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Intrahepatic Cholestasis of Pregnancy The Effect of Bile Acids on Fetal Heart Rate Tracings

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Intrahepatic Cholestasis of Pregnancy The Effect of Bile Acids on Fetal Heart Rate Tracings

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Abstract

INTRODUCTION: Fetal death from intrahepatic cholestasis of pregnancy can be a sudden event and is not reliably predicted by findings on fetal heart rate tracing. Our objective is to assess whether there are differences in antenatal testing and delivery outcomes between patients with severe compared with mild intrahepatic cholestasis of pregnancy. METHODS: This is a retrospective analysis on 87 patients with intrahepatic cholestasis of pregnancy who underwent antenatal testing and subsequent delivery at a single institution. Patients with severe intrahepatic cholestasis of pregnancy were defined as having total bile acids levels greater than 40 IU/mL, whereas those with mild intrahepatic cholestasis of pregnancy had total bile acids of less than 40 IU/mL. The primary outcome was the presence of decelerations in antenatal testing. Secondary outcomes included birth weight, delivery route, meconium, and neonatal intensive care admission. Fisher's exact, [chi]2, and Mann-Whitney U tests were used as indicated. RESULTS: Eighty-seven patients were identified; 20 had severe intrahepatic cholestasis of pregnancy, whereas 67 had mild intrahepatic cholestasis of pregnancy. The severe group had significantly higher median total bile acids (P=.001), alkaline phosphatase (P=.006), and aspartate and alanine aminotransferase levels (P=.001; Table 1). There were no differences between the two groups in fetal heart rate at baseline or presence of decelerations. Patients with severe intrahepatic cholestasis of pregnancy were older (33 [26.5-36] compared with 27.7 [22.25-32] years, P=.024). Cesarean delivery rate, meconium, and neonatal intensive care unit admission were not different ( Table 2).

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... Abnormal heart rate (≤100 or ≥180 bpm) is associated with an elevated risk in some studies, although cardiotocograph monitoring cannot reliably predict the risk of complications, and normal cardiotographs are observed within 24 h of intrauterine demise (10)(11)(12). Furthermore, fetal heart rate tracing does not correlate with disease severity (13). The results of a study using the fetal biophysical profile and obstetric Doppler examination findings were not conclusive, mainly because of the absence of fetal mortality and morbidity in that series (14). ...
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The aim of this study was to evaluate changes in fetal cardiac and peripheral circulation in pregnancies complicated with intrahepatic cholestasis. 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. 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. 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.
Article
Intrahepatic cholestasis of pregnancy (ICP) is the most frequent pregnancy-specific liver disease. It is characterized by pruritus and an accompanying elevation of serum bile acid concentrations and/or alanine aminotransferase (ALT), which are the key parameters in the diagnosis. Despite good maternal prognosis, elevated bile acid concentration in maternal blood is an influencing factor to advers fetal outcome. The ICP is associated with increased rates of preterm birth, neonatal unit admission and stillbirth. This is the result of acute fetal asphyxia as opposed to a chronic uteroplacental insufficiency. Reliable monitoring or predictive tools (e.g. cardiotocography (CTG) or ultrasound) that help to prevent advers events are yet to be explored. Medicinal treatment with ursodeoxycholic acid (UDCA) does not demonstrably reduce adverse perinatal outcomes but does improve pruritus and liver function test results. Bile acid concentrations and gestational age should be used as indications to determine delivery. There is a high risk of recurrence in subsequent pregnancies.
Article
Aim: Intrahepatic cholestasis of pregnancy (ICP) is reported to be associated with an increased risk of sudden fetal death. The possible mechanism is thought to be cardiac arrhythmia. Prolonged QT interval of the electrocardiogram (ECG) is associated with arrhytmogenic events. The aim of the study was to compare the fetal ECG QT interval during labor in pregnancies complicated with ICP to healthy controls. Methods: The fetal ECG and QT interval was reviewed retrospectively. The intrapartum QT interval was measured in 61 fetuses born to mothers with ICP and in a control group of similar size. The corrected QT interval (QTc) was calculated using Bazett's formula: QT/√RR. The occurrence of ST segment depression was also included in the analysis. Results: The groups were similar regarding to maternal age, parity, BMI, gestational age and smoking habits. The rate of labor induction was significantly higher in ICP patients (P < 0.001). The QTc at the beginning and the end of recording was analyzed and there were no significant differences in these values between the ICP patients and healthy controls (P = 0.467). Most ICP patients used ursodeoxycholic acid (UDCA) for mediation. We analyzed separately patients who had elevated liver enzymes before labor. No significant differences in the QTc were noted in these patients either. Nor were there any significant ST depressions in ICP patients. Conclusions: The etiology of adverse perinatal outcome and even sudden fetal death in ICP is still controversial. No differences in QTc intervals and ST waveforms during labor were found in our study material.
Article
Objective: The aim of our study was to investigate the predictors of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy (ICP) with dichorionic diamniotic (DCDA) twin pregnancies. Methods: This study was a retrospective study of women diagnosed with ICP and DCDA twin pregnancies in Chengdu’s women and children’s central hospital. These patients were subdivided into mild and severe ICP groups according to total bile acid (TBA) level. The clinical characteristics and perinatal outcomes were collected and compared between the two groups. Logistic regression analysis was developed to evaluate predictors of adverse perinatal outcomes. Results: About 134 cases were included in the study. Eighty-four cases were in the mild ICP group, and the other 50 cases were in the severe ICP group. Level of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), total bilirubin (TBIL), and direct bilirubin (DBIL) in the severe ICP group were significant higher than those in the mild ICP group. The rate of delivery before 34 gestational weeks, meconium-stained amniotic fluid, and composite adverse neonatal outcome were higher in the severe ICP group than those in the mild ICP group. After adjusting for confounders, ICP onset gestational age (GA) <30 weeks and AST >200U/l were associated with GA at delivery <34 weeks. ALP >400U/l was an independent risk factor of meconium-stained amniotic fluid. ICP onset GA <30 weeks was an independent risk factor of composite adverse neonatal outcome. Conclusion: ICP onset GA <30 weeks, TBA >40 µmol/l, AST >200U/l, and ALP >400U/l were associated with composite adverse perinatal outcomes in ICP with DCDA twin pregnancies. For those patients with these characteristics, fetal surveillance and treatment should be enhanced.
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