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Khedr L, Ekram M. Azathioprine Associated with Intrahepatic Cholestasis in a Patient with Twin Pregnancy after a Second Kidney Transplant. Eur J Case Rep Intern Med 2024; 11:004385. [PMID: 38584904 PMCID: PMC10997401 DOI: 10.12890/2024_004385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Most pregnancies in women after a kidney transplant result in a live birth, but kidney functions should be stable for one year before conception. For immunosuppression modification occurring before pregnancy, azathioprine is used because it is considered safe for major congenital malformations during pregnancy. However, there may be an association between exposure to azathioprine during pregnancy and the onset of an unusual, early and severe form of intrahepatic cholestasis. Case description A young patient with a twin pregnancy after a second kidney transplant experienced intrahepatic cholestasis. There was a wide range of differential diagnosis. A battery of tests was requested including autoimmune markers, virology, and imaging. The conclusion that azathioprine was contributing to intrahepatic cholestasis with pregnancy was reached after exclusion of all other differentials. Conclusions Complications of pregnancy after a kidney transplant include hypertension, pre-eclampsia, deterioration of graft function up to rejection, but also unusual side effects of immunosuppression medication. LEARNING POINTS A twin pregnancy after a second kidney transplant is rare.In addition to bone marrow suppression and elevation of liver enzymes, azathioprine can contribute to intrahepatic cholestasis of pregnancy.Complications of pregnancy after kidney transplant include hypertension, pre-eclampsia, deterioration of graft function up to rejection, but also unusual side effects of immunosuppression medication.
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Affiliation(s)
- Lamis Khedr
- Nephrology Department, Ain Shams University, Cairo, Egypt
| | - Mohamed Ekram
- Internal Medicine Department, New Giza University, Cairo, Egypt
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Farisoğullari N, Tanaçan A, Sakcak B, Denizli R, Başaran E, Kara Ö, Yazihan N, Şahin D. Evaluation of maternal serum vascular endothelial growth factor C and D levels in intrahepatic cholestasis of pregnancy. Int J Gynaecol Obstet 2024; 164:979-984. [PMID: 37680091 DOI: 10.1002/ijgo.15107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE This study aimed to investigate maternal serum vascular endothelial growth factor (VEGF) C and D levels in patients with intrahepatic cholestasis of pregnancy (ICP). METHODS A total of 83 patients, including 41 patients with ICP and 42 healthy pregnant women, were included in the study. We first compared the maternal serum VEGF-C and VEGF-D levels between the ICP and control groups and then examined the correlation between the serum VEGF-C level and the bile acid level in patients with severe ICP. RESULTS We observed statistically significantly higher serum VEGF-C levels and lower VEGF-D levels in the ICP group compared with the healthy controls (P < 0.001 and P = 0.015, respectively). According to receiver operating characteristic analysis, the optimal cutoff value for ICP was 147 ng/mL in the determination of the VEGF-C level (specificity and sensitivity: 76%). In patients with severe ICP, the serum VEGF-C statistically significantly correlated with the bile acid level (P = 0.019). CONCLUSION This study showed that the maternal serum VEGF-C level was higher and the VEGF-D level was lower in patients with ICP compared with healthy pregnant women. We also found that the VEGF-C level was correlated with the serum bile acid level in patients with severe ICP. Serum VEGF-C level can be used in the diagnosis and follow-up of intrahepatic pregnancy cholestasis.
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Affiliation(s)
- Nihat Farisoğullari
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara City Hospital, Turkish Ministry of Health, Ankara, Turkey
| | - Atakan Tanaçan
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara City Hospital, Turkish Ministry of Health, Ankara, Turkey
| | - Bedri Sakcak
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara City Hospital, Turkish Ministry of Health, Ankara, Turkey
| | - Ramazan Denizli
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara City Hospital, Turkish Ministry of Health, Ankara, Turkey
| | - Ezgi Başaran
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara City Hospital, Turkish Ministry of Health, Ankara, Turkey
| | - Özgür Kara
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara City Hospital, Turkish Ministry of Health, Ankara, Turkey
| | - Nuray Yazihan
- Department of Pathophysiology, Internal Medicine, Ankara University Medical School, Ankara, Turkey
| | - Dilek Şahin
- Division of Perinatology, Department of Obstetrics and Gynecology, Ankara City Hospital, Turkish Ministry of Health, University of Health Sciences, Ankara, Turkey
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Morton A. Investigating gastrointestinal disorders in pregnancy. Obstet Med 2024; 17:5-12. [PMID: 38660319 PMCID: PMC11037196 DOI: 10.1177/1753495x231206211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/21/2023] [Accepted: 09/20/2023] [Indexed: 04/26/2024] Open
Abstract
This article reviews anatomical and physiological changes and alterations in reference intervals for laboratory tests in healthy pregnancy, pertinent to investigation of the gastrointestinal system. The safety of procedures and radiological investigations relevant to the investigation of gastrointestinal disorders in pregnancy are also reviewed.
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Affiliation(s)
- Adam Morton
- Mater Health, Raymond Terrace, South Brisbane, QLD, 4101, Australia
- Department of Medicine, University of Queensland, Herston, Brisbane, QLD, 4029, Australia
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Selinger CP, Rosiou K, Broglio G, Lever G, Chiu CM, Stocker LJ, Chipeta H, Glanville T. Antenatal thiopurine exposure in women with IBD is associated with intrahepatic cholestasis of pregnancy. Expert Opin Drug Saf 2023; 22:1091-1097. [PMID: 37417244 DOI: 10.1080/14740338.2023.2234813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/05/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Pregnant women with inflammatory bowel disease (IBD) continue thiopurines to maintain remission. Other studies have reported intrahepatic cholestasis of pregnancy (ICP) in IBD pregnancies exposed to thiopurines. We aimed to investigate whether thiopurines are associated with an increased risk of ICP. RESEARCH DESIGN AND METHODS Single-center retrospective cohort study comparing incidence of ICP in thiopurine-exposed versus non-exposed patients with IBD compared with age-matched pregnant controls. RESULTS The IBD cohort consisted of 386 pregnancies in 243 patients with IBD, with 386 age-matched controls. In patients with IBD, ICP was significantly more common among thiopurine-exposed pregnancies (9.0% vs 1.8%; odds ratio [95% confidence interval] = 5.34 [1.78-16.02]; p = 0.021). IBD patients with thiopurine exposure were significantly more likely to experience ICP compared to non-IBD controls (9.0% vs 1.3%; p < 0.001). Patients with IBD not exposed to thiopurines had a comparable ICP incidence with controls (1.8% vs 1.3%; p = 0.75). Severe ICP occurred in 80% of thiopurine-exposed ICP cases versus 40% in non-exposed (p = 0.25), versus 20% in controls (p = 0.09). CONCLUSION Thiopurine exposure was associated with a significantly increased risk of ICP among patients with IBD compared to non-exposed IBD patients and age-matched general population controls. The course of ICP was not significantly different in thiopurine-exposed cases.
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Affiliation(s)
| | | | - Giacomo Broglio
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds, UK
- Gastroenterology, IRCCS Fondazione Policlinico San Matteo, Internal Medicine, Pavia, Italy
| | - Gillian Lever
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds, UK
| | - Chun Ming Chiu
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals, Leeds, UK
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Dong R, Ye N, Wang J, Zhao S, Wang T, Wang G, Shi X, Cheng J, Zhang Y, Yao T, Chen M, Zhang T, Luo L. Serum Exosomes MicroRNAs Are Novel Non-Invasive Biomarkers of Intrahepatic Cholestasis of Pregnancy. Front Endocrinol (Lausanne) 2022; 13:832577. [PMID: 35600587 PMCID: PMC9114354 DOI: 10.3389/fendo.2022.832577] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background Intrahepatic cholestasis of pregnancy (ICP) is closely related to the occurrence of adverse outcomes. Currently, total bile acids (TBAs) are the only diagnostic index for ICP, and its sensitivity and specificity have certain limitations. In this study, we aimed to develop potential biomarkers for the diagnosis of ICP. Methods Sixty pregnant women diagnosed with ICP and 48 healthy pregnant controls were enrolled in this study. We used the Agilent microRNA (miRNA) array followed by quantitative reverse transcriptase polymerase chain reaction assays to identify and validate the serum exosome miRNA profiles in ICP and healthy pregnant controls. We employed bioinformatics to identify metabolic processes associated with differentially expressed serum exosome miRNAs. Results The expression levels of hsa-miR-4271, hsa-miR-1275, and hsa-miR-6891-5p in maternal serum exosomes were significantly lower in ICP patients compared to controls; the diagnostic accuracy of hsa-miR-4271, hsa-miR-1275, and hsa-miR-6891-5p was evaluated with the area under the receiver operating characteristic curve (AUC) values of 0.861, 0.886, and 0.838, respectively. Multiple logistic regression analysis showed that a combination of the levels of hsa-miR-4271and hsa-miR-1275 afforded a significantly higher AUC (0.982). The non-error rate of a combination of all three exosome miRNAs was the highest (95%), thus more reliable ICP diagnosis. The expression levels of all three exosome miRNAs were negatively associated with TBAs. Furthermore, according to bioinformatics analysis, the three exosome miRNAs were related to lipid metabolism, apoptosis, oxidative stress, and the Mitogen Activated Protein Kinase (MAPK) signaling pathway. Conclusions This study may identify the novel non-invasive biomarkers for ICP and provided new insights into the important role of the exosome miRNA regulation in ICP.
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Affiliation(s)
- Ruirui Dong
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Ningzhen Ye
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Jing Wang
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Shaojie Zhao
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Tiejun Wang
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Gaoying Wang
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Xinrui Shi
- School of Medicine, Jiangnan University, Wuxi, China
| | - Jing Cheng
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Yan Zhang
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Tingting Yao
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Minjian Chen
- State Key Laboratory of Reproductive Medicine, Institute of Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
- Key Laboratory of Modern Toxicology of Ministry of Education, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Ting Zhang
- The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Liang Luo
- Intensive Care Medicine, The Affiliated Wuxi No. 2 People’s Hospital of Nanjing Medical University, Wuxi, China
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Jain N, Gupta P, Sahoo S, Mallick B. Non-coding RNAs and their cross-talks impacting reproductive health of women. WILEY INTERDISCIPLINARY REVIEWS. RNA 2022; 13:e1695. [PMID: 34825502 DOI: 10.1002/wrna.1695] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 09/02/2021] [Accepted: 09/10/2021] [Indexed: 12/26/2022]
Abstract
Non-coding RNAs (ncRNAs) work as crucial posttranscriptional modulators of gene expression regulating a wide array of biological processes that impact normal physiology, including reproductive health. The health of women, especially reproductive health, is now a prime focus of society that ensures the females' overall physical, social, and mental well-being. Furthermore, there has been a growing cognizance of ncRNAs' possible applications in diagnostics and therapeutics of dreaded diseases. Hence, understanding the functions and mode of actions of ncRNAs in the context of women's health will allow us to develop effective prognostic and therapeutic strategies that will enhance the quality of life of women. Herein, we summarize recent progress on ncRNAs, such as microRNAs (miRNAs) and long ncRNAs (lncRNAs), and their implications in reproductive health by tying the knot with lifestyle factors that affect fertility complications, pregnancy outcomes, and so forth. We also discourse the interplay among the RNA species, especially miRNAs, lncRNAs, and protein-coding RNAs, through the competing endogenous RNA regulations in diseases of women associated with maternal and fetal health. This review provides new perspectives correlating ncRNAs, lifestyle, and reproductive health of women, which will attract future studies to improve women's lives. This article is categorized under: RNA in Disease and Development > RNA in Disease Regulatory RNAs/RNAi/Riboswitches > Regulatory RNAs.
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Affiliation(s)
- Neha Jain
- RNAi and Functional Genomics Laboratory, Department of Life Science, National Institute of Technology, Rourkela, India
| | - Pooja Gupta
- RNAi and Functional Genomics Laboratory, Department of Life Science, National Institute of Technology, Rourkela, India
| | - Swapnil Sahoo
- RNAi and Functional Genomics Laboratory, Department of Life Science, National Institute of Technology, Rourkela, India
| | - Bibekanand Mallick
- RNAi and Functional Genomics Laboratory, Department of Life Science, National Institute of Technology, Rourkela, India
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Mohan M, Prabhu SS, Pullattayil AK, Lindow S. A meta-analysis of the prevalence of gestational diabetes in patients diagnosed with obstetrical cholestasis. AJOG GLOBAL REPORTS 2021; 1:100013. [PMID: 36277255 PMCID: PMC9563540 DOI: 10.1016/j.xagr.2021.100013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Gestational diabetes and obstetrical cholestasis are common clinical conditions seen in clinical practice. There is evidence suggesting a coexisting relationship that could have a potential clinical implication related to stillbirth outcomes. OBJECTIVE This study aimed to determine the prevalence of gestational diabetes in women with obstetrical cholestasis. STUDY DESIGN A predefined protocol with a literature search was used to obtain all possible articles. A systematic review and meta-analysis of observational studies with quantifiable data published since 2010 were performed. Articles were evaluated and included in the study with specified criteria for the risk of bias using the Newcastle-Ottawa Scale. A meta-analysis was performed using Meta-analysis of Observational Studies in Epidemiology specifications to determine the prevalence of gestational diabetes in women with obstetrical cholestasis. RESULTS A total of 16,748 patients with obstetrical cholestasis from 21 studies were included. The prevalence of gestational diabetes in women with obstetrical cholestasis was 13.9% (20 studies analyzed). Gestational diabetes was more common in women with obstetrical cholestasis than in women without obstetrical cholestasis (odds ratio, 2.129; 95% confidence interval, 1.697-2.670;10 studies). Gestational diabetes is twice more common in women with severe cholestasis than in women with mild cholestasis (odds ratio, 2.168; 95% confidence interval, 1.429-3.289; 4 studies). CONCLUSION There is an increase in the prevalence of gestational diabetes among women diagnosed with obstetrical cholestasis. Compared with women with mild cholestasis, the increased risk of gestational diabetes in women with severe cholestatis is more than doubled. This suggests that the 2 conditions may have some biological similarities that affect clinical outcomes.
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Affiliation(s)
- Manoj Mohan
- Department of Obstetrics and Gynecology, Aster DM Healthcare, Doha, Qatar (Dr Mohan)
| | | | | | - Stephen Lindow
- Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland (Dr Lindow)
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Céruti H, Kayem G, Guilbaud L, Dussaux C, Gervais A, Beaufrère A, Coffin B, Mandelbrot L, Maisonneuve E. Intrahepatic cholestasis of pregnancy associated with azathioprine: A case series. J Gynecol Obstet Hum Reprod 2021; 50:102083. [PMID: 33601075 DOI: 10.1016/j.jogoh.2021.102083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is characterised by otherwise unexplained maternal pruritus, increased serum bile acid concentration over 10 μmol/L and spontaneous relief of symptoms and liver abnormalities after delivery. It occurs most frequently during the third trimester and is usually not induced by medication. Besides, azathioprine is recommended as first-line immunosuppressant in patients with steroid-dependent inflammatory bowel disease and is allowed during pregnancy, in order to stabilize maternal disease. METHODS We reviewed all cases of ICP between 2010 and 2018 in two French perinatal centers. RESULTS We encountered eight pregnancies complicated by atypical ICP among patients treated with azathioprine. ICP associated with azathioprine appears to be biologically more severe and to occur earlier than "standard" ICP. Furthermore, clinical and biochemical abnormalities related to ICP disappear when azathioprine is discontinued. Azathioprine safety should be reconsidered and practitioners advised to discuss discontinuing this drug as soon as ICP diagnosis is established.
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Affiliation(s)
- Hélène Céruti
- Obstetrics and Gynecology Department, Armand-Trousseau Hospital, Paris, France
| | - Gilles Kayem
- Obstetrics and Gynecology Department, Armand-Trousseau Hospital, Paris, France; Sorbonne Université, Paris, France
| | - Lucie Guilbaud
- Fetal Medicine Department, Armand-Trousseau Hospital, Paris, France
| | - Chloé Dussaux
- Obstetrics and Gynecology Department, Louis Mourier Hospital, Colombes, France
| | - Anne Gervais
- Hepatology and Gastroenterology Department, AP-HP Hôpital Louis Mourier, Colombes, France
| | | | - Benoit Coffin
- Hepatology and Gastroenterology Department, AP-HP Hôpital Louis Mourier, Colombes, France; Université de Paris Diderot, Paris, France
| | - Laurent Mandelbrot
- Obstetrics and Gynecology Department, Louis Mourier Hospital, Colombes, France; Université de Paris Diderot, Paris, France
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Tamiru AT, Rade BK, Ali O. The Recurrent Liver Disorder of a Pregnant Mother: Intrahepatic Cholestasis of Pregnancy - A Case Report and Literature Review. Int Med Case Rep J 2021; 14:73-76. [PMID: 33603498 PMCID: PMC7882788 DOI: 10.2147/imcrj.s299354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Intrahepatic cholestasis of pregnancy (ICP) is a form of liver disease which is unique to pregnancy with a worldwide prevalence ranging from 0.3% and 5.6% of pregnancies. It is presented with skin pruritus and elevated total serum bile salt and liver function test with unknown etiologic agent but suggested hormonal, environmental and genetic risk factors. Case Presentation A 31-year-old Gravida III and Para II mother came to University of Gondar specialized hospital at the outpatient clinic in January 2019 with complain of generalized pruritus along with jaundice at 24 weeks gestational age (GA). She presented with singleton and intrauterine pregnancy with a history of one neonatal loss, one living child, and elevated bilirubin, on admission blood serum test showed elevated serum transaminases, and bilirubin. At 30 weeks GA her bilirubin total and bilirubin direct tests were 4.52 mg/dl and 3.45 mg/dl respectively. At 34 weeks GA her bilirubin values became elevated. At 37 weeks GA fetal delivery was carried out via successful caesarean section with an indication of non-reassuring fetal heart rate pattern after induction with oxytocin. The outcome was stable for both mother and baby. After a two week follow up in the outpatient set up, her liver biochemistry test was normal, and free of the clinical features with normal physical growth and intact primitive reflexes of a newborn. Conclusion Presenting with a typical marker of increased liver function tests, bilirubin values and pruritus as a clinical feature, ICP was diagnosed. After an attempt at an oxytocin induction, an effective cesarean section was performed to deliver a live female baby, weighing 2.8 kg. The case disappeared after three weeks follow up in the puerperium.
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Affiliation(s)
- Animut Tagele Tamiru
- Department of General Midwifery, School of Midwifery, College of Medicine and Health Sciences Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
| | - Bayew Kelkay Rade
- Department of General Midwifery, School of Midwifery, College of Medicine and Health Sciences Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
| | - Oumer Ali
- Department of Obstetrics and Gynecology, College of Medicine and Health Sciences Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
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Morton A. Jaundice and pregnancy. Med J Aust 2019; 211:475-475.e1. [PMID: 31663144 DOI: 10.5694/mja2.50396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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