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Federación Mexicana de Ginecología y Obstetricia, A.C.

2019, Number 09

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Ginecol Obstet Mex 2019; 87 (09)

Intrahepatic cholestasis of pregnancy: Maternal and perinatal implications

Palacios-Llorente MA, Ramírez-Sierra L, Campo-Campo MN, Sanín-Blair JE, Echavarría-Restrepo LG, Parra-Rodas LM, Cuesta-Castro DP

Language: Spanish
References: 36
Page: 567-575
PDF size: 270.51 Kb.


ABSTRACT

Objective: To evaluate the maternal and perinatal outcomes associated with intrahepatic cholestasis of pregnancy.
Materials and Methods: A retrospective cohort study carried out in pregnant patients diagnosed with intrahepatic cholestasis, who attended the Bolivarian University Clinic of Medellín, Colombia, between January 2000 and June 2016. Maternal variables evaluated: preeclampsia, diabetes gestational, hypertensive disorders of pregnancy, preterm birth, cholelithiasis, intrauterine growth restriction, postpartum hemorrhage, gestational age at birth, birth route. Perinatal outcomes: meconium in amniotic fluid, birth weight, Apgar score; Hyaline membrane disease, transient tachypnea of the newborn, intraventricular hemorrhage, admission to the neonatal intensive care unit and neonatal mortality. The association with maternal-perinatal outcomes was estimated using relative risk adjusted by covariates.
Results: 271 patients were included: 134 in the intrahepatic cholestasis group and 137 in the control group. Patients with intrahepatic cholestasis manifested pruritus and abnormal liver tests. Intrahepatic cholestasis showed statistical significance with advanced maternal age, multiple pregnancy, induction of labor and termination of pregnancy by caesarean section. Cholelithiasis (RRa 15.9 95% CI 2.19-115.86), preterm birth (RRa 2.57, 95% CI 1.37-4.83), meconium in amniotic fluid (RRa 3.04, 95% CI 1.14-8.08) and low birth weight (medium difference 300 g ; 95% CI 190-400) were independent factors associated with intrahepatic cholestasis. No statistically significant relationship was found between intrahepatic cholestasis and maternal, fetal or neonatal mortality.
Conclusions: Intrahepatic cholestasis is usually associated with maternal and perinatal adverse outcomes that induce labor at a gestational age at the lower limit of term pregnancy. The decision to end the pregnancy has a positive impact on neonatal morbidity and mortality.


REFERENCES

  1. Williamson C, et al. Intrahepatic cholestasis of pregnancy. Obstet Gynecol 2014;124(1):120-33. DOI: 10.1097/ AOG.0000000000000346.

  2. Arthur C, et al. Intrahepatic cholestasis of pregnancy: diagnosis and management; a survey of Royal Australian and New Zealand College of Obstetrics and Gynaecology fellows. Aust N Z J Obstet Gynaecol 2014;54:263-267. DOI: 10.1111/ajo.12178.

  3. Royal College of Obstetricians and Gynaecologists. Obstetric cholestasis: green-top. Guideline No. 43. https://www. rcog.org.uk/en/guidelines-research-services/guidelines/ gtg43/

  4. Floreani A, et al. New insights on intrahepatic cholestasis of pregnancy. Clin Liver Dis 2016;20(1):177-89. DOI: 10.1016/j.cld.2015.08.010.

  5. Dixon PH, et al. The pathophysiology of intrahepatic cholestasis of pregnancy. Clin Res Hepatol Gastroenterol 2016;40(2):141-53. DOI: 10.1016/j.clinre.2015.12.008.

  6. Arrese M, et al. Molecular pathogenesis of intrahepatic cholestasis of pregnancy. Expert Rev Mol Med 2008;10:e9. DOI: 10.1017/S1462399408000628.

  7. Kawakita T, et al. Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol 2015;213(4):570.e1-8. DOI: 10.1016/j. ajog.2015.06.021.

  8. Kohari K, et al. Outcome after implementation of a modern management strategy for intrahepatic cholestasis of pregnancy. J Matern Fetal Neonatal Med 2017;30(11):1342- 1346. DOI: 10.1080/14767058.2016.1212833.

  9. Baliutavičienė D, et al. Pregnancy outcome in cases of intrahepatic cholestasis of pregnancy. Int J Gynaecol Obstet 2011;112(3):250-1. DOI: 10.1016/j.ijgo.2010.11.002.

  10. Medina-Lomelí JM, et al. Colestasis intrahepática del embarazo: una revisión. Ginecol Obstet Mex 2012;80(4):285- 294. https://ginecologiayobstetricia.org.mx/secciones/ articulos-de-revision/colestasis-intrahepatica-del-embarazo- una-revision/

  11. Chappell LC, et al. Ursodeoxycholic acid versus placebo, and early term delivery versus expectant management, in women with intrahepatic cholestasis of pregnancy: semifactorial randomized clinical trial. BMJ 2012;344:e3799. DOI: 10.1136/bmj. e3799.

  12. Bacq Y, et al. Efficacy of ursodeoxycholic acid in treating intrahepatic cholestasis of pregnancy: a meta–analysis. Gastroenterology 2012;143(6):1492-501. DOI: 10.1053/j. gastro.2012.08.004.

  13. Gurung V, et al. Interventions for treating cholestasis in pregnancy. Cochrane Database Syst Rev 2013;(6):CD000493. DOI: 10.1002/14651858.CD000493.pub2.

  14. Wikström Shemer E, et al. Intrahepatic cholestasis of pregnancy and associated adverse pregnancy and fetal outcomes: a 12-year population-based cohort study. BJOG 2013;120(6):717-23. DOI: 10.1111/1471- 0528.12174.

  15. Geenes V, et al. Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: A prospective population-based case-control study. Hepatology 2014;59(4):1482-91. DOI: 10.1002/hep.26617.

  16. Carballo-Núñez E, et al. Resultados perinatales en pacientes con colestasis gravídica. Ginecol Obstet Mex 2015;83:776- 784. https://ginecologiayobstetricia.org.mx/historico/ 2015/volumen-83-num-12-diciembre-2015/resultadosperinatales- en-pacientes-con-colestasis-gravidica/

  17. Wikström Shemer EA, et al. Risks of emergency cesarean section and fetal asphyxia after induction of labor in intrahepatic cholestasis of pregnancy: A hospital-based retrospective cohort study. Sex Reprod Healthc 2013;4:17- 22. DOI: 10.1016/j.srhc.2012.11.005.

  18. Webster JR, et al. Operative delivery rates following induction of labor for obstetric cholestasis. Obstetric Medicine 2011;4(2):66-9. DOI: 10.1258/om.2011.110080.

  19. Williamson C, et al. Clinical outcome in a series of cases of obstetric cholestasis identified via a patient support group. BJOG 2004;111(7):676-81. DOI: 10.1111/j.1471- 0528.2004. 00167.x

  20. Puljic A, et al. The risk of infant and fetal death by each additional week of expectant management in intrahepática cholestasis of pregnancy by gestational age. Am J Obstet Gynecol 2015;212(5):667.e1-5. DOI: 10.1016/j. ajog.2015.02.012.

  21. Lo JO, et al. Intrahepatic cholestasis of pregnancy and timing of delivery. J Matern Fetal Neonatal Med 2015;28(18):2254- 8. DOI: 10.3109/14767058.2014.984605.

  22. Henderson CE, et al. Primum non nocere: how active management became modus operandi for intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol 2014;211(3):189-96. DOI: 10.1016/j.ajog.2014.03.058.

  23. Ropponen A, et al. Intrahepatic cholestasis of pregnancy as an indicator of liver and biliary diseases: a populationbased study. Hepatology 2006;43(4):723-8. DOI: 10.1002/ hep.21111.

  24. Marschall HU, et al. Intrahepatic cholestasis of pregnancy and associated hepatobiliary disease: a populationbased cohort study. Hepatology 2013;58(4):1385-91. DOI: 10.1002/hep.26444.

  25. Martineau M, et al. Intrahepatic cholestasis of pregnancy is associated with an increased risk of gestational diabetes. Eur J Obstet Gynecol Reprod Biol 2014;176:80-5. DOI: 10.1016/j.ejogrb.2013.12.037

  26. Shan D, et al. Intrahepatic Cholestasis of Pregnancy in Women with Twin Pregnancy. Twin Res Hum Genet 2016;19(6):697-707. DOI: 10.1017/thg.2016.74

  27. Raz Y, et al. Severe intrahepatic cholestasis of pregnancy is a risk factor for preeclampsia in singleton and twin pregnancies. Am J Obstet Gynecol 2015;213(3):395.e1-8. DOI: 10.1016/j.ajog.2015.05.011.

  28. Ovadia C, et al. Intrahepatic cholestasis of pregnancy: Recent advances. Clin Dermatol 2016;34(3):327-34. DOI: 10.1016/j.clindermatol2016.02.004.

  29. Al Shobaili HA, et al. Obstetrical and fetal outcomes of a new management strategy in patients with intra-hepatic cholestasis of pregnancy. Arch Gynecol Obstet 2011;283(6):1219- 25. DOI: 10.1007/s00404-010-1506-1.

  30. Maya JJ, et al. Diagnóstico y manejo de la colestasis intrahepática del embarazo. Reporte de un caso y revisión de la literatura. Acta Med Grupo Ángeles. 2013;11(1):17-22. https:// www.medigraphic.com/pdfs/actmed/am-2013/am131c.pdf

  31. Lee RH, et al. Pregnancy outcomes during an era of aggressive management of intrahepática cholestasis of pregnancy. Am J Perinatol 2008;25(6):341-5. DOI: 10.1055/s-2008-1078756.

  32. Walker IA, et al. Role of bile acid measurement in pregnancy. Ann Clin Biochem 2002;39(Pt2):105-13. DOI: 10.1258/0004563021901856.

  33. Glantz A, et al. Intrahepatic cholestasis of pregnancy: Relationships between bile acid levels and fetal complication rates. Hepatology 2004;40(2):467-474. DOI: 10.1002/ hep.20336.

  34. Brouwers L, et al. Intrahepatic cholestasis of pregnancy: maternal and fetal outcomes associated with elevated bile acid levels. Am J Obstet Gynecol 2015;212(1):100.e1-100. e7. DOI: 10.1016/j.ajog.2014.07.026.

  35. Jin J, et al. Risk factors for adverse fetal outcomes among women with early- versus late-onset intrahepatic cholestasis of pregnancy. Int J Gynaecol Obstet. 2015;128(3):236- 240. DOI: 10.1016/j.ijgo.2014.09.013.

  36. Frailuna MA, et al. Colestasis intrahepática gestacional. Consenso Federación Argentina de Sociedades de Ginecología y Obstetricia 2016:1-17. http://www.fasgo. org.ar/archivos/consensos/Consenso_de_obstetricia_ Colestasis_y_embarazo_2016.pdf




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