.26 to 4.01) in the high tertile. An interaction effect of IR-GRS with taurochenodeoxycholic acid (TCDCA) on the risk of GDM was evidenced (p=0.005). Women with high IR-GRS and low concentration of TCDCA had a markedly higher OR of 14.39 (95% CI 1.59 to 130.16; p=0.018), compared with those with low IR-GRS and high TCDCA.

CONCLUSIONS

Genetic variants related to BC dysfunction and IR in T2D potentially influence BAs at early pregnancy and the development of GDM. The identification of both modifiable and non-modifiable risk factors may facilitate the identification of high-risk individuals to prevent GDM.

The BACH project protocol: an international multicentre total Bile Acid Comparison and Harmonisation project and sub-study of the TURRIFIC randomised trial

OBJECTIVES

Multicentre international trials relying on diagnoses derived from biochemical results may overlook the importance of assay standardisation from the participating laboratories. Here we describe a study protocol aimed at harmonising results from total bile acid determinations within the context of an international randomised controlled Trial of two treatments, URsodeoxycholic acid and RIFampicin, for women with severe early onset Intrahepatic Cholestasis of pregnancy (TURRIFIC), referred to as the Bile Acid Comparison and Harmonisation (BACH) study, with the aims of reducing inter-laboratory heterogeneity in total bile acid assays.

METHODS

We have simulated laboratory data to determine the feasibility of total bile acid recalibration using a reference set of patient samples with a consensus value approach and subsequently used regression-based techniques to transform the data.

RESULTS

From these simulations, we have demonstrated that mathematical recalibration of total bile acid results is plausible, with a high probability of successfully harmonising results across participating laboratories.

CONCLUSIONS

Standardisation of bile acid results facilitates the commutability of laboratory results and collation for statistical analysis. It may provide the momentum for broader application of the described techniques in the setting of large-scale multinational clinical trials dependent on results from non-standardised assays.

Liver injury associated with drug intake during pregnancy

Drug use during pregnancy is not common. Drug-induced liver injury (DILI) is a potential complication that is rare but can adversely affect both the mother and the fetus. Although many drugs can directly cause hepatotoxicity, idiosyncratic liver injury is common in pregnancy. Underreporting of adverse drug reactions, lack of adequate literature regarding drug safety in pregnancy, and the inherent difficulty in diagnosing DILI during pregnancy make the management of this condition challenging. This review attempts to describe the existing literature regarding DILI in pregnancy, which is mainly in the form of case reports; several studies have looked at the safety of antithyroid drugs, antiretroviral drugs, and paracetamol, which have an indication for use in pregnancy; the relevant data from these studies with regard to DILI has been presented. In addition, the review describes the diagnosis of DILI, grading the disease severity, assessment of causality linking the drug to the adverse event, regulatory guidelines for evaluating the potential of drugs to cause liver injury, efforts to ensure better participation of women in clinical trials and studies in pregnant women population in particular, and the challenges involved in generating adequate research evidence. The establishment of DILI registries in various countries is an encouraging development; however, there is a need for promoting active, spontaneous reporting of adverse events during pregnancy to ensure rapid generation of evidence regarding the safety of a drug in pregnant women.

Impact on Bile Acid Concentrations by Alveolar Echinococcosis and Treatment with Albendazole in Mice

Alveolar echinococcosis (AE) caused by Echinococcus multilocularis is a chronic, progressive liver disease widely distributed in the Northern Hemisphere. The main treatment options include surgical interventions and chemotherapy with benzimidazole albendazole (ABZ). To improve the current diagnosis and therapy of AE, further investigations into parasite-host interactions are needed. This study used liquid chromatography-tandem mass spectrometry (LC-MS/MS) to assess serum and liver tissue bile acid profiles in the i.p. chronic E. multilocularis-infected mouse model and evaluated the effects of the anthelmintic drug ABZ. Additionally, hepatic mRNA and protein expression of enzymes and transporters regulating bile acid concentrations were analyzed. AE significantly decreased unconjugated bile acids in serum and liver tissue. Taurine-conjugated bile salts were unchanged or increased in the serum and unchanged or decreased in the liver. Ratios of unconjugated to taurine-conjugated metabolites are proposed as useful serum markers of AE. The expression of the bile acid synthesis enzymes cytochrome P450 (CYP) 7A1 and aldo-keto reductase (AKR) 1D1 tended to decrease or were decreased in mice with AE, along with decreased expression of the bile acid transporters Na+/taurocholate cotransporting polypeptide (NTCP) and bile salt efflux pump (BSEP). Importantly, treatment with ABZ partially or completely reversed the effects induced by E. multilocularis infection. ABZ itself had no effect on the bile acid profiles and the expression of relevant enzymes and transporters. Further research is needed to uncover the exact mechanism of the AE-induced changes in bile acid homeostasis and to test whether serum bile acids and ratios thereof can serve as biomarkers of AE and for monitoring therapeutic efficacy.

Association of Elevated Maternal Serum Total Bile Acids With Low Birth Weight and Intrauterine Fetal Growth Restriction

IMPORTANCE

Bile acids play essential roles in metabolic modulation. Excessive serum total bile acid (sTBA) levels during pregnancy are associated with adverse perinatal outcomes; however, their association with the risk of intrauterine growth restriction (IUGR) remains unclear.

OBJECTIVE

To investigate the association between maternal sTBA concentration during pregnancy and the risk of IUGR.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included pregnant individuals who delivered live singleton neonates and had regular antenatal examination records available at a hospital-based center in Shanghai, China, from 2014 to 2018. Data were analyzed from July to November 2020.

EXPOSURES

Maternal sTBA concentration during pregnancy.

MAIN OUTCOMES AND MEASURES

Fetal birth weight and probability of low birth weight (LBW) and IUGR.

RESULTS

This study included 68 245 singleton pregnancies with live births for analysis. The mean (SD) age of the pregnant individuals was 30.5 (3.8) years, 67 168 patients (98.4%) were Han, and 50 155 (73.5%) were nulliparous. Nonlinear regression models suggested that there was an inverted J-shaped association between maternal sTBA level during pregnancy and fetal birth weight, with a steep decrease in birth weight at high sTBA levels (estimated mean [SE] birth weight for sTBA of 40.8 ug/mL, 2879 [39.9] g) and greater birth weights at lower sTBA levels (estimated mean [SE] birth weight for sTBA 0.4 μg/mL, 3290 [3.9] g; and for 4.1 μg/mL, 3334 [1.6] g). Lower birth weight and a higher incidence of IUGR were observed in patients with gestational hypercholanemia (sTBA ≥4.08 μg/mL) compared with those without gestational hypercholanemia (birth weight: estimated adjusted mean [SE], 3309 [3.32] vs 3338 [0.80] g; P = .005; incidence of IUGR: 62 of 4467 [1.4%] vs 312 of 63 778 [0.5%]; P < .001). Moreover, compared with patients with sTBA concentrations of less than 4.08 μg/mL, those with gestational hypercholanemia had an increased risk of LBW (adjusted odds ratio [aOR], 1.29; 95% CI, 1.09-1.53) and IUGR (aOR, 2.18; 95% CI, 1.62-2.91). In addition, there was an additive interaction between hypertensive disorders in pregnancy (HDP) and hypercholanemia on LBW and IUGR risk. The highest risks of LBW and IUGR were found in pregnant individuals with both HDP and hypercholanemia compared with those with normotensive pregnancies with sTBA concentrations less than 4.08 μg/mL (LBW: aOR, 9.13; 95% CI, 6.88-12.12; IUGR: aOR, 19.14; 95% CI, 12.09-30.28).

CONCLUSIONS AND RELEVANCE

This study found that gestational hypercholanemia was associated with an increased risk of LBW and IUGR, especially in pregnant individuals with HDP. Therefore, it would be meaningful to monitor sTBA concentration during the follow-up of pregnancies with potential IUGR.

Intrahepatic cholestasis of pregnancy: machine-learning algorithm to predict elevated bile acid based on clinical and laboratory data

PURPOSE

Applying machine-learning models to clinical and laboratory features of women with intrahepatic cholestasis of pregnancy (ICP) and creating algorithm to identify these patients without bile acid measurements.

METHODS

This retrospective study included 336 pregnant women with a chief complaint of pruritis without rash during the second/third trimesters. Data extracted included: demographics, obstetric, clinical and laboratory features. The primary outcome was an elevated bile acid measurement  ≥ 10 µmol/L, regardless of liver enzyme levels. We used different machine-learning models and statistical regression to predict elevated bile acid levels.

RESULTS

Among 336 women who complained about pruritis, 167 had bile acids  ≥ 10 µmol/L and 169 had normal levels. Women with elevated bile acids were older than those with normal levels (p = 0.001), higher parity (p = 0.001), and higher glutamic oxaloacetic transaminase ( GOT) (p = 0.001) and glutamic-pyruvic transaminase (GPT) levels (p = 0.001). Using machine-learning models, the XGB Classifier model was the most accurate (area under the curve (AUC), 0.9) followed by the K-neighbors model (AUC, 0.86); and then the Support Vector Classification (SVC) model (AUC, 0.82). The model with the lowest predicative ability was the logistic regression (AUC, 0.72). The maximum sensitivity of the XGB model was 86% and specificity 75%. The best predictive parameters of the XGB model were elevated GOT (Importance 0.17), elevated GPT (Importance 0.16), family history of bile disease (0.16) and previous pregnancy with ICP (0.13).

CONCLUSION

Machine-learning models using clinical data may predict ICP more accurately than logistic regression does. Using detection algorithms derived from these techniques may improve identification of ICP, especially when bile acid testing is not available.

Oral herbal medicine for women with intrahepatic cholestasis in pregnancy: a systematic review of randomized controlled trials

Background

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy complication whose range has been calculated to be between 0.01 and 15.6% all around the world. We wanted to systematically evaluate the effect and safety of oral herbal medicine on treatment for ICP.

Methods

Details of the methods could be found in the registered protocol on PROSPERO (CRD42018096013). Trials assessing the effectiveness of herbal medicine for ICP were searched from seven electronic databases from inception to 28th February 2020. RevMan 5.3 software was used to perform all statistical analysis. Meta-analysis, additional analysis, Trial Sequential Analysis (TSA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were conducted if data permitted.

Results

Totally 43 randomized controlled trials with 3556 patients were included. Meta-analysis showed potential good adjunctive effect of herbal medicine on decreasing the pruritus scores (MD -0.58, 95% CI − 0.79 to − 0.36), the serum TBA scores (MD − 3.99 μmol/L, 95% CI − 4.24 to − 3.74) on the basis with Ursodesoxycholic acid. Compared to the medicine alone, significantly lower incidence of fetal distress (RR 0.41, 95% CI 0.32 to 0.51), asphyxia neonatorum (RR 0.35, 95%CI 0.25 to 0.49), cesarean section (RR 0.73, 95% CI 0.63 to 0.85), postpartum hemorrhage (RR 0.45, 95% CI 0.28 to 0.72) were observed in the combination group. But the comparison between herbal medicine and medicine showed inconsistent results among trials. Insufficient information could be used to evaluate the safety of herbal medicine for ICP.

Conclusion

This review found the current evidence may support the effectiveness of combination of herbal medicine and conventional medicine for decreasing the maternal pruritus scores, the serum TBA, and the number of fetal distress, or asphyxia neonatorum events related to this condition (which was supported by TSA results). Since there were obvious statistical and clinical heterogeneity among trials, and the methodological quality of the included studies was poor, the level of the evidence could only be defined as “very low” according to the GRADE criteria. Further high quality studies are still needed to testify the effectiveness and safety of herbal medicine for ICP.