Investigation and management of recurrent cholestasis of pregnancy
Minakshi Rohilla in Recurrent Pregnancy Loss and Adverse Natal Outcomes, 2020
Intrahepatic cholestasis of pregnancy (ICP) has long been implicated as a rare cause of antepartum stillbirths, now being categorized under the Antepartum hypoxia category (A3) for the fetus and Maternal medical condition (M4) in the World Health Organization (WHO) application of the International Classification of Diseases, 10th Revision, to deaths during the perinatal period (ICD–Perinatal Mortality, ICD-PM) classification of stillbirths [1]. Intrahepatic cholestasis of pregnancy is a pregnancy-related liver disorder [2]. It usually presents in the second and third trimesters, though cases in the first trimester have also reported [3]. It is characterized by pruritis without a rash, especially on the palms and soles, that manifests itself more at night. A rise in bile acids is noted. This entity is characterized by a resolution of the symptoms and biochemical indicators after pregnancy. Cholestasis of pregnancy is associated with adverse fetal outcome, and so it is significant in women with previously unfavorable obstetric history. A history of recurrent cholestasis with jaundice and neonatal death should also be evaluated for genetic diseases, such as progressive familial intrahepatic cholestasis (PFIC) [4]. These women are also predisposed to develop various hepatobiliary, cardiovascular, and immune-mediated diseases in later life. The defining criteria and recommendations for management and delivery timing vary in the literature.
Dermatological emergencies in pregnancy
Biju Vasudevan, Rajesh Verma in Dermatological Emergencies, 2019
Intrahepatic cholestasis of pregnancy is a reversible form of hormonally triggered cholestasis that typically develops in genetically predisposed individuals in late pregnancy. The prevalence ranges from 0.7% in the United Kingdom, 1.2% in Asians of Indian origin in the United Kingdom, 2% in China, to 4% in Chile [9–11]. A defect in excretion of bile salts results in elevated bile acids in the serum. This leads to severe pruritus in the mother and may have deleterious effects on the fetus due to acute placental anoxia and cardiac depression. Etiology is multifactorial, involving genetics, hormones, environmental, dietary, and underlying liver, biliary, or pancreatic conditions. Approximately half of affected individuals have a positive family history. Mutations of genes encoding for transport proteins for bile excretion, i.e., ABCB4 gene (multidrug resistance gene 3), ATP8B1, and ABC11 have been implicated.
Dermatoses of Pregnancy
Vincenzo Berghella in Maternal-Fetal Evidence Based Guidelines, 2022
Stretch marks are the only dermatologic condition for which there are trials for interventions. Dermatoses of pregnancy as well as melanoma in pregnancy are not well studied, with no specific trials regarding treatment. Most evidence regarding pathogenesis and etiology, as well as typical disease presentation is based on case reports and case series. Dermatoses of pregnancy have been plagued by disagreements about their nomenclature and classification. Though likely to be reworked and reclassified in the future, the current widely accepted classification, based on the largest series to date, consists of four major categories: (1) polymorphic eruption of pregnancy (PEP), (2) atopic eruption of pregnancy (AEP), (3) pemphigoid gestationis (PG), and (4) intrahepatic cholestasis of pregnancy (ICP). Under this classification, AEP has subsumed atopic dermatitis (eczema) of pregnancy, prurigo of pregnancy (PP), and pruritic folliculitis of pregnancy (PFP). Intrahepatic cholestasis of pregnancy, while not associated with any primary skin lesions, is currently accepted as one of the dermatoses of pregnancy. The most common skin disorder in pregnancy is atopic eruption of pregnancy. Pruritus represents a significant symptom in all four dermatoses. Differentiating among these entities, especially in their early stages, may pose a significant diagnostic challenge, requiring excluding each of the dermatoses methodically. Though not included in the current classification, impetigo herpetiformis (IH), a variant of pustular psoriasis, is frequently discussed together with dermatoses of pregnancy, considered by some as the fifth dermatosis of pregnancy. Table 45.1 provides a summary and classification of the dermatoses of pregnancy. Multidisciplinary management involving a dermatologist expert in dermatologic conditions in pregnancy is of paramount importance.
Effect of the increase rate of blood lipid concentration during pregnancy on the adverse pregnancy outcomes: a cohort study of 1051 singleton pregnancy
Published in Gynecological Endocrinology, 2022
Xiaoping Yu, Jinfeng Gao, Yan Huang, Yufei Zou, Ying Huang, Tao Du, Ju Zhang
The study showed that the TG concentration in pregnant women with GDM, hypertension during pregnancy, and LGA in the early and late trimesters was higher than those in non-patients, and blood lipid concentration was generally higher among pregnant women with complications during pregnancy. It suggested that blood lipid concentration during pregnancy was associated with various pregnancy complications. A previous study has reported the risk of GDM in the high TG group in the first trimester is 3.86 times that of the low TG group [14]. Other studies have also shown that TG in the first, second, and third trimesters of pregnancy is closely related to GDM and hypertension in pregnancy; TC, HDL-C, and LDL-C in the third trimester are closely related to the risk of intrahepatic cholestasis of pregnancy [5]. Unlike other adverse pregnancy outcomes, the pathogenesis of intrahepatic cholestasis of pregnancy is unclear. Moreover, there is no unified international opinion on diagnosis and treatment, and it is difficult to implement effective preventive measures. It is helpful to play an early warning role through the correlation study of other biochemical examination indexes. In addition, Wu et al. [15] demonstrated that the TG concentration in the second trimester of non-advanced pregnant women aged 20–34 are also related to the occurrence of premature babies.
Recognizing skin conditions in patients with cirrhosis: a narrative review
Published in Annals of Medicine, 2022
Ying Liu, Yunyu Zhao, Xu Gao, Jiashu Liu, Fanpu Ji, Yao-Chun Hsu, Zhengxiao Li, Mindie H. Nguyen
Pruritus is a sensation that induces persistent or intermittent itching and involuntary scratching. It can affect the whole body or be confined to the limbs, especially the footplate and palm, where more intensive itchiness may occur. It is one of the most common skin abnormalities that occur in liver disease, particularly in patients with cholestatic liver disease. As a frequent concomitant symptom without visible lesions of liver cirrhosis, pruritus is usually linked to cholestasis in PBC, primary sclerosing cholangitis, obstructive gallstone disease and carcinoma of the bile duct. It can also be the most prominent symptom in certain pregnancy-associated liver conditions such as intrahepatic cholestasis of pregnancy [60]. Viral hepatitis-related cirrhosis can lead to intense pruritus, accompanied by solid crusty nodules, which are called prurigo nodularis (Figure 3(d)). Usually distributed in the extremities, especially between the knee and ankle and forearm, the lesion is associated with the topical deposition of an immune complex consisting of HBV/HCV in the skin [1]. Data from a large cohort of patients with chronic liver disease (n = 1631) suggest that the overall prevalence of pruritus was about 40% overall, higher among those with cirrhosis and as high as 50% in those with PBC and 60% in those with autoimmune overlap syndrome [61].
Outcomes of subsequent pregnancies in patients following treatment of cesarean scar pregnancy with high intensity focused ultrasound followed by ultrasound-guided dilation and curettage
Published in International Journal of Hyperthermia, 2019
Cai Zhang, Yuqi Zhang, Jia He, Lian Zhang
All patients were followed-up for at least 18 months. As shown in Figure 3, among the 154 patients treated, 28 patients attempted to conceive following treatment, whereas the rest had no desire for future pregnancy. At the end of the follow-up period, 23 out of those 28 patients (82.14%) conceived. The average interval between conception and HIFU treatment was 18.38 ± 10.04 months. Among these pregnancies, 18 (64.29%) were intrauterine, 3 (10.71%) were tubal, and 2 (7.14%) were recurrent CSPs (Table 3). Of the18 patients with intrauterine pregnancy, 13 women chose to continue with the pregnancy, whereas the other 5 women chose induced abortion. Of the 13 patients who decided to continue with their pregnancies, one had mild anemia and another had intrahepatic cholestasis during pregnancy. Twelve of them underwent cesarean delivery at terms (≥37 weeks), and 1 has a non-going pregnancy at the time of this paper’s writing. The 12 newborn babies were healthy; all of them had an Apgar score of 10 both 1 min and 5 min after birth. The average weight of the newborns was 3225.00 ± 235.00 g (Table 4). No complications occurred. The three patients with tubal ectopic pregnancies and the two patients with recurrent CSPs had accepted laparoscopic excision of the ectopic lesion within the first trimester.