Sudden Fetal Death in Intrahepatic Cholestasis of Pregnancy

Simplifying Management of Cholestasis: A Proposal for a Classification System

Given the stillbirth risk associated with intrahepatic cholestasis of pregnancy, management to reduce this adverse outcome has primarily involved planned delivery as early as 36 weeks gestation. While earlier planned delivery has decreased the incidence of stillbirth in this population, recently, there have been multiple published retrospective studies to better correlate the association of adverse outcomes with cholestasis severity. Despite these new data, the uptake of individualized management for cholestasis has been varied from provider to provider. In this opinion, we briefly review the current literature and evidence regarding cholestasis and adverse outcomes and propose a cholestasis classification system with subsequent algorithms for management. KEY POINTS: · Recently, multiple studies have further characterized adverse outcomes with cholestasis.. · Incorporation of severity-associated management into clinical practice is variable.. · A cholestasis classification system will simplify and streamline management..

Cord blood troponin I levels: biomarker evidence of fetal cardiac injury in intrahepatic cholestasis of pregnancy

BACKGROUND

Intrahepatic cholestasis of pregnancy has been linked to sudden stillbirth. The suddenness of the stillbirths in these cases have led clinicians to suspect that the pathogenesis of stillbirth in women with intrahepatic cholestasis of pregnancy is not related to asphyxia but rather to an undefined etiology. One leading hypothesis relates certain bile acid metabolites to myocardial injury.

OBJECTIVE

The purpose of this study was to determine whether cord blood troponin I levels are increased in fetuses born to mothers with a diagnosis of intrahepatic cholestasis of pregnancy.

STUDY DESIGN

A prospective, case-control study was performed at a single institution between 2017 to 2019 in which 87 pregnant patients with a diagnosis of intrahepatic cholestasis of pregnancy (total bile acids ≥10 μmol/L) were enrolled as cases and 122 randomly selected pregnant patients (asymptomatic with intrapartum total bile acids <10 μmol/L) were enrolled as controls. Cord blood troponin I levels were measured at delivery in both groups using a commercially available chemiluminescent immunoassay. Values ≤0.04 ng/mL were considered negative. Values >0.04 ng/mL were considered positive. The primary outcome was the presence of elevated troponin levels in both cases and controls as a surrogate marker for cardiac status. Our secondary outcomes included neonatal intensive care unit stay, low Apgar scores, neonatal acidosis, and hypoxia indicated by cord blood pH and base excess levels at the time of birth. Chi square and t tests were performed to compare social and obstetrical variables. A P value of <.05 was considered significant. A stratification by total bile acids range of <40 μmol/L, 40 to 100 μmol/L, and >100 μmol/L was performed to assess the relationship between the different severities of intrahepatic cholestasis of pregnancy (by risk of fetal demise with those with total bile acids of >100 μmol/L considered at greatest risk) and the likelihood of a positive troponin I result. Finally, a logistic regression analysis was performed to determine if levels of ≥10 μmol/L were associated with elevated troponin levels.

RESULTS

The mean gestational age at delivery was 38.96±1.47 and 37.71±1.59 weeks of gestation in the controls and cases respectively (P<.001). The mean total bile acids values were 5.2±1.28 ng/mL and 43.2±40.62 ng/mL in the controls and cases respectively (P<.001). Cord blood troponin I was positive in 15 of 122 (12.30%) controls and in 20 of 87 (22.99%) cases. (P<.001). When further stratified by total bile acids levels of <40, 40 to 100, and >100 μmol/L, we found a positive correlation between higher total bile acids levels and a positive troponin I test (P=.002). When controlling for gestational age at delivery, maternal age, and body mass index, higher total bile acids levels were associated with a positive troponin I level (adjusted odds ratio, 1.015; 95% confidence interval, 1.004-1.026).

CONCLUSION

Elevated troponin I was more likely to be found in patients with intrahepatic cholestasis of pregnancy than in those without intrahepatic cholestasis of pregnancy. When stratified by total bile acids levels, a positive troponin I level was more likely to be found with higher levels of total bile acids. In addition, as total bile acids levels increased, they were more likely to be associated with a positive troponin I level. Although there were no stillbirths in our cohort, our findings suggest a potential relationship between cardiac injury and high levels of total bile acids demonstrated by the presence of elevated troponin I levels in cord blood at the time of birth.

[Intrahepatic cholestasis of pregnancy: French College of Obstetricians and Gynecologists guidelines for clinical practice]

OBJECTIVE

To identify strategies for reducing neonatal and maternal morbidity associated with intrahepatic cholestasis pregnancy (ICP).

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE methodology with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 14 questions (from 12 PICO questions and one definition question outside the PICO format), there was agreement between the working group and the external reviewers on 14 (100%). The level of evidence of the literature was insufficient to provide a recommendation on two questions. ICP is defined by the occurrence of suggestive pruritus (palmoplantar, nocturnal) associated with a total bile acid level>10μmol/L or an alanine transaminase level above 2N after ruling out differential diagnoses. In the absence of suggestive symptoms of a differential diagnosis, it is recommended not to carry out additional biological or ultrasound tests. In women with CIP, ursodeoxycholic acid is recommended to reduce the intensity of maternal pruritus (Strong recommendation. Quality of the evidence moderate) and to decrease the level of total bile acids and alanine transaminases. (Strong recommendation. Quality of the evidence moderate). S-adenosyl-methionine, dexamethasone, guar gum or activated charcoal should not be used to reduce the intensity of maternal pruritus (Strong recommendation. Quality of evidence low), and there is insufficient data to recommend the use of antihistamines (No recommendation. Quality of evidence low). Rifampicin (Weak recommendation. Very low quality of evidence) or plasma exchange (Strong recommendation. Very low quality of evidence) should not be used to reduce maternal pruritus and perinatal morbidity. Serum monitoring of bile acids is recommended to reduce perinatal morbidity and mortality (stillbirth, prematurity) (Low recommendation. Quality of the evidence low). The level of evidence is insufficient to determine whether fetal heart rate or fetal ultrasound monitoring are useful to reduce perinatal morbidity (No recommendation). Birth is recommended when bile acid level is above 99μmol/L from 36 weeks gestation to reduce perinatal morbidity, in particular stillbirth. When bile acid level is above 99μmol/L is below 100μmol/L, women should be informed that induction of labor could be considered 37 and 39 weeks gestation to reduce perinatal morbidity. (Strong recommendation. Quality of evidence low). In postpartum, total bile acids and alanine transaminases level should be checked and normalized before prescribing estrogen-progestin contraception, ideally with a low estrogen dose (risk of recurrence of pruritus and cytolysis) (Low recommendation. Quality of evidence very low).

CONCLUSION

Although the quality of evidence regarding ICP gestational cholestasis remains low, there is a strong consensus in France, as shown by our Delphi study, on how to manage women with ICP. The reference first-line treatment is ursodeoxycholic acid.

Updates on Evaluation and Treatment of Common Complaints in Pregnancy

Patients experience many new and concerning symptoms during pregnancy and it is the role of the obstetric clinician to provide appropriate guidance, recommendations, and treatment options. Often times, these symptoms are related to hormonal and physiologic changes that occur and will resolve in the postpartum period. However, clinicians must be able to recognize more concerning pathologic symptoms that require further evaluation and treatment. This review provides updates on the evaluation and management of some of the common symptoms during pregnancy.

Intrahepatic cholestasis of pregnancy and fetal cardiac dysfunction: a systematic review and meta-analysis

OBJECTIVE

Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcomes. Fetal cardiac dysfunction may be 1 part of the pathophysiology of pregnancies complicated by intrahepatic cholestasis of pregnancy. This systematic review and meta-analysis aimed to evaluate the association between intrahepatic cholestasis of pregnancy and fetal cardiac dysfunction.

DATA SOURCES

Systematic searches were performed on the databases of Medline, Embase, and Cochrane Library (up to March 2, 2023) for studies evaluating fetal cardiac function in pregnancies complicated by intrahepatic cholestasis of pregnancy in addition to the reference lists of included studies.

STUDY ELIGIBILITY CRITERIA

Studies were eligible for inclusion if they assessed the fetal cardiac function by fetal echocardiography in women with intrahepatic cholestasis of pregnancy (mild or severe) and compared with fetuses of healthy pregnant women. The studies published in English were included.

METHODS

The quality of the retrieved studies was assessed using the Newcastle-Ottawa Scale. Data on fetal myocardial performance index, E wave/A wave peak velocities ratio, and PR interval were pooled for the meta-analysis using random-effects models. The results were presented as weighted mean differences and 95% confidence intervals. This meta-analysis was registered with the International Prospective Register of Systematic Reviews (registration number: CRD42022334801).

RESULTS

A total of 14 studies were included in this qualitative analysis. Of note, 10 studies that reported data on fetal myocardial performance index, E wave/A wave peak velocities ratio, and PR interval were included in the quantitative analysis and showed a significant association between intrahepatic cholestasis of pregnancy and fetal cardiac dysfunction. Significantly higher fetal left ventricular myocardial performance index values (weighted mean difference, 0.10; 95% confidence interval, 0.04-0.16) and longer fetal PR intervals (weighted mean difference, 10.10 ms; 95% confidence interval, 7.34-12.86) were revealed in pregnancies complicated by intrahepatic cholestasis of pregnancy. Compared with the situation in pregnancies complicated by mild intrahepatic cholestasis of pregnancy, PR intervals were even longer in pregnancies complicated by severe intrahepatic cholestasis of pregnancy (weighted mean difference, 5.98 ms; 95% confidence interval, 0.20-11.77). There was no significant difference in fetal E wave/A wave peak velocities ratio between the group with intrahepatic cholestasis of pregnancy and the healthy pregnant group (weighted mean difference, 0.01; 95% confidence interval, -0.03 to 0.05).

CONCLUSION

Our findings supported the idea that intrahepatic cholestasis of pregnancy is associated with overall impaired fetal myocardial performance and impaired fetal cardiac conduction system. However, current evidence about the association between fetal cardiac dysfunction and intrahepatic cholestasis of pregnancy-induced stillbirth is lacking. Further studies are needed to reveal the relationship between fetal cardiac dysfunction and adverse perinatal outcomes in pregnancies complicated by intrahepatic cholestasis of pregnancy.

Maternal and Neonatal Outcomes in Intrahepatic Cholestasis of Pregnancy

The aims of our study were to evaluate the maternal and fetal outcomes of intrahepatic cholestasis of pregnancy (ICP). In this observational, retrospective case-control study, we included all pregnant women who gave birth with a diagnosis of ICP between January 2010 and December 2020 at the Unit of Obstetrics and Gynecology, University Hospital of Messina. The data were compared with those from a control group of pregnant women who did not have ICP. One hundred twenty-nine and eighty-five patients were included, respectively, in the study and in the control group. There was a significant difference between the two groups in the incidence of hypothyroidism, thrombophilia, gestational diabetes, gestational hypertension, postpartum hemorrhage, and preterm delivery, which were more frequent in the ICP patients. No neonatal adverse events were recorded, although a significant difference in the meconium-stained amniotic fluid condition was noted. After a 24-month follow-up, 48/129 patients with ICP accepted to be reassessed by liver ultrasound, elastographic examination, and liver function blood tests. No patient showed signs of chronic liver disease. This study confirmed a higher probability of adverse short-term maternal outcomes in ICP pregnant patients, but a lower probability of adverse short-term fetal outcomes and the absence of a long-term maternal risk of chronic liver disease.

Stress regulation of WFS1 and PERK-p-eIF2α-ATF4 signaling pathway in placental tissue cells of intrahepatic cholestasis of pregnancy

INTRODUCTION

The placental tissue stress of intrahepatic cholestasis of pregnancy (ICP) is activated by ERS under hypoxia condition. PERK signaling pathway is the key pathway for UPR regulation, and is first to activated during ERS. WFS1, as an important regulatory gene of UPR pathway, participates in ERS regulation. The purpose of our study is to explore the expression level and mutual regulation mechanisms of WFS1 and PERK-mediated UPR pathway in ICP placental tissue cell under stress.

METHODS

Blood and placenta samples were obtained from the ICP patients and ethinylestradiol (EE)-induced intrahepatic cholestasis pregnant rats. IHC and WB were used to detect the expression of WFS1, key factors of PERK pathway (GRP78, PERK, eIF2a, P-eIF2α, ATF4) and placental stress peptides (CRH, UCN). Furthermore, qPCR was carried out to detect mRNA expression of above indicators.

RESULTS

The expression levels of WFS1 and key factors of PERK pathway were significantly increased in severe ICP placental tissues. Moreover, qPCR and WB showed that relative mRNA and protein expression levels of WFS1 and key factors of PERK pathways in placenta tissues of severe ICP and EE-induced intrahepatic cholestasis pregnant rats were higher than those in control group to varying degrees, while CRH and UCN were descended. Meanwhile, after WFS1-siRNA targeted silencing of the WFS1 gene, the protein expression levels of PERK, P-eIF2α, ATF4 were significantly increased, while CRH and UCN protein were significantly decreased.

DISCUSSION

Our study revealed that the activation of WFS1 and PERK-p-eIF2α-ATF4 signaling pathway may contribute to stress regulation in placental tissue cells of intrahepatic cholestasis of pregnancy, thereby avoiding adverse pregnancy outcomes.

Intrahepatic cholestasis of pregnancy: a comparison of Society for Maternal-Fetal Medicine and the Royal College of Obstetricians and Gynaecologists' guidelines

This study reviewed the literature regarding the diagnosis, antepartum surveillance, and timing of delivery of pregnancies complicated by intrahepatic cholestasis of pregnancy, comparing the guidelines published by the Society for Maternal-Fetal Medicine in February 2021 and those published by the Royal College of Obstetricians and Gynaecologists in the United Kingdom in June 2022. Several key differences exist in the clinical guidelines between the 2 organizations. With regard to the diagnosis of intrahepatic cholestasis of pregnancy, the Society for Maternal-Fetal Medicine considers any elevation in bile acids above the upper limit of normal in the setting of maternal pruritus diagnostic of intrahepatic cholestasis of pregnancy, whereas the Royal College of Obstetricians and Gynaecologists requires a pregnancy-specific elevated bile acid level of ≥19 mmol/L for diagnosis. Regarding the treatment of intrahepatic cholestasis of pregnancy, the Society for Maternal-Fetal Medicine recommends ursodeoxycholic acid as the first-line treatment of maternal symptoms. In contrast, the Royal College of Obstetricians and Gynaecologists specifically recommends against the routine use of ursodeoxycholic acid for intrahepatic cholestasis of pregnancy because of a lack of evidence regarding both maternal and fetal benefit. The Society for Maternal-Fetal Medicine recommends fetal surveillance at a gestational age when abnormal fetal testing would result in delivery being performed, whereas the Royal College of Obstetricians and Gynaecologists does not recommend any fetal testing beyond fetal kick count assessment. The Society for Maternal-Fetal Medicine recommends delivery at 36 to 39 weeks' gestation for intrahepatic cholestasis of pregnancy with bile acids <100 mmol/L and delivery at 36 weeks for bile acid levels >100 mmol/L. The Royal College of Obstetricians and Gynaecologists recommends serial assessment of bile acids with delivery timing stratified between 35- and 40-weeks' gestation according to bile acid levels.

Modified myocardial performance index for evaluation of fetal heart function and perinatal outcomes in intrahepatic pregnancy cholestasis

This study aims to evaluate cardiac function in cases of intrahepatic cholestasis of pregnancy (ICP) and compare results with those from healthy controls using the fetal left ventricular modified myocardial performance index (LMPI) and E-wave/A-wave peak velocities (E/A ratio). Moreover, the association between LMPI values, total bile acid (TBA) levels, fetal Doppler measurements, and adverse neonatal outcomes was evaluated. A prospective cross-sectional study of 120 pregnant women was conducted, with 60 having ICP and the other 60 serving as controls. Doppler ultrasound and two-dimensional gray-scale fetal echocardiography were used to calculate the LMPI values and E/A ratios, respectively. The association between LMPI values and TBA levels, fetal Doppler measurements, and adverse neonatal outcomes was evaluated. Fetal LMPI values were significantly higher in the ICP group than in the control group (0.54 ± 0.54 vs. 0.44 ± 0.03; p < 0.001), but the E/A ratio was similar in both groups (0.69 ± 0.10 vs. 0.66 ± 0.14; p = 0.203). TBA levels were positively and significantly correlated with LMPI values (r = 0.546, p < 0.01); however, no significant correlation was found between umbilical arterial pulsatility index values and LMPI values (r = 0.071, p > 0.01). LMPI values were not associated with adverse neonatal outcomes in ICP cases. Fetal cardiac function (LMPI) is associated with increased bile acid levels in ICP. However, because it was not associated with adverse neonatal outcomes in ICP cases, the clinical significance of this finding is unclear. Further studies are required to evaluate the implications of increased LMPI.

Intrahepatic cholestasis of pregnancy: from an obstetrician point of view

Intrahepatic cholestasis of pregnancy (ICP) is the commonest among the specific dermatoses of pregnancy. The disease is characterised by intense pruritus and specifically by elevated bile acid levels and owing to the rarity of data published in this context, the disease carries a great challenge in both diagnosis and management. The disease is associated with significant maternal as well as perinatal adverse effects, hence, this article aims at improving the knowledge of the women's health carers with the up-to-date and evidence-based, whenever possible, recommendations while managing patients with ICP.

Beyond stillbirth: association of intrahepatic cholestasis of pregnancy severity and adverse outcomes

BACKGROUND

Intrahepatic cholestasis of pregnancy is associated with adverse pregnancy outcomes, including sudden fetal cardiac arrhythmias, resulting in stillbirth. This association has been correlated with the total bile acid levels, which are a marker for disease severity. Studies are yet to determine if intrahepatic cholestasis of pregnancy severity is also associated with increased rates of other adverse neonatal outcomes.

OBJECTIVE

This study aimed to determine whether pregnancies complicated by intrahepatic cholestasis of pregnancy show a bile acid severity-based relationship with other adverse obstetrical outcomes beyond stillbirth alone.

STUDY DESIGN

This was a retrospective cohort study of singleton, nonanomalous gestations complicated by intrahepatic cholestasis of pregnancy at the Elmhurst Hospital Center from 2005 to 2019. Severity was defined by the peak total bile acid levels (μmol/L): mild (10-19), low moderate (20-39), high moderate (40-99), and severe (>100). We examined the rates of spontaneous preterm labor, fetal growth restriction, preterm prelabor rupture of membranes, iatrogenic preterm birth, meconium-stained amniotic fluid, cesarean delivery for nonreassuring fetal heart tracing, umbilical artery pH, neonatal intensive care unit admission, and neonatal birthweight. The chi-square, Fisher exact, Student t, Mann-Whitney, and multivariate regression tests were used to determine the association of intrahepatic cholestasis of pregnancy severity and adverse neonatal outcomes. In all analyses, mild severity was used as the base comparator. A P value of <.05 and 95% confidence interval not crossing 1.00 indicated statistical significance.

RESULTS

Of the 1202 pregnancies complicated by intrahepatic cholestasis of pregnancy, 306 (25.5%) were mild, 449 were low moderate (37.4%), 327 were high moderate (27.2%), and 120 were severe (10.0%). After adjusting for confounders, progressive intrahepatic cholestasis of pregnancy severity was associated with an increased risk of spontaneous preterm labor (low moderate adjusted odds ratio, 1.60; 95% confidence interval, 0.76-3.38; high moderate adjusted odds ratio, 3.49; 95% confidence interval, 1.69-7.22; severe adjusted odds ratio, 6.58; 95% confidence interval, 2.97-14.55), iatrogenic preterm birth (low moderate adjusted odds ratio, 1.54; 95% confidence interval, 0.95-2.52; high moderate adjusted odds ratio, 3.11; 95% confidence interval, 1.91-5.06; severe adjusted odds ratio, 4.94; 95% confidence interval, 2.81-8.71), and meconium-stained amniotic fluid (low moderate adjusted odds ratio, 1.33; 95% confidence interval, 0.75-2.36; high moderate adjusted odds ratio, 2.63; 95% confidence interval, 1.48-4.65; severe adjusted odds ratio, 3.91; 95% confidence interval, 1.98-7.69). There was no significant association between intrahepatic cholestasis of pregnancy severity and other adverse outcomes.

CONCLUSION

The findings suggest that intrahepatic cholestasis of pregnancy disease severity is associated with an increased risk of spontaneous preterm labor, iatrogenic preterm birth, and meconium-stained amniotic fluid. These findings provide valuable insight toward patient anticipatory counseling.

Intrahepatic Cholestasis of Pregnancy: Toward Improving Perinatal Outcome

Intrahepatic cholestasis of pregnancy (ICP) is associated with poor perinatal outcomes in some women such as preterm delivery and fetal demise. Ursodeoxycholic acid (UDCA) is the main therapeutic agent for ICP, but recent evidence failed to show an impact on most perinatal outcomes. Our objective is to summarize the latest evidence in the management of ICP, with a focus on perinatal outcome. We propose a practical approach that combines pharmacotherapy with biochemical and fetal testing, as well as delivery planning.

Fetal cardiac dysfunction in intrahepatic cholestasis of pregnancy is associated with elevated serum bile acid concentrations

BACKGROUND & AIMS

Intrahepatic cholestasis of pregnancy (ICP) is associated with an increased risk of stillbirth. This study aimed to assess the relationship between bile acid concentrations and fetal cardiac dysfunction in patients with ICP who were or were not treated with ursodeoxycholic acid (UDCA).

METHODS

Bile acid profiles and NT-proBNP, a marker of ventricular dysfunction, were assayed in umbilical venous serum from 15 controls and 76 ICP cases (36 untreated, 40 UDCA-treated). Fetal electrocardiogram traces were obtained from 43 controls and 48 ICP cases (26 untreated, 22 UDCA-treated). PR interval length and heart rate variability (HRV) parameters were measured in 2 behavioral states (quiet and active sleep).

RESULTS

In untreated ICP, fetal total serum bile acid (TSBA) concentrations (r = 0.49, p = 0.019), hydrophobicity index (r = 0.20, p = 0.039), glycocholate concentrations (r = 0.56, p = 0.007) and taurocholate concentrations (r = 0.44, p = 0.039) positively correlated with fetal NT-proBNP. Maternal TSBA (r = 0.40, p = 0.026) and alanine aminotransferase (r = 0.40, p = 0.046) also positively correlated with fetal NT-proBNP. There were no significant correlations between maternal or fetal serum bile acid concentrations and fetal HRV parameters or NT-proBNP concentrations in the UDCA-treated cohort. Fetal PR interval length positively correlated with maternal TSBA in untreated (r = 0.46, p = 0.027) and UDCA-treated ICP (r = 0.54, p = 0.026). Measures of HRV in active sleep and quiet sleep were significantly higher in untreated ICP cases than controls. HRV values in UDCA-treated cases did not differ from controls.

CONCLUSIONS

Elevated fetal and maternal serum bile acid concentrations in untreated ICP are associated with an abnormal fetal cardiac phenotype characterized by increased NT-proBNP concentration, PR interval length and HRV. UDCA treatment partially attenuates this phenotype.

LAY SUMMARY

The risk of stillbirth in intrahepatic cholestasis of pregnancy (ICP) is linked to the level of bile acids in the mother which are thought to disrupt the baby's heart rhythm. We found that babies of women with untreated ICP have abnormally functioning hearts compared to those without ICP, and the degree of abnormality is closely linked to the level of harmful bile acids in the mother and baby's blood. Babies of women with ICP who received treatment with the drug UDCA do not have the same level of abnormality in their hearts, suggesting that UDCA could be a beneficial treatment in some ICP cases, although further clinical trials are needed to confirm this.

Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy: Replaces Consult #13, April 2011

Intrahepatic cholestasis of pregnancy is a hepatic disorder characterized by pruritus and an elevation in serum bile acid levels. Although intrahepatic cholestasis of pregnancy poses little risk for women, this condition carries a significant risk for the fetus, including complications such as preterm delivery, meconium-stained amniotic fluid, and stillbirth. The purpose of this Consult is to review the current literature on intrahepatic cholestasis of pregnancy and provide recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend measurement of serum bile acid and liver transaminase levels in patients with suspected intrahepatic cholestasis of pregnancy (GRADE 1B); (2) we recommend that ursodeoxycholic acid be used as the first-line agent for the treatment of maternal symptoms of intrahepatic cholestasis of pregnancy (GRADE 1A); (3) we suggest that patients with a diagnosis of intrahepatic cholestasis of pregnancy begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal fetal testing results or at the time of diagnosis if the diagnosis is made later in gestation (GRADE 2C); (4) we recommend that patients with total bile acid levels of ≥100 μmol/L be offered delivery at 36 0/7 weeks of gestation, given that the risk of stillbirth increases substantially around this gestational age (GRADE 1B); (5) we recommend delivery between 36 0/7 and 39 0/7 weeks of gestation for patients with intrahepatic cholestasis of pregnancy and total bile acid levels of <100 μmol/L (GRADE 1C); (6) we recommend administration of antenatal corticosteroids for fetal lung maturity for patients delivering before 37 0/7 weeks of gestation if not previously administered (GRADE 1A); (7) we recommend against preterm delivery at <37 weeks of gestation in patients with a clinical diagnosis of intrahepatic cholestasis of pregnancy without laboratory confirmation of elevated bile acid levels (GRADE 1B).

Effect of ursodeoxycholic acid therapy due to pregnant intrahepatic cholestasis on chemerin and irisin levels

The purpose of the work was to assess changes in chemerin and irisin levels in women with diagnosed intrahepatic cholestasis of pregnant women treated with ursodeoxycholic acid. The study group consisted of 50 patients with diagnosed and confirmed intrahepatic cholestasis of pregnant women at 24-25 weeks of pregnancy treatment by ursodeoxycholic acid (UDCA). The study also included a group of 40 pregnant women, without concomitant intrahepatic cholestasis of pregnancy (ICP). In the pregnant ICP group, whole blood was collected 4 times: before the first dose of drug, 4 and 8 weeks after the first dose, and day after delivery. It was observed that statistically significant differences in the concentration of irisine occur between the time before starting treatment and the 8-week therapy and 1 day after delivery. The Pearson correlation analysis (r's) showed two statistically significant relationships (p < .05). The first of these can be found between the concentration of irisine and chemerin in the group of nonpregnant women and the second in the group of patients with intrahepatic pregnant cholestasis before the first dose of UDCA. A significant relationship between irisin and chemerin concentrations was confirmed in the group of pregnant ICP patients during UDCA acid therapy and among healthy pregnant women.

Enzymatic quantification of total serum bile acids as a monitoring strategy for women with intrahepatic cholestasis of pregnancy receiving ursodeoxycholic acid treatment: a cohort study

OBJECTIVE

To evaluate enzymatic total serum bile acid quantification as a monitoring strategy for women with intrahepatic cholestasis of pregnancy (ICP) treated with ursodeoxycholic acid (UDCA).

DESIGN

Cohort.

SETTING

One UK university hospital.

POPULATION

29 ICP cases treated with UDCA.

METHODS

Serial samples were collected prospectively throughout gestation. Total serum bile acids were measured enzymatically and individual bile acids by high-performance liquid chromatography-tandem mass spectrometry. Data were log-transformed and analysed with random effects generalised least square regression.

MAIN OUTCOME MEASURES

The relationship between enzymatic total bile acid measurements and individual bile acid concentrations after UDCA treatment.

RESULTS

In untreated women, cholic acid was the principal bile acid (51%) and UDCA concentrations were <0.5%, whereas UDCA constituted 60% (IQR 43-69) of serum bile acids following treatment and cholic acid fell to <20%. Changes in the total bile acid measurement reflected similar alterations in the concentrations of the pathologically elevated bile acids, e.g. a two-fold increase in enzymatic total bile acids is accompanied by approximately a two-fold increase in cholic acid and chenodeoxycholic acid at most UDCA doses (P < 0.001). Most of the effects of UDCA on cholic acid occur in the first week of treatment (60% relative reduction, P = 0.025, 95% CI 0.2-0.9, from 10 micromol/l (4.7-17.6) to 3.5 micromol/l (1.4-7.5).

CONCLUSION

Ursodeoxycholic acid becomes the main component of the bile acid measurement after treatment. Enzymatic total bile acid assays are good predictors of both cholic acid and chenodeoxycholic acid, the primary bile acids that are raised prior to treatment.

TWEETABLE ABSTRACT

Ursodeoxycholic acid constitutes approximately 60% of the bile acid measurement and reduces pathological cholic acid in treated women.

Intrahepatic Cholestasis of Pregnancy: A Review of Diagnosis and Management

Importance

Intrahepatic cholestasis of pregnancy (ICP) complicates approximately 0.2% to 2% of pregnancies and can lead to increased fetal risks in pregnancy.

Objective

This review aims to increase the knowledge of women's health care providers regarding the diagnosis, management, and fetal risks associated with ICP.

Results

The diagnosis of ICP is based on symptoms of pruritus that typically include the palms and soles, as well as elevated bile acid levels. Other liver function tests such as alanine aminotransferase and aspartate aminotransferase are also frequently elevated, and other causes of liver dysfunction should be ruled out. Fetal risks of ICP include increased risk of preterm birth, meconium-stained amniotic fluid, respiratory distress syndrome, or stillbirth. There is evidence that as bile acid levels increase, so does the risk of adverse neonatal outcomes. Ursodeoxycholic acid treatment has been shown to improve maternal pruritus symptoms, as well as biochemical tests, but no treatment has been shown to definitively improve fetal outcomes.

Conclusions and Relevance

Providers should be aware of the signs and symptoms of ICP and provide accurate diagnosis and management of affected women. Women with a diagnosis of ICP should be treated with ursodeoxycholic acid to improve maternal symptoms. Given the increased risk of stillbirth in the setting of ICP, delivery may be considered at 37 weeks' gestation.

Heart and bile acids - Clinical consequences of altered bile acid metabolism

Cardiac dysfunction has an increased prevalence in diseases complicated by liver cirrhosis such as primary biliary cholangitis and primary sclerosing cholangitis. This observation has led to research into the association between abnormalities in bile acid metabolism and cardiac pathology. Approximately 50% of liver cirrhosis cases develop cirrhotic cardiomyopathy. Bile acids are directly implicated in this, causing QT interval prolongation, cardiac hypertrophy, cardiomyocyte apoptosis and abnormal haemodynamics of the heart. Elevated maternal serum bile acids in intrahepatic cholestasis of pregnancy, a disorder which causes an impaired feto-maternal bile acid gradient, have been associated with fatal fetal arrhythmias. The hydrophobicity of individual bile acids in the serum bile acid pool is of relevance, with relatively lipophilic bile acids having a more harmful effect on the heart. Ursodeoxycholic acid can reverse or protect against these detrimental cardiac effects of elevated bile acids.

Perinatal outcomes associated with intrahepatic cholestasis of pregnancy. J Matern Fetal Neonatal Med 2017;31:1913-1920. [PMID: 28581354 DOI: 10.1080/14767058.2017.1332036]

OBJECTIVE

The objective of this study is to examine perinatal outcomes associated with cholestasis of pregnancy according to bile acid level and antenatal testing practice.

STUDY DESIGN

Retrospective cohort study of women with symptoms and bile acid testing from 2005 to 2014. Women were stratified by bile acid level: no cholestasis (<10 μmol/L), mild (10-39 μmol/L), moderate (40-99 μmol/L), and severe (≥100 μmol/L). The primary outcome was composite neonatal morbidity (hypoxic ischemic encephalopathy, severe intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, or death).

RESULTS

785 women were included; 487 had cholestasis (347 mild, 108 moderate, 32 severe) and 298 did not. After controlling for gestational age (GA), severe cholestasis was associated with the composite neonatal outcome (aRR 5.6, 95% CI 1.3-23.5) and meconium-stained fluid (aRR 4.82, 95%CI 1.6-14.2). Bile acid levels were not correlated with the frequency of testing (p = .50). Women who underwent twice weekly testing were delivered earlier (p = .016) than women tested less frequently, but the difference in GA was ≤4 d. Abnormal testing prompting delivery was uncommon. Among women with cholestasis, there were three stillbirths. One of these women was undergoing antenatal testing, which was normal 1 d prior to the fetal demise.

CONCLUSION

Severe cholestasis is associated with neonatal morbidity which antenatal testing may not predict.

Alanine aminotransferase as a predictor of adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy

Objective:

To evaluate the associations between adverse perinatal outcomes and serum transaminase levels at the time of diagnosis in patients with intrahepatic cholestasis of pregnancy.

Methods:

We performed a retrospective analysis of patients hospitalized for evaluation of intrahepatic cholestasis of pregnancy from January 2013 to June 2014 in a tertiary center. Seventy-one patients were divided into two groups according to the presence (Group I) or absence of adverse perinatal outcomes (Group II).

Results:

The mean aminotransferase levels and conjugated bilirubin levels at the time of diagnosis were significantly higher in Group I than in Group II. Receiver operating characteristic curve analysis revealed that the alanine aminotransferase level could predict adverse perinatal outcomes with 76.47% sensitivity and 78.38% specificity, and the cut-off value was 95 IU/L. Among patients with intrahepatic cholestasis of pregnancy, those with adverse perinatal outcomes were significantly older, had an earlier diagnosis, and had higher alanine aminotransferase levels. Using the 95-IU/L cut-off value, patients with intrahepatic cholestasis of pregnancy had a 3.54-fold increased risk for adverse perinatal outcomes.

Conclusions:

Patients with intrahepatic cholestasis of pregnancy and high alanineaminotransferase levels should be followed up for possible adverse perinatal outcomes.

Severe First Trimester Recurrent Intrahepatic Cholestasis of Pregnancy: A Case Report and Literature Review

Background Intrahepatic cholestasis of pregnancy (ICP) is a disorder of defective bile acid transport that results in systemic accumulation of bile acids and typically presents in the third trimester of pregnancy with intense pruritus. A positive linear correlation exists between total bile acid level and poor pregnancy outcome, and labor is typically induced at 37 weeks gestation to prevent intrauterine fetal demise (IUFD). Case Study We present the most severe reported case of recurrent ICP presenting early in the first trimester. The patient was delivered by repeat cesarean section at 31 (6/7) weeks gestation resulting in a viable female infant. Conclusion Iatrogenic preterm delivery may be indicated in early-severe recurrent ICP to prevent IUFD, but more research is needed.

Severe intrahepatic cholestasis of pregnancy is a risk factor for preeclampsia in singleton and twin pregnancies

OBJECTIVE

Intrahepatic cholestasis of pregnancy (ICP) is known to be associated with fetal complications. It recently was suggested to be associated possibly with preeclampsia (PET) as well. The objective of this study was to investigate that possibility.

STUDY DESIGN

The study group included 78 women (54 singleton and 24 twin pregnancies) who had been diagnosed with ICP based on clinical presentation, elevated liver enzymes, and elevated total bile acids (>10 μmol/L). Disease severity was based on total bile acids levels as being severe (>40 μmol/L), moderate (20-40 μmol/L), or mild (10-20 μmol/L). The course of disease was reviewed carefully in each case. The control groups were comprised of apparently healthy women with singleton (n = 200) and twin (n = 100) pregnancies that were drawn randomly from a computerized registry of all the deliveries in our institution during the study period.

RESULTS

The total incidence of PET was significantly higher for the patients with ICP who had singleton and twin pregnancies compared with the control groups (singletons: 7.4% vs 1.5%; P < .05; twins: 33.3% vs 6.2%; P < .05, respectively). The incidence of severe PET was also significantly higher in both singleton (11-fold) and twin (8-fold) pregnancies compared with control subjects. Severe ICP, but not mild ICP, was a major risk factor for PET among women with either singleton or twin pregnancies. The timing of the initial presentation of ICP had no effect on PET incidence rates. Preeclampsia occurred usually 2-4 weeks after the diagnosis of ICP, and proteinuria preceded elevated blood pressure in all cases. Moreover, the total bile acid levels among 33 women who were diagnosed as having PET, but not ICP, were within normal range.

CONCLUSION

ICP increases the incidence of PET; severe disease was a major risk factor for preeclampsia. Therefore, we strongly suggest including routine evaluation for preeclampsia in the treatment of women with moderate and severe ICP.

The impact of total bile acid levels on fetal cardiac function in intrahepatic cholestasis of pregnancy using fetal echocardiography: a tissue Doppler imaging study

AIM

The aim of this study was to assess total bile acid (TBA) levels and its impact on systolic and diastolic functions in fetuses of mothers with intrahepatic cholestasis of pregnancy (ICP) using tissue Doppler imaging (TDI), and to explore the correlation between TBA levels and fetal cardiac function.

SUBJECTS AND METHODS

The study employed 98 pregnant women with ICP who were divided into two groups according to their bile acid levels. Fifty pregnant women without ICP represented the control group.

RESULTS

Significant differences in the myocardial tissue velocities of both mitral and tricuspid valves were found between the fetuses of mothers with ICP and TBA levels of <40 mmol/L and the control group, versus fetuses of mothers with ICP and TBA levels >40 mmol/L. There was a significant increase in neonatal respiratory distress, meconium staining and neonatal TBAs in group II compared to the control group and group I. There was a correlation between maternal TBA levels and preterm delivery, APGAR scores and neonatal TBA levels at birth. There was also a positive correlation between maternal TBA and fetal myocardial tissue velocities of both mitral and tricuspid, and fetal diastolic myocardial tissue Doppler velocities.

CONCLUSION

ICP is a very serious condition especially when maternal TBA levels are >40 mmol/L. Fetal echocardiography with tissue Doppler is a useful tool for fetal assessment in patients with ICP. It could be an indication of induction of labor in cases of ICP and bile acid levels ≥40 mol/L. Neonatal echocardiography is mandatory for follow-up and management of these neonates.

The impact of intrahepatic cholestasis of pregnancy on fetal cardiac and peripheral circulation

OBJECTIVE

The aim of this study was to evaluate changes in fetal cardiac and peripheral circulation in pregnancies complicated with intrahepatic cholestasis.

MATERIAL AND METHODS

The Doppler examination results of 22 pregnant subjects complicated with intrahepatic cholestasis of pregnancy (ICP) and 44 healthy controls were compared. The parameters of fetal cardiac circulation were pulmonary artery and aortic (Ao) peak systolic velocity (PSV), pulmonary vein (Pv), peak velocity index (PVI) and pulsatility index (PI), mitral valve (MV) and tricuspid valve (TV), early diastole (E)- and atrial contraction (A)-wave peak velocity ratio (E/A), and isthmus aortic peak systolic velocity (IAo PSV). The parameters of fetal peripheral circulation were middle cerebral artery (MCA) and umbilical artery (UA) PI, resistance index (RI), systolic/diastolic (S/D) ratio. Fetal obstetric Doppler monitoring was conducted weekly before 36 weeks and biweekly after that, and the results were compared with the normal reference values for gestational age.

RESULTS

The Doppler parameters of fetal cardiac and peripheral circulation did not significantly differ between the two groups. S/D ratio readings in the ICP group were significantly above 2 SD before 35 weeks of gestation. Women with ICP had increased risks of preterm delivery, neonatal unit admission, and meconium-stained amniotic fluid compared with those in the controls.

CONCLUSION

Fetuses of pregnant women with ICP showed no differences in the evaluation of cardiac and peripheral Doppler measurements compared with fetuses of healthy mothers. The Doppler investigation of the umbilical artery may be useful in monitoring of pregnancies complicated by early onset intrahepatic cholestasis.

Expression of urocortin and corticotrophin-releasing hormone receptor-2 in patients with intrahepatic cholestasis of pregnancy

INTRODUCTION

Intrahepatic cholestasis of pregnancy (ICP) is associated with an increased risk of adverse pregnancy outcomes. Fetal distress in ICP is an acute process, and the abnormal expression of placental local vasodilatory factors play an essential role. Urocortin (UCN) exhibits a powerful concentration-dependent vasodilatation effect in the utero-placental-fetal unit. Our study aimed to investigate placental and serum UCN expression in ICP patients.

METHODS

Blood and placenta samples were obtained from the ICP patients and controls. UCN and corticotrophin-releasing hormone receptor-2 (CRH-R2) expression were detected by ELISA, immunohistochemistry, Western Blotting and real-time PCR.

RESULTS

Placental UCN expression of ICP was lower compare to the controls (0.27 ± 0.11 vs. 0.85 ± 0.21) (P < 0.05). Placental CRH-R2 (0.97 ± 0.09 vs. 0.86 ± 0.09) showed no difference between the ICP and controls (P > 0.05). Placental UCN mRNA (1.45 ± 0.31 vs. 0.72 ± 0.29) and CRH-R2 mRNA expression (1.11 ± 0.10 vs. 0.84 ± 0.24) were higher compared to the controls (all P < 0.05). Maternal serum UCN levels demonstrated no difference from 34 (79.47 ± 11.35 pg/ml) to 37 (84.24 ± 13.62 pg/ml) weeks of gestation in controls (P > 0.05). Maternal serum UCN levels of ICP were decreased from 34 (68.53 ± 16.95 pg/ml) to 37 (47.91 ± 15.65 pg/ml) weeks of gestation (P < 0.05) and were lower than controls at 35 (64.19 ± 22.50 pg/ml), 36 (50.06 ± 13.98 pg/ml) and 37 weeks of gestation (all P < 0.05).

DISCUSSION

The down-regulated UCN expression in the placenta and maternal serum during ICP may impair the blood flow regulation of the utero-placental-fetal unit and contribute to fetal distress. Maternal serum UCN levels might represent a potential clinical predictor of adverse fetal outcomes and optimize the clinical management.

A case-control review of placentas from patients with intrahepatic cholestasis of pregnancy

OBJECTIVE

To compare the incidence of histopathological features in placentas from women with cholestasis of pregnancy to healthy individuals without ICP.

METHODS

Placentas from mothers with and without cholestasis of pregnancy were reviewed by a pathologist masked to the study group. Subjects were excluded if they had medical problems already associated with placental histopathology.

RESULTS

Twenty-four cases and 30 controls placentas were reviewed. Seventeen placental histopathological features were found. There was no statistically significant difference between the groups. Amongst patients with cholestasis, there was a decrease in villitis of unknown etiology in those treated with ursodeoxycholic acid.

CONCLUSION

There is no difference in the placental histopathology in cholestasis of pregnancy compared to normal pregnancies, but treatment of patients with cholestasis of pregnancy with ursodeoxycholic acid may decrease findings of villitis of unknown etiology.

The impact of intrahepatic cholestasis of pregnancy with hepatitis B virus infection on perinatal outcomes

Introduction

To investigate the impact of intrahepatic cholestasis of pregnancy (ICP) with hepatitis B virus (HBV) infection on perinatal outcomes.

Methods

In the study, 200 pregnant women were divided into four groups, including 50 cases with ICP and HBV infection, 50 cases with ICP, 50 cases with HBV infection, and 50 healthy pregnancies. The delivery process and perinatal outcomes were analyzed among different groups.

Results

When compared to the healthy pregnancy group, significantly increased rates of premature rupture of membranes, meconium-stained amniotic fluid, and cesarean section were observed in cases of ICP, HBV infection, or ICP patients with HBV (P<0.05). Specifically, the rates of HBV infection in the newborn, fetal distress, neonatal asphyxia, and birth defects in the newborn, and infant Apgar scores were higher in ICP pregnancies with HBV (56%, 48%, 16%, and 48%, respectively) than in the other groups (P<0.05).

Conclusion

ICP combined with HBV infection has a clear influence on perinatal infant outcomes.

Bile acids in a multicenter, population-based case-control study of stillbirth

OBJECTIVE

We sought to compare bile acids in women with and without stillbirth in a population-based study.

STUDY DESIGN

The Stillbirth Collaborative Research Network conducted a multisite, population-based case-control study of stillbirth (fetal deaths ≥20 weeks). Maternal sera were obtained at the time of enrollment and frozen at -80°C until assay for bile acids.

RESULTS

Assays were performed in 581 women with stillbirth and 1546 women with live births. Bile acid levels were slightly higher in women with stillbirth (geometric mean [95% confidence interval {CI}] = 3.2 [3.0-3.5]) compared to live births (2.9 [2.7-3.1], P = .0327). However, the difference was not significant after adjustment for baseline risk factors for stillbirth. The proportion of women with elevated levels (≥10 or ≥40 μmol/L) was similar in stillbirths and live births. Results were similar when the analysis was limited to subsets of stillbirths and live births. In women with stillbirths not associated with fetal anomalies or obstetric complications bile acid levels were higher than in women with term live births (geometric mean [95% CI] = 3.4 [3.0-3.8] vs 2.9 [2.7-3.0], P = .0152, unadjusted; P = .06, adjusted). However, a similar proportion of women in both groups had levels ≥10 μmol/L (10.7 vs 7.2%; odds ratio [OR], 1.54; 95% CI, 0.97-2.44; adjusted OR, 1.29; 95% CI, 0.78-2.15) and ≥40 μmol/L (1.7 vs 0.7%; OR, 2.58; 95% CI, 0.85-7.84; adjusted OR, 2.28; 95% CI, 0.79-6.56).

CONCLUSION

Our data do not support testing for bile acids in cases of stillbirth in the absence of clinical evidence of intrahepatic cholestasis of pregnancy.

Comparative proteomics analysis of placenta from pregnant women with intrahepatic cholestasis of pregnancy

Introduction

Intrahepatic cholestasis of pregnancy (ICP) usually occurs in the third trimester and associated with increased risks in fetal complications. Currently, the exact cause of this disease is unknown. In this study we aim to investigate the potential proteins in placenta, which may participate in the molecular mechanisms of ICP-related fetal complications using iTRAQ-based proteomics approach.

Methods

The iTRAQ analysis combined with liquid chromatography-tandem mass spectrometry (LC-MS/MS) was performed to separate differentially expressed placental proteins from 4 pregnant women with ICP and 4 healthy pregnant women. Bioinformatics analysis was used to find the relative processes that these differentially expressed proteins were involved in. Three apoptosis related proteins ERp29, PRDX6 and MPO that resulted from iTRAQ-based proteomics were further verified in placenta by Western blotting and immunohistochemistry. Placental apoptosis was also detected by TUNEL assay.

Results

Proteomics results showed there were 38 differentially expressed proteins from pregnant women with ICP and healthy pregnant women, 29 were upregulated and 9 were downregulated in placenta from pregnant women with ICP. Bioinformatics analysis showed most of the identified proteins was functionally related to specific cell processes, including apoptosis, oxidative stress, lipid metabolism. The expression levels of ERp29, PRDX6 and MPO were consistent with the proteomics data. The apoptosis index in placenta from ICP patients was significantly increased.

Conclusion

This preliminary work provides a better understanding of the proteomic alterations of placenta from pregnant women with ICP and may provide us some new insights into the pathophysiology and potential novel treatment targets for ICP.

Risks of emergency cesarean section and fetal asphyxia after induction of labor in intrahepatic cholestasis of pregnancy: a hospital-based retrospective cohort study

OBJECTIVES

Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy liver-specific disease. Induction of labor in gestational weeks 37-39 is commonly performed with the perspective to avoid the complication of stillbirth. We aimed to study whether this practice increases the risks of emergency cesarean section (CS) and fetal asphyxia.

STUDY DESIGN

We assessed the risk of emergency CS and fetal asphyxia in ICP among women with spontaneous and induced onset of labor in comparison to women without ICP. We performed a hospital based retrospective cohort study with 25,870 singleton pregnancies, 333 with ICP (1.3%), of which 231 gave birth in weeks 37-39. Obstetric outcome was assessed through linkage of the Swedish Medical Birth Registry and a local obstetrical database based on the patient's medical files.

MAIN OUTCOME MEASURE

Risk for emergency CS; fetal asphyxia and postpartum hemorrhage.

RESULTS

The risk of emergency CS in ICP with spontaneous onset of labor (12.5%) did not differ from non ICP women with spontaneous onset of labor (9.3%; aOR, 1.33; 95% CI 0.60-2.96). When labor was induced, risk of emergency CS was significantly lower among women with ICP than among without ICP (aOR, 0.47; 95% CI 0.26-0.86). Exclusion of women with preeclampsia, gestational hypertension or diabetes mellitus did not alter the result. The risk for fetal asphyxia was not significantly associated with ICP status.

CONCLUSION

Induction of labor in women with ICP gestational weeks 37-39 did not increase the risks of emergency CS or fetal asphyxia.

Impaired fetal adrenal function in intrahepatic cholestasis of pregnancy

Background

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-associated liver disease of unknown etiology. The aim of this study was to investigate the change in maternal and fetal adrenal function in clinical and experimental ICP.

Material/Methods

The maternal and fetal serum levels of cortisol and dehydroepiandrosterone sulfate (DHEAS) were determined in 14 women with ICP and in pregnant rats with estrogen-induced intrahepatic cholestasis.

Results

In women with ICP, the fetal serum cortisol and DHEAS levels were significantly higher than those in women with normal pregnancy, after correcting the impact of gestational age at delivery. The relationship between fetal cortisol and maternal cholic acid levels was bidirectional; the fetal cortisol tended to increase in mild ICP, while it decreased in severe ICP. In pregnant rats with estrogen-induced cholestasis, the fetal cortisol level was significantly lower in the group with oxytocin injection, compared with the group without oxytocin injection (191.92±18.86 vs. 272.71±31.83 ng/ml, P<0.05). In contrast, the fetal cortisol concentration was increased after oxytocin injection in normal control rats.

Conclusions

The data indicate that fetal stress-responsive system is stimulated in mild ICP, but it is suppressed in severe ICP, which might contribute to the occurrence of unpredictable sudden fetal death. Further studies are warranted to explore the role of impaired fetal adrenal function in the pathogenesis of ICP and the clinical implications.

Operative delivery rates following induction of labour for obstetric cholestasis

The aim of this study was to determine whether women induced for obstetric cholestasis (OC) have increased rates of operative delivery compared with women without OC who are induced. This retrospective case-control study included 64 women with OC (singleton pregnancies), who had labour induced compared with two control groups (matched for parity and gestational week at delivery). The majority of women were induced at 37 weeks. We found no significant increase in the rate of operative or assisted delivery in OC cases compared with either control group. Women with OC who are induced between 36 and 40 weeks gestation do not have increased rates of assisted or operative delivery compared with induced controls.

Cholestasis of pregnancy

Intrahepatic cholestasis (ICP) of pregnancy is a disease that is likely multifactorial in etiology and has a prevalence that varies by geography and ethnicity. The diagnosis is made when patients have a combination of pruritus and abnormal liver-function tests. It is associated with a high risk for adverse perinatal outcome, including preterm birth, meconium passage, and fetal death. As of yet, the cause for fetal death is unknown. Because fetal deaths caused by ICP appear to occur predominantly after 37 weeks, it is suggested to offer delivery at approximately 37 weeks. Ursodeoxycholic acid appears to be the most effective medication to improve maternal pruritus and liver-function tests; however, there is no medication to date that has been shown to reduce the risk for fetal death.

The active management of intrahepatic cholestasis of pregnancy

PURPOSE OF REVIEW

To review the literature regarding the active management of intrahepatic cholestasis of pregnancy.

RECENT FINDINGS

There has been an increasing trend toward the active management of cholestasis of pregnancy. This trend exists because clinicians have yet to discover adequate solutions to avert the morbidities and mortalities associated with the disorder. It is believed that early intervention by induction of labor before the 38th week of gestation will decrease the incidence of intrauterine fetal demise associated with cholestasis of pregnancy. It is also believed that treating the clinical symptoms of cholestasis with 2-5 ursodeoxycholic acid will improve maternal symptoms, facilitate the prolongation of pregnancy, and possibly improve fetal outcomes.

SUMMARY

The current literature encourages the induction of labor between 37-38 weeks' gestation in order to reduce the incidence of stillbirth in women with intrahepatic cholestasis of pregnancy. The most widely used medication for both the treatment of maternal pruritus and the elevations in maternal liver enzymes associated with cholestasis of pregnancy is 2-5 ursodeoxycholic acid. Neither mode of practice has been subjected to randomized clinical trials.