Prevalence and risk factors of intrahepatic cholestasis of pregnancy in a Chinese population

The role of Ca2+ signalling and InsP3R in the pathogenesis of intrahepatic cholestasis of pregnancy

BACKGROUND

In order to contribute new insights for future prevention and treatment of intrahepatic cholestasis of pregnancy (ICP), and to promote positive pregnancy outcomes, we evaluated serum Ca2+ levels and inositol 1,4,5-trisphosphate receptor (InsP3R) expression in the liver tissue of a rat ICP model.

METHODS

After establishing the model by injection of oestradiol benzoate and progesterone into pregnant rats, animals were divided into normal control (n = 5) and ICP model groups (n = 5). The expression of InsP3R protein in the liver, and serum levels of Ca2+, glycocholic acid and bile acid were detected.

RESULTS

InsP3R mRNA and protein were significantly lower in the ICP model group compared to the normal group, as determined by qPCR and immunohistochemistry, respectively. Serum enzyme-linked immunosorbent assay results revealed significantly higher levels of glycocholic acid and bile acid in the ICP model group compared to the normal group, while Ca2+ levels were significantly lower. The levers of Ca2+ were significantly and negatively correlated with the levels of glycocholic acid. The observed decrease in Ca2+ was associated with an increase in total bile acids, but there was no significant correlation.

CONCLUSIONS

Our results revealed that the expression of InsP3R and serum Ca2+ levels was significantly decreased in the liver tissue of ICP model rats. Additionally, Ca2+ levels were found to be negatively correlated with the level of glycocholic acid.

Associations of clinical subtypes and bile acid levels of intrahepatic cholestasis of pregnancy with pregnancy outcomes

Intrahepatic cholestasis of pregnancy (ICP) can lead to many adverse pregnancy outcomes, and the influencing factors remain unclear at present. This study retrospectively analyzed clinical data from 1815 pregnant women with ICP and evaluated the relationship between ICP subtypes, gestational age at onset, and pregnancy outcomes. The results of this study show that during pregnancy, the levels of biochemical indicators (TBA, DBIL and ALT) in the serum of pregnant women initially diagnosed with subtypes of ICP were noted to constantly change, and the subtype of ICP and its severity also changed. The incidence of adverse pregnancy outcomes [meconium-stained amniotic fluid (MSAF), NICU transfer, Apgar score ≤ 7 at 1 min, and preterm birth] in patients with ICP1 (icteric type) was significantly higher than for patients with ICP2, ICP3 or ICP4. The preterm birth rate of early-onset ICP was higher than that of late-onset ICP in ICP1 and ICP3 subtypes. In conclusion, the outcome of pregnancy in women with ICP is closely related to the serum TBA level and ICP subtype, which should be recognized in the clinic.

The Incidence of Intrahepatic Cholestasis of Pregnancy and its Maternal, Fetal, and Neonatal Adverse Outcomes: A Systematic Review and Meta-Analysis

INTRODUCTION

Intrahepatic cholestasis of pregnancy (ICP) is a problem with an increasing incidence and negative maternal, fetal, and neonatal consequences. This problem is becoming increasingly important. This systematic review and meta-analysis aimed to determine the incidence of ICP and its adverse maternal, fetal, and neonatal adverse outcomes based on primary research studies.

METHODS

This systematic review and meta-analysis used Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines and was conducted between June and September 2023 using the following keywords: obstetric cholestasis OR intrahepatic cholestasis AND pregnancy OR pregnant OR prenatal OR antenatal OR perinatal OR maternal OR fetal OR neonatal. Quality assessment of the studies was performed using the Critical Appraisal Checklists developed by the JBI Institute. Data were synthesized using meta-analysis methods.

RESULTS

The analysis included 10 studies published between 2013 and 2023. The meta-analysis showed that the incidence of ICP was 1.7% (odds ratio [OR], 0.021; 95% CI, 0.012-0.027), whereas maternal, fetal, and neonatal adverse outcomes included cesarean birth (OR, 2.938; 95% CI, 1.467-5.881), preterm birth or preterm prelabor rupture of membranes (OR, 4.241; 95% CI, 1.996-9.009), hypertensive disorders of pregnancy (OR, 3.715; 95% CI, 1.545-8.929), maternal infection (OR, 3.301; 95% CI, 2.917-3.737), neonatal intensive care unit admission (OR, 2.715; 95% CI, 1.458-5.056), birth weight less than or equal to 2500 g (OR, 2.518; 95% CI, 1.296-4.892), and small for gestational age (OR, 1.915; 95% CI, 1.424-2.573).

DISCUSSION

This systematic review and meta-analysis revealed that ICP has a high incidence and several maternal, fetal, and neonatal adverse outcomes. Therefore, midwives and other health professionals must be aware of these outcomes and provide appropriate care to pregnant individuals with ICP.

Metabolomic profiling of serum and tongue coating of pregnant women with intrahepatic cholestasis in pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is associated with an increased risk of cesarean section and adverse fetal outcomes. Currently, ICP diagnosis depends largely on serum levels of bile acids and lacks sensitivity and specificity for accurate diagnosis. Tongue diagnosis is an important diagnostic tool in traditional Chinese medicine (TCM) and is used in our clinic as complementary treatment and personalized medicine for ICP. However, the molecular basis of the manifestation of greasy white tongue coatings in ICP remains unknown. In this study, we performed untargeted metabolomic profiling of the serum, tongue coating, and saliva of 66 pregnant women, including 22 with ICP. The metabolomic profiles of the serum and tongue coatings showed marked differences between the two clinical groups. Forty-six differentially abundant metabolites were identified, and their relative concentrations correlated with total bile acid levels. These differential metabolites included bile acids, lipids, microbiota- and diet-related metabolites, and exposomes. Conventional biochemical markers, including serum aminotransferases and bilirubin, were not significantly increased in the ICP group, whereas the total cholesterol and triglyceride levels were significantly increased as early as the first trimester. Our data provide insights into the pathophysiology of ICP and implicate the gut-liver axis and environmental exposure. Tongue coating has the potential to be a non-invasive diagnostic approach. Further studies are required to validate the clinical utility of these findings.

Verification of bile acid determination method and establishing reference intervals for biochemical and haematological parameters in third-trimester pregnant women

OBJECTIVES

The aims of this study were to verify the bile acids (BA) method and to establish reference intervals (RIs) for bile acids (BA) and biochemical and haematological parameters in Croatian pregnant women.

METHODS

BA spectrophotometric method verification was performed on Siemens Atellica Solution CH 930 automated analyser using Sentinel reagent. Stability, precision, trueness, linearity, and RIs, as well as lipemia interference were tested according to CLSI guidelines. BA, biochemical, and haematological parameters were measured in serum (BA, biochemical) and whole blood (haematological) samples of fasting healthy third-trimester pregnant women from Croatia (n=121). The establishment of the RIs was done a priori according to the CLSI EP28-A3C:2010 guideline. Selected reference individuals' data were analysed using parametric, non-parametric, and robust methods.

RESULTS

Stability study showed that BA are stable in serum samples for 2 days at 20 °C, 14 days at 4-8 °C, and 22 days at -20 °C. The precision study and adult RIs verification met the criteria. Linearity was verified for the concentration range of 3.5-172.1 μmol/L whereas the lipemia interference test showed a positive bias (%) in BA concentration. The determined reference limits generally exhibited better precision for haematological parameters, being lower than the upper recommended value 0.2, unlike biochemical parameters. Haematological parameters showed notable differences between pregnant and non-pregnant women, while many biochemical parameters' RIs remained similar. Only ALT and GGT showed lower non-comparable RI upper limits in the population pregnant women.

CONCLUSIONS

Spectrophotometric BA method showed satisfactory performance and all examined parameters were within the set criteria. Moreover, RIs for key biochemical and haematological parameters, including BAs, have been established for the first time in the population of Croatian pregnant women.

Exosomes from Intrahepatic Cholestasis of Pregnancy Induce Cell Apoptosis Through the miRNA-6891-5p/YWHAE Pathway

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is associated with adverse pregnancy outcomes; however, the underlying mechanisms are not fully understood.

AIMS

This study aimed to determine the role of exosomal miR-6891-5p in placental trophoblast dysfunction in ICP and identify new biomarkers for ICP diagnosis.

METHODS

Serum samples were collected from ICP patients and healthy pregnant women, and serum exosomes were extracted and identified. Fluorescent dye labeling of exosomes and cell-verified cell phagocytosis were performed. In vitro experiments were conducted by adding taurocholic acid to simulate the ICP environment. Cell proliferation and apoptosis levels were detected using flow cytometry and the cell counting kit-8 assay. Mimics were constructed to overexpress miR-6891-5p in cells, and the binding site between miR-6891-5p and YWHAE was verified using luciferase reporter genes.

RESULTS

miR-6891-5p expression was significantly decreased in serum exosomes of ICP patients. Co-culturing with exosomes derived from ICP patients' serum (ICP-Exos) decreased HTR-8/SVeno cell proliferation and increased apoptosis levels. miR-6891-5p upregulation in HTR-8/SVeno cells significantly increased cell viability and reduced cell apoptosis levels, as determined by the cell counting kit-8 assay and flow cytometry. A double luciferase assay confirmed that miR-6891-5p affected the expression of the downstream YWHAE protein.

CONCLUSIONS

This study indicates that serum exosomes from ICP patients can impact the apoptosis of placental trophoblast HTR-8/SVeno cells through the miR-6891-5P/YWHAE pathway and can serve as specific molecular markers for ICP diagnosis.

Predictors of Adverse Fetal Outcomes in Intrahepatic Cholestasis of Pregnancy (ICP): a Narrative Review

Intrahepatic cholestasis of pregnancy (ICP) is a hepatic disorder in pregnancy linked with adverse fetal outcomes, which primarily manifests in the late second and third trimesters of pregnancy. This review aims to recapitulate the existing evidence on factors that can predict detrimental perinatal outcomes in pregnant women diagnosed with intrahepatic cholestasis of pregnancy. We searched PubMed, Web of Science, Cochrane Library, Scopus, Medline, and Embase databases and selected studies related to predictors of fetal outcome in intrahepatic cholestasis of pregnancy. Studies of the articles showed that predictors of an adverse fetal outcome include in vitro fertilization (IVF) pregnancy, multifetal pregnancy, biochemical markers, gestational age of ICP onset, presence of comorbidities (preeclampsia and gestational diabetes mellitus), maternal history of ICP, and hepatobiliary disease.Intrahepatic cholestasis of pregnancy (ICP) complicates the pregnancy. Hence, early assessment of low-risk and high-risk groups will help to administer definite management protocols and strategies to prevent adverse neonatal outcomes. Further research should concentrate on the number of conditions/factors and the predictive power of different factors to determine the most reliable predictors and biomarkers that can predict adverse fetal outcomes and improve the assessment of risk in pregnancy complicated with ICP.

An omics review and perspective of researches on intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is one of the common pregnancy complications that may threaten the health of both pregnant women and their fetuses. Hence, it is of vital importance to identify key moleculars and the associated functional pathways of ICP, which will help us to better understand the pathological mechanisms as well as to develop precise clinical biomarkers. The emerging and developing of multiple omics approaches enable comprehensive studies of the genome, transcriptome, proteome and metabolome of clinical samples. The present review collected and summarized the omics based studies of ICP, aiming to provide an overview of the current progress, limitations and future directions. Briefly, these studies covered a broad range of research contents by the comparing of different experimental groups including ICP patients, ICP subtypes, ICP fetuses, ICP models and other complications. Correspondingly, the studied samples contain various types of clinical samples, in vitro cultured tissues, cell lines and the samples from animal models. According to the main research objectives, we further categorized these studies into two groups: pathogenesis and diagnosis analyses. The pathogenesis studies identified tens of functional pathways that may represent the key regulatory events for the occurrence, progression, treatment and fetal effects of ICP. On the other hand, the diagnosis studies tested more than 40 potential models for the early-prediction, diagnosis, grading, prognosis or differential diagnosis of ICP. Apart from these achievements, we also evaluated the limitations of current studies, and emphasized that many aspects of clinical characteristics, sample processing, and analytical method can greatly affect the reliability and repeatability of omics results. Finally, we also pointed out several new directions for the omics based analyses of ICP and other perinatal associated conditions in the future.

Maternal and neonatal outcomes of intrahepatic cholestasis of pregnancy after in vitro fertilization

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is an idiopathic disease of pregnancy. Little is known about how it specifically affects pregnancies resulting from in vitro fertilization (IVF). Our aim is to evaluate the impact of IVF on the perinatal outcomes of ICP.

METHODS

A retrospective study of 242 patients with intrahepatic cholestasis of pregnancy, comprising 36 conceived through IVF and 206 spontaneous conceptions (SC), enrolled between 2019 and 2021 was carried out. Data were analyzed from the medical archives of the Huazhong University of Science and Technology, Tongji Hospital.

RESULTS

Numerical values of transaminases (ALT, alanine aminotransferase; AST, aspartate aminotransferase) and serum total bile acid (TBA) are significantly lower in the IVF group than that in the spontaneous conceived group (p < 0.05). The incidence of gestational diabetes mellitus (GDM) was higher in the IVF group than in SC group (30.6% vs. 16%, p = 0.037). The cesarean section (CS) rates are higher in the IVF group (97.2% vs. 85.4%, p = 0.023). On the other hand, the prevalence of premature rupture of membranes (PROM) was higher in the SC group (10.7%) while none was reported in the IVF-ICP group. Other maternal comorbidities and neonatal outcomes were similar between the two groups.

CONCLUSION

ICP patients who underwent IVF are more likely to suffer from GDM. Therefore, monitoring and management of blood glucose should be strengthened during pregnancy. Fortunately, IVF does not seem to worsen the progression or outlook of ICP, so sticking to standard management practices is recommended.

Pregnancy outcomes following antenatal screening for intrahepatic cholestasis of pregnancy (ICP)

OBJECTIVE

To evaluate the maternal and perinatal outcomes following antenatal screening for ICP using a retrospective approach.

MATERIALS AND METHODS

A retrospective study was conducted at the second affiliated hospital of Chongqing Medical University, Chongqing, China, from 2012 to 2017. Pregnant women registered for antenatal in our hospital were screened for ICP. The pregnant women with detailed delivery record and presenting with the diagnosis of ICP based on TBA level ≥10 mmol/L and abnormal liver enzymes were included in the study.

METHOD

The pregnant women with detailed delivery records presenting with the diagnosis of ICP based on TBA level ≥10 mmol/L and abnormal liver enzymes were included in the study. 1410 pregnant women were enrolled in this study. We selected 940 pregnant women without the diagnosis of ICP as our control and 470 pregnant women diagnosed with ICP as our case study. Data collection and sampling in the control group was done using microsoft excel (version 16.61) random number generator.

RESULTS

The mean age of the pregnant women and the gestational age at the time of diagnosis of ICP were 29.01 ± 4.3 years and 31.90 ± 8.83 weeks, respectively. It was found that a significant number of patients with ICP had a preterm birth and low birth weight (LBW), n = 151 (32.5%) P < 0.001 and n = 70 (14.9%) P < 0.001, respectively. A significant number of patients in the case group had a history of liver disease and gall bladder disease, p < 0.001 and p = 0.005, respectively, and a higher rate of GDM p < 0.001. Despite treatment, high TBA titer among ICP patients was associated with preterm delivery.

CONCLUSION

ICP in pregnancy leads to complications and poor perinatal outcomes. Fetal outcomes depend on the TBA levels; therefore, early diagnosis of ICP through routine screening followed by treatment is recommended in high-risk persons/areas.

Per- and Poly-fluoroalkyl Substances and Bile Acid Profiles in Pregnant Women

Alterations in bile acid (BA) profiles are closely associated with adverse outcomes in pregnant women and their offspring and may be one potential pathway underlying the related metabolic effects of per- and poly-fluoroalkyl substances (PFAS) exposure. However, evidence of associations between PFAS exposure and BA profiles in pregnant women is scarce. This study examined the associations of individual PFAS and PFAS mixture with BA profiles of pregnant women. We obtained quantitative data on the plasma concentrations of 13 PFAS and 15 BAs in 645 pregnant women from the Jiashan birth cohort. In Bayesian kernel machine regression models, the PFAS mixture was associated with increased plasma CA, TCA, TCDCA, and GLCA levels but with decreased GCA and LCA concentrations. Furthermore, the PFAS mixture was associated with increased concentrations of total BAs and the secondary/primary BA ratio but with decreased conjugated/unconjugated and glycine/taurine-conjugated BA ratios. PFHxS, PFUdA, PFOS, PFNA, and PFDA were the dominant contributors. The results of the linear regression analysis of individual PFAS were generally similar. Our findings provide the first epidemiological evidence for the associations of a PFAS mixture with BA profiles in pregnant women and may provide explanatory insights into the biological pathways underlying the related metabolic effects of PFAS exposure.

The role of noncoding RNA and its diagnostic potential in intrahepatic cholestasis of pregnancy: a research update

Intrahepatic cholestasis of pregnancy (ICP) is a common liver disorder that generally occurs during the second or third trimester of pregnancy. It rarely causes any harm to the mother; however, it can result in short- and long-term complications in the offspring. Therefore, it is crucial to diagnose and treat this condition to avoid poor pregnancy outcomes. The identification of novel markers with potential diagnostic, prognostic, and therapeutic utility in ICP has gained attention. Noncoding RNAs (ncRNAs), including microRNA, long noncoding RNA, and circular RNA, are a type of transcripts that are not translated into proteins. They possess vital biological functions, including transcriptional and translational regulation and DNA, RNA, and protein interactions. The pathogenesis of ICP is related to the aberrant expression of several circulating or placenta-related ncRNAs. In this review, we summarized all recent findings on ncRNAs and ICP and outlined the concepts that form the basis for the early diagnosis and targeted treatment of ICP.

Identification of Yinchenwuling fang's active components and hepatoprotective effects against cholestatic liver damage induced by alpha-naphthyl isothiocyanate in mice

Yinchenwuling Fang (YCWLF), a famous traditional Chinese medicine, has been used clinically for cholestatic liver disease treatment. However, quantification analysis for YCWLF components and their pharmacological effects remains largely unknown. Therefore, we aimed to determine the YCWLF components and their activities. Quantification analysis of 12 YCWLF components was performed using a comprehensive ultra-performance liquid chromatography (UPLC) coupled with the triple-quadrupole mass spectrometry method. Then, the anti-cholestasis effect and potential mechanism of YCWLF were performed in a mouse model induced by alpha-naphthyl isothiocyanate (ANIT). YCWLF decreased serum biochemical indicators (ALT, AST, ALP, TBA, TBIL, and DBIL) and ameliorated liver tissue damage in cholestatic mice. Mechanically, YCWLF increased the expression of the farnesoid X receptor (FXR) and its downstream efflux transporters and metabolic enzyme genes, reversed the disordered homeostasis of bile acids, and decreased cholestatic liver injury. Based on the important role of FXR in YCWLF amelioration on cholestasis, a dual-luciferase assay was used to screen the potential agonist of FXR from 12 YCWLF components. Chlorogenic acid, 4-hydroxyacetophenone, scoparone, atractylenolide Ⅰ, atractylenolide Ⅱ, and alisol B 23-acetate exhibited an activity effect of FXR. This study provides novel a therapeutic mechanism and potential active compounds of YCWLF on cholestatic liver injury.

Body mass index implications in intrahepatic cholestasis of pregnancy and placental histopathological alterations

INTRODUCTION AND OBJECTIVES

Intrahepatic cholestasis is a frequent disease during pregnancy. It is unknown if liver function alterations produce specific placental lesions. The aim of this study was to evaluate placental histopathological changes in patients with intrahepatic cholestasis of pregnancy (ICP), and to explore correlations between the placental histopathology and hepatic function alteration or patient comorbidities, and body mass index.

PATIENTS AND METHODS

A retrospective cohort study included women with ICP, most of them showing comorbidities such as overweight/obesity, preeclampsia and gestational diabetes. They were attended at the National Institute of Perinatology in Mexico City for three years. Placental histopathological alterations were evaluated according to the Amsterdam Placental Workshop Group Consensus Statement. Data was analyzed using Graph-Pad Prism 5.

RESULTS

The results indicated that the placenta of ICP patients showed many histopathological alterations; however, no correlations were observed between the increase in bile acids or liver functional parameters and specific placental lesions. The most frequent comorbidities found in ICP patients were obesity, overweight and preeclampsia. Surprisingly, high percentage of ICP patients did not respond to UDCA treatment independently of the BMI group to which they belonged.

CONCLUSION

The data suggest that ICP contribute to placental lesions. In addition, in patients with normal weight, an increase of chorangiosis and a reduced accelerated villous maturation without syncytial knots were observed in comparison with overweight and obese patients. It is necessary to improve the medical strategies in the treatment and liver disfunction surveillance of ICP patients.

Prevalence, risk factors and adverse perinatal outcomes for Chinese women with intrahepatic cholestasis of pregnancy: a large cross-sectional retrospective study

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.

Perinatal outcomes of intrahepatic cholestasis of pregnancy from two birth cohorts: A population-based study

Background

Intrahepatic cholestasis of pregnancy (ICP) is a complex liver disease with varying incidence worldwide. We compared ICP incidence and pregnancy outcomes with outcomes for normal pregnant controls.

Methods

We conducted a retrospective data analysis of perinatal registry data for the years 2011 and 2017 to compare the following outcome measures: stillbirths, labour induction, gestational diabetes, pre-eclampsia, antepartum haemorrhage, postpartum haemorrhage, preterm births, low Apgar score, acute neonatal respiratory morbidity, meconium aspiration and in-hospital neonatal death.

Results

The incidence of ICP was 8 per 1000 births from a total 31,493 singleton births with more cases in 2017 than in 2011. Women with ICP were almost six times more likely to have labour induced including significantly more moderate preterm births (defined as between 32 weeks and 36 weeks and 6 days of gestation)) seen more in 2011 than in 2017.

Conclusion

Women with ICP showed higher incidence of moderate preterm birth and induced labour but favourable maternal and neonatal outcomes.

Perinatal outcomes associated with ICP in twin pregnancies were worse than singletons: an almost 5-year retrospective cohort study

Background

Intrahepatic cholestasis of pregnancy (ICP) is associated with an increased risk of adverse perinatal outcomes leading to high perinatal morbidity and mortality. However, few studies have examined twin pregnancies complicated by ICP. To assess the perinatal outcomes of twin pregnancies with ICP, a retrospective cohort study was conducted.

Methods

A total of 633 twin pregnancies and 1267 singleton pregnancies with ICP were included. In addition, a correlation study was performed on the matched total bile acid (TBA) levels from maternal serum, fetal umbilical venous blood, and amniotic fluid of 33 twin pregnancies from twin groups.

Results

When compared to singletons, twin pregnancies with ICP had a higher risk of cesarean section (CS) (96.4% vs. 76.1%), preterm birth (PTB) (82.6% vs. 19.7%), fetal distress (2.0% vs. 1.3%), and neonatal intensive care unit (NICU) admission (23.6% vs. 5.1%), which was significantly related to increasing TBA levels (P < 0.05). In twin pregnancies with TBA ≥100 μmol/L, the incidences of CS, PTB, fetal distress, neonatal asphyxia, and meconium-stained amniotic fluid were 94.4, 100, 11.1, 5.6, and 36.1%, respectively. Furthermore, the maximum maternal TBA levels were positively correlated with TBA levels in the amniotic fluid (r = 0.61, P < 0.05) and umbilical cord blood (r = 0.44, P < 0.05), and a similar correlation was found for maternal TBA levels at delivery. TBA levels in umbilical cord blood and amniotic fluid also had a significant and positive correlation (r = 0.52, P < 0.05).

Conclusions

Twin pregnancies with ICP had a higher risk for adverse perinatal outcomes than singletons, which was associated with higher TBA levels. TBA can be transported through the placenta and is involved in uterus-placenta-fetal circulation.

Immune Dysfunction Mediated by the ceRNA Regulatory Network in Human Placenta Tissue of Intrahepatic Cholestasis Pregnancy

Pregnancy-related intrahepatic cholestasis (ICP) is a serious complication with adverse perinatal outcomes of preterm labor, fetal distress, or stillbirth. As a result, it is important to investigate and identify the potential critical pathogenic mechanisms of ICP. First, we collected the placental tissues from the ICP with placental weight and fetal birth weight loss for the whole transcriptome sequencing. Then we analyzed the differentially expressed (DE) circRNAs (DEcircRNAs) by SRPBM, DElncRNAs by FRKM, DEmiRNAs by TPM, and DEmRNAs by TPM and RSEM. Based on differential expression of term pregnancy placental tissues from pregnancies impacted by ICP (n=7) as compared to gestational aged matched control tissues (n=5), the circ/lncRNA-miRNA-mRNA competitive endogenous RNA (ceRNA) regulatory networks were constructed. The ceRNA regulatory networks covered 3,714 events, including 21 DEmiRNAs, 36 DEcircRNAs, 146 DElncRNAs, and 169 DEmRNAs. According to the functional analysis, ICP complications were linked to the immune system, signal transduction, endocrine system, cell growth and death, and transport and catabolism. Further evidence suggested that the expression of immune-related genes KLRD1, BRAF, and NFATC4 might have a potential ceRNA mechanism by individual lncRNA sponging miR372-3p, miR-371a-3p, miR-7851-3p, and miR-449a to control downstream the level of TNF-α, IFN-γ, and IL-10, thereby regulating the pathophysiology of ICP. Furthermore, our results were validated by the qRT-PCR, western blotting and ELISA assays. In conclusion, this study is the first to evaluate placental ceRNA networks in pregnancies affected by ICP, showing alterations in immune regulatory networks which may impact fetal and placental growth. Overall our these data suggest that the ceRNA regulatory network may refine biomarker predictions for developing novel therapeutic approaches in ICP.

Gestational cholestasis induced intrauterine growth restriction through triggering IRE1α-mediated apoptosis of placental trophoblast cells

Epidemiological and animal experimental studies suggest an association between gestational cholestasis and intrauterine growth restriction (IUGR). Here, we explored the mechanism through which gestational cholestasis induced IUGR. To establish gestational cholestasis model, pregnant mice were subcutaneously injected with 17α-Ethynylestradiol (E2) on gestational day 13 (GD13)-GD17. Some pregnant mice were intraperitoneally injected with 4μ8C on GD13-GD17. The results found that the apoptosis of trophoblast cells was elevated in placentas of mice with gestational cholestasis and in deoxycholic acid (DCA)-treated human trophoblast cell lines and primary mouse trophoblast cells. Correspondingly, the levels of placental cleaved caspase-3 and Bax were increased, while placental Bcl2 level was decreased in mice with gestational cholestasis and in DCA-treated trophoblast cells. Further analysis found that placental IRE1α pathway was activated in mice with gestational cholestasis and in DCA-treated trophoblast cells. Interestingly, 4μ8C, an IRE1α RNase inhibitor, significantly inhibited caspase-3 activity and apoptosis of trophoblast cells in vivo and in vitro. Importantly, 4μ8C rescued gestational cholestasis-induced placental insufficiency and IUGR. Furthermore, a case-control study demonstrated that placental IRE1α and caspase-3 pathways were activated in cholestasis cases. Our results provide evidence that gestational cholestasis induces placental insufficiency and IUGR may be via triggering IRE1α-mediated apoptosis of placental trophoblast cells.

Unfolding newer concepts in placental pathology of obstetric cholestasis-a cause for prematurity

Intrahepatic cholestasis of pregnancy (ICP) has an increased predisposition to occur in the third trimester of pregnancy and has a varied population incidence rates due to genetic influences. Owing to the adverse and unpredictable fetal outcomes, it poses a serious therapeutic challenge to the clinician. A rise in the incidence of iatrogenic prematurity has been observed, raising concerns over the perinatal outcomes. Excess bile acids and altered placental transport mechanisms have been strongly implicated in the pathogenesis of ICP and its complications. The exact etiology is not known; yet major underlying risk factors that are thought to contribute to the disease process include genetic, environmental, hormonal, and immunological. Newer molecular processes acting at the placental level, apart from specific histopathological changes, have assumed significance in recent times. In this review, we attempt to highlight the recent understanding of the mechanisms that operate in the placenta in patients with obstetric cholestasis that lead to poor fetal outcomes, through various studies published in the literature. Despite these additions to the existing knowledge on the etiopathogenesis of obstetric cholestasis and its possible placental origin, further studies are needed to validate the newer concepts.

Intrahepatic Cholestasis of Pregnancy: An Autobiographical Case Report

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disorder of pregnancy. This case report describes the author’s experience of being diagnosed with the condition, the course of treatment and outcome for her baby, and the emotional aspects of the disease.

Association of Maternal Thyroid Function with Gestational Hypercholanemia

Background: High bile acid concentration is associated with adverse perinatal outcomes (i.e., stillbirth and preterm birth) and experimental studies indicate that thyroid hormone regulates bile acid metabolism, but this has not yet been translated to clinical data in pregnant women. We aim to explore the association of thyroid function with bile acid concentrations and the risk of gestational hypercholanemia. Methods: This study comprised 68,016 singleton pregnancies without known thyroid or hepatobiliary diseases before pregnancy and thyroid medication based on a prospective cohort. Thyroid function and serum total bile acid (TBA) were routinely screened in both early (9-13 weeks) and late pregnancy (32-36 weeks). Hypercholanemia was defined as serum TBA concentration ≥10 μmol/L. Multiple linear regression models and multiple logistic regression models were performed. Results: A higher free thyroxine (fT4) during both early or late pregnancy was associated with a higher TBA concentration and a higher risk of hypercholanemia (all p < 0.01). A higher thyrotropin (TSH) in early pregnancy was associated with a higher TBA concentration in early pregnancy (p = 0.0155), but with a lower TBA concentration during later pregnancy (p < 0.0001), and there was no association of TSH with hypercholanemia. Overt hyperthyroidism in late pregnancy was associated with a 2.12-fold higher risk of hypercholanemia ([confidence interval; CI 1.12-4.03], p = 0.021) and subclinical hyperthyroidism during later pregnancy was associated with a 1.5-fold higher risk of hypercholanemia ([CI 1.14-1.97], p = 0.0034). Sensitivity analyses indicated that a high fT4 throughout pregnancy was associated with a higher risk of hypercholanemia rather than only in early or late pregnancy. Conclusions: A higher fT4 concentration during either early or late pregnancy, but not the TSH concentration, is associated with higher TBA and a higher risk of gestational hypercholanemia. Furthermore, hyperthyroidism during pregnancy could be a novel risk factor for hypercholanemia.

Serum Bile Acid Levels in Women With Intrahepatic Cholestasis of Pregnancy in India

Introduction

Intrahepatic cholestasis of pregnancy (ICP) manifests as unexplained intense pruritus in the third trimester of pregnancy and is often diagnosed based on elevated serum bile acid measurement. There are no data from India on serum bile acid levels in pregnant women with ICP.

Methods

Pregnant women with significant pruritus during the third trimester of gestation and with elevated serum alanine aminotransferase and/or aspartate aminotransferase (normal: <40 IU/L) were taken as having ICP. Serum BA levels were measured in them and in nonpregnant women and healthy pregnant women without itching.

Results

Of the 3735 pregnant women screened, 105 (2.8%) had ICP (age 28 [26-32] years; gestational age 32 [30-36] weeks; primigravida 32.3%, and 95.3% normal fetal growth). Median (interquartile range) serum bile acid levels in nonpregnant women (n = 61; 28 [25-31] years) and pregnant women without ICP (n = 59; 28 [25-31] years) were similar (3.7 [1.6-5.1] μmol/L and 3.7 [2.2-5.8] μmol/L, respectively). By comparison, serum bile acid level in women with ICP (n = 105; 28 [26-32] years) was significantly higher (20.2 [12.7-39.5] μmol/L; P < 0.05 each), being above 10 μmol/L in 88 (83.8%). The optimum cut-off for the diagnosis of ICP in our population was ≥8.6 μmol/L, with sensitivity of 87.6%, specificity of 93.3% and area under the receiver-operator characteristics curve of 0.937 (95% CI: 0.904-0.970).

Conclusion

Serum BA levels in healthy Indian nonpregnant and pregnant women are similar to those in other populations and can be used to diagnose ICP with an optimal cut-off being 8.6 μmol/L.

Research progress in the role of gut microbiota and its metabolites in intrahepatic cholestasis of pregnancy

INTRODUCTION

Intrahepatic cholestasis of pregnancy (ICP) is a liver disease that occurs during pregnancy. While ICP has a minimal impact on the mother, it primarily affects the pregnancy outcome of fetus, resulting in spontaneous miscarriage and even the intrauterine death of fetus.

AREAS COVERED

This review covers current progress in the role of gut microbiota and bile acids in ICP.

EXPERT OPINION

The causes and pathogenesis of ICP are currently unclear, and the serum bile acid level is the main clinical evidence for ICP diagnosis. The gastrointestinal tract is home to a tremendous number and type of microbes, which play critical roles in the synthesis and metabolism of bile acids. Studies in recent years have shown that the changes in gut microbiota and bile acid metabolic profiles are closely associated with ICP. This review discusses some of the future prospects in this area of research.

Prediction of intrahepatic cholestasis of pregnancy in the first 20 weeks of pregnancy

AIM

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disease associated with a significant risk of fetal complications including pre-term delivery and fetal death. Typically, it was diagnosed in the third trimester of pregnancy. This study utilized characteristics from routine maternal examinations in the first 20 weeks' gestation to predict ICP in pregnant women.

METHODS

This is a retrospective case-control study. 13,329 medical records were collected on pregnant women presenting to the West China Second University Hospital between December 2017 and December 2018. After screening according to strict criteria, a total of 487 patients, 250 intrahepatic cholestasis of pregnancy cases, and 237 controls were selected for this study. We collected seven maternal characteristics indices for analysis and forty-three routine blood examination indices were obtained from routine hepatic, renal, and coagulation function examinations. The least absolute shrinkage and selection operator regression was applied for variable selection. Classification and regression trees, logistic regression, random forests, and light gradient boosting machines were fit for predictive modeling. We randomly divided 25% of the original data as testing set to conduct internal validation of the performance of the prediction model. The area under the receiver operating characteristic curves (AUC) was used to compare methods.

RESULTS

Eight variables were selected out as potentially significant predictors that could reliably predict ICP. The sensitivity, specificity, accuracy, and AUC of the final prediction model obtained by light gradient boosting machines were 72.41, 79.69, 76.23, and 79.77%, respectively. Significantly higher platelet large cell ratio, alanine aminotransferase, glutamyl transpeptidase, and fibrinogen levels were found in cases as compared to healthy controls, while activated partial thromboplastin time and mean corpuscular hemoglobin concentration levels were significantly lower (p < .001).

CONCLUSIONS

The combination of alanine aminotransferase, glutamyl transpeptidase, fibrinogen, platelet large cell ratio, activated partial thromboplastin time, lactate dehydrogenase, creatinine, and mean corpuscular hemoglobin concentration levels can effectively predict ICP in the first 20 weeks of gestation. These could help provide direction for earlier detection and prevention of ICP.

RISK ASSESSMENT IN PREGNANCY AMONG WOMEN AGED OVER FORTY

The objective of this study was to assess the relationship between women's age and risk of pregnancy-related complications. The study was a retrospective cohort analysis of the pregnancy-related complications and outcomes between two age groups of parturient women. Categorical data were expressed as absolute and relative frequencies. Statistical analysis was performed using χ²-test. The incidence of gestational diabetes was higher in the 40-47 age group as compared with the 20-24 age group. The rates of hypertension, preeclampsia, intrahepatic cholestasis of pregnancy and hypothyroidism did not differ between the two groups. The rates of labor induction, oxytocin use, vaginal delivery, and need for episiotomy were higher in younger age group. Dystocia and breech presentation as indications for cesarean section were more common among younger women. According to study results, the risk of gestational diabetes and rates of cesarean delivery increased with advanced maternal age.

Intrahepatic Cholestasis of Pregnancy and Associated Adverse Maternal and Fetal Outcomes: A Retrospective Case-Control Study

Objective

Intrahepatic cholestasis of pregnancy (ICP) is a common pregnancy-related liver disease and is associated with an increased risk of adverse neonatal outcomes. Ursodeoxycholic acid (UDCA) is the most effective treatment. This study was aimed at investigating the adverse outcomes of ICP and evaluating the effects of treatment with UDCA in patients with ICP.

Methods

We included 114 women with ICP and 3725 women without ICP (no-ICP group) who delivered in our hospital between September 2017 and August 2019. The prevalence of ICP in this study was 3.15%. We matched each woman with ICP to five controls. Of all the 114 women with ICP, 73 (64.04%) received UDCA while 41 (35.96%) did not. Logistic multivariate regression analysis was used to compare the adverse outcomes between those with ICP and matched controls as well as between those who received UDCA (UDCA group) and those who did not (non-UDCA group).

Results

Compared with controls, women with ICP were more likely to have preeclampsia (adjusted odds ratio, aOR = 16.74, 95% CI 5.29-52.98), cesarean section (aOR = 1.76, 95% CI 1.10-2.81), and preterm birth (aOR = 24.35, 95% CI 2.74-216.67). Administration of UDCA reduced the rate of preterm birth (1.37% vs. 14.63%, aOR = 0.10, 95% CI 0.01-0.90).

Conclusion

ICP increased the risk of preeclampsia, cesarean section, and preterm birth. UDCA could reduce the rate of preterm birth.

Intrahepatic Cholestasis of Pregnancy: Role of Baby's Sex on Itch Severity and Bile Acid Levels

Background

Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disorder of pregnancy. It occurs when bile flow from the liver is obstructed, causing bile acid to accumulate. ICP usually presents with itching that lasts for the remainder of pregnancy. Untreated ICP has been shown to increase the incidence of adverse outcomes for the baby, including respiratory distress, meconium aspiration, neonatal intensive care unit hospitalization, and stillbirth. The probability of these events increases when bile acid levels are greater than 40 mmol/L. The current standard of care for ICP patients is a combination of ursodeoxycholic acid by mouth and early delivery, as the risk of stillbirth due to ICP increases in the last weeks of pregnancy. ICP has been linked to preeclampsia and gestational diabetes; studies have shown that the occurrence of both diseases is greater when the baby is male. The purpose of this study was to investigate if the occurrence, timing of diagnosis, peak bile acid levels, or severity of itching is dependent on the baby’s sex in mothers who had ICP.

Methods

An online question-set (survey) was offered to women who had had ICP and were members of three different online support groups.

Results

A total of 1,502 women responded for a total of 2,289 documented ICP pregnancies, in which there were 1,059 female babies and 1,230 male babies. Based on chi-square analysis of differences in frequencies, no difference was found between pregnancies with male versus female babies regarding the occurrence, timing of diagnosis, peak bile acid levels, or severity of itching in the evaluated population. However, surprisingly, the findings revealed that first-trimester diagnosis of ICP was made in 5.6% of the pregnancies, and there were 30 (1.8%) cases of ICP diagnosed in the absence of itching.

Conclusions

The findings suggest that the baby’s sex does not impact the occurrence, timing of diagnosis, peak bile acid levels, or itch severity in ICP. The findings that 5.6% of the ICP pregnancies in the present study were diagnosed in the first trimester and 1.8% were diagnosed without the presence of itching reinforce the need to investigate these less common presentations. More studies are needed to determine if these findings are consistent across other populations.