Intrahepatic cholestasis of pregnancy as an indicator of liver and biliary diseases: A population-based study

Ropponen, Anne; Sund, Reijo; Riikonen, Seija; Ylikorkala, Olavi; Aittomäki, Kristiina

doi:10.1002/hep.21111

Cited by 194 publications

(141 citation statements)

References 41 publications

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“…Some studies suggest a higher prevalence in patients with hepatitis C, cholelithiasis, and nonalcoholic fatty liver disease ( 37,39,40 ). Evaluation for alternative etiologies should be pursued if cholestasis fails to resolve aft er delivery.…”

Section: Second and Third Trimestermentioning

confidence: 99%

ACG Clinical Guideline: Liver Disease and Pregnancy

Tran

Ahn

Reau

2016

American Journal of Gastroenterology

235

257

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Consultation for liver disease in pregnant women is a common and oftentimes vexing clinical consultation for the gastroenterologist. The challenge lies in the need to consider the safety of both the expectant mother and the unborn fetus in the clinical management decisions. This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women. Am J Gastroenterol 2016; 111:176-194; doi: 10.1038/ajg.2015 Initial evaluation of pregnant patientA pregnant patient presenting with abnormal liver tests should undergo standard workup as with any non-pregnant individual (strong recommendation, very low level of evidence). Imaging in pregnancyUltrasound is safe and the preferred imaging modality used in assessment of abnormal liver tests suggestive of biliary tract disease (strong recommendation, low level of evidence).Magnetic resonance imaging without gadolinium can be used in the second and third trimester (conditional recommendation, low level of evidence).Computed tomography scans carry a risk of teratogenesis and childhood hematologic malignancies but may be used judiciously with minimized radiation protocols (2-5 rads; conditional recommendation, very low level of evidence). Endoscopy in pregnancyEndoscopy is safe in pregnancy but should be deferred until the second trimester if possible (strong recommendation, low level of evidence).Meperidine and propofol can be used for endoscopic sedation (strong recommendation, moderate level of evidence). Management of biliary disease in pregnancyERCP can be performed when indicated for pregnant women presenting with biliary disease that strongly necessitates intervention such as biliary pancreatitis, symptomatic choledocholithiasis, and/or cholangitis. Minimizing fetal exposure to fl uoroscopy is imperative (strong recommendation, low level of evidence).Symptomatic cholecystitis should be managed with early surgical intervention with laparoscopic cholecystectomy (strong recommendation, low level of evidence). Liver masses in pregnancyAsymptomatic hemangioma and focal nodular hyperplasia do not need routine imaging or surveillance during pregnancy (strong recommendation, very low level evidence).Hepatic adenomas should be monitored with ultrasound during pregnancy for growth. Patients with large adenomas (>5 cm) should be referred for resection prior to pregnancy (strong recommendation, low level of evidence). Hepatitis B in pregnancyActive-passive immunoprophylaxis with hepatitis B immunoglobulin and the HBV vaccination series should be administered to all infants born to HBV-infected mothers to prevent perinatal transmission (strong recommendation, low level of evidence).Women chronically infected with HBV and high viral load (>10 6 log copies/ml (200,000 IU/ml) and higher) should be offered antiviral medication with tenofovir or telbivudine in the third trimester to reduce perinatal transmission of HBV (strong recommendation, low level of evidence).C-section should not be performed electively in HBV-pos...

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Section: Second and Third Trimestermentioning

confidence: 99%

ACG Clinical Guideline: Liver Disease and Pregnancy

Tran

Ahn

Reau

2016

American Journal of Gastroenterology

235

257

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“…ICP resolves with fetal delivery to recur in 45%-70% of subsequent pregnancies and occasionally with oral contraceptives. Some rare familial cases of apparent ICP have persisted postpartum, with progression to subsequent fibrosis and cirrhosis, but 15 with more than 10,000 patients showed that patients who have had ICP subsequently have more gallstones and cholecystitis, more nonalcoholic pancreatitis, more hepatitis C, and more nonalcoholic cirrhosis. Therefore, in some patients, ICP may be an indicator of more serious subsequent liver disease.…”

Section: Intrahepatic Cholestasis Of Pregnancymentioning

confidence: 99%

Liver disease in pregnancy

2008

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Abnormal liver tests occur in 3%-5% of pregnancies, with many potential causes, including coincidental liver disease (most commonly viral hepatitis or gallstones) and underlying chronic liver disease. However, most liver dysfunction in pregnancy is pregnancy-related and caused by 1 of the 5 liver diseases unique to the pregnant state: these fall into 2 main categories depending on their association with or without preeclampsia. The preeclampsiaassociated liver diseases are preeclampsia itself, the hemolysis (H), elevated liver tests (EL), and low platelet count (LP) (HELLP) syndrome, and acute fatty liver of pregnancy. Hyperemesis gravidarum and intrahepatic cholestasis of pregnancy have no relationship to preeclampsia. Although still enigmatic, there have been recent interesting advances in understanding of these unique pregnancy-related liver diseases. Hyperemesis gravidarum is intractable, dehydrating vomiting in the first trimester of pregnancy; 50% of patients with this condition have liver dysfunction. Intrahepatic cholestasis of pregnancy is pruritus and elevated bile acids in the second half of pregnancy, accompanied by high levels of aminotransferases and mild jaundice. Maternal management is symptomatic with ursodeoxycholic acid; for the fetus, however, this is a high-risk pregnancy requiring close fetal monitoring and early delivery. Severe preeclampsia itself is the commonest cause of hepatic tenderness and liver dysfunction in pregnancy, and 2%-12% of cases are further complicated by hemolysis (H), elevated liver tests (EL), and low platelet count (LP)-the HELLP syndrome. Immediate delivery is the only definitive therapy, but many maternal complications can occur, including abruptio placentae, renal failure, subcapsular hematomas, and hepatic rupture. Acute fatty liver of pregnancy is a sudden catastrophic illness occurring almost exclusively in the third trimester; microvesicular fatty infiltration of hepatocytes causes acute liver failure with coagulopathy and encephalopathy. Early diagnosis and immediate delivery are essential for maternal and fetal survival. (HEPATOLOGY 2008;47:1067-1076.) M ost pregnant women are young and healthy, and physiological changes in pregnancy must not be mistaken for liver dysfunction (Table 1). Abnormal liver tests occur in 3%-5% of pregnancies, with many potential causes (Table 2). Although relatively uncommon, any liver disease can occur coincidentally in the pregnant patient and pregnancy may occur in a patient with underlying chronic liver disease. However, most liver dysfunction in pregnancy is pregnancy-related 1 and due to one of the 5 liver diseases unique to the pregnant state-hyperemesis gravidarum (HG), intrahepatic cholestasis of pregnancy (ICP), preeclampsia, the HELLP syndrome, and acute fatty liver of pregnancy (AFLP). These conditions are complications of pregnancy itself, and each has a characteristic timing in relation to the trimesters of pregnancy: HG in the first trimester, ICP in the second half of pregnancy, and the other 3 in the third trimes...

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“…A icterícia, quando se instala, é do tipo colestático, permanecendo durante quatro ou mais semanas. Sabe-se que as hepatites cursam com grande morbidade maternofetal, determinando muitas vezes prematuridade e óbito fetal 6 .…”

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Influência da icterícia obstrutiva na capacidade reprodutiva, desenvolvimento fetal e morfologia ovariana em ratas

Resende¹,

Petroianu²,

Alves³

et al. 2009

Rev. Col. Bras. Cir.

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Influência da icterícia obstrutiva na capacidade reprodutiva, Influência da icterícia obstrutiva na capacidade reprodutiva, Influência da icterícia obstrutiva na capacidade reprodutiva, Influência da icterícia obstrutiva na capacidade reprodutiva, Influência da icterícia obstrutiva na capacidade reprodutiva, desenvolvimento fetal e morfologia ovariana em ratas desenvolvimento fetal e morfologia ovariana em ratas desenvolvimento fetal e morfologia ovariana em ratas desenvolvimento fetal e morfologia ovariana em ratas desenvolvimento fetal e morfologia ovariana em ratas Influence of jaundice in the reproductive capacity, fetal development and Influence of jaundice in the reproductive capacity, fetal development and Influence of jaundice in the reproductive capacity, fetal development and Influence of jaundice in the reproductive capacity, fetal development and Influence of jaundice in the reproductive capacity, fetal development and ovarian morphology in rats ovarian morphology in rats ovarian morphology in rats ovarian morphology in rats ovarian morphology in rats VIVIAN ? dia pós-operatório, as ratas foram acasaladas e seus ciclos estrais avaliados diariamente por meio de esfregaços vaginais, que permitiram determinar o dia da cópula e a idade gestacional em que foram mortas. Realizou-se estudo histológico dos corpos lúteos nos ovários de todas as ratas e analisou-se macroscopicamente a morfologia externa dos fetos. Resultados:Resultados: Resultados: Resultados: Resultados: Observou-se que 23 ratas controle (92%) e 11 ratas ictéricas (39,3%) desenvolveram prenhez (p=0,0002). As 17 ratas com hiperbilirrubinemia e sem prenhez (60,7%) apresentaram somente corpos lúteos com aspecto involutivo em seus ovários e sofreram modificações em seus ciclos estrais, permanecendo vários dias em proestro ou estro. As ratas prenhes com hiperbilirrubinemia não apresentaram alterações em seus corpos lúteos, porém os seus fetos eram anormais. ConcluConclu-ConcluConclu-Conclusão: são: são: são: são: Em presença de hiperbilirrubinemia, a fertilização é viável, a capacidade reprodutiva é muito reduzida, os ciclos estrais tornamse irregulares, o epitélio vaginal permanece cornificado, os corpos lúteos ovarianos regridem, os corpos lúteos gravídicos não são alterados aumentando progressivamente durante a prenhez e o desenvolvimento fetal é gravemente alterado. . Nos casos em que essa afecção ocorre, observa-se mais recém-nascidos com sofrimento fetal intra-uterino, além de alto índice de prematuridade 3-5 . Hepatites virais agudas e crônicas são afecções que podem acometer pacientes grávidas. As hepatites virais agudas estao em seu período de incubação quando do iní-cio da gravidez ou são adquiridas durante a gestação. As hepatites crônicas podem cursar com quadro de icterícia subclínica. A icterícia, quando se instala, é do tipo colestático, permanecendo durante quatro ou mais semanas. Sabe-se que as hepatites cursam com grande morbidade maternofetal, determinando muitas vezes prematuridade e óbito fetal 6 . DescritoresTêm sido descri...

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Intrahepatic cholestasis of pregnancy as an indicator of liver and biliary diseases: A population-based study

Cited by 194 publications

References 41 publications

ACG Clinical Guideline: Liver Disease and Pregnancy

ACG Clinical Guideline: Liver Disease and Pregnancy

Liver disease in pregnancy

Influência da icterícia obstrutiva na capacidade reprodutiva, desenvolvimento fetal e morfologia ovariana em ratas

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