morphine and Cholestasis--Intrahepatic

To study the nature and clinical outcome of pregnancies with obstetric cholestasis on active management and to correlate perinatal outcome to gestational age at delivery.. This prospective randomized study included 69 women with obstetric cholestasis. Fetal surveillance began at 34 weeks or later at diagnosis and included daily maternal record of fetal movements, and biophysical profile (i.e. non stress test, the four quadrant amniotic fluid index). Fetal monitoring was conducted weekly before 36 weeks and biweekly after that. Randomization into two groups was done where one group was planned for delivery at 37 weeks whereas in the other group, pregnancy was carried to 38 weeks under surveillance. The primary outcome variable was correlation of fetal and neonatal complication rates to gestational age at delivery.. There were no stillbirths in the study. No episode of fetal asphyxia or bradycardia was observed. The overall rate of meconium passage was 7.46% (5/67). However, there was no case of meconium aspiration syndrome. Women delivering at or after 38 weeks had a lower incidence of cesarean section (17.85% vs 25.8%), neonatal nursery admission (17.85% vs 22.5%), and neonatal jaundice (17.85% vs 19.35%) compared to those delivering at 37 weeks. The differences between the two groups were, however, not found to be statistically significant.. The current study demonstrates that with active intervention, pregnancies with obstetric cholestasis can be carried to a later gestation under surveillance.

Topics: Adult; Cesarean Section; Cholestasis, Intrahepatic; Female; Humans; India; Infant, Newborn; Infant, Newborn, Diseases; Meconium; Obstetric Labor Complications; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Risk

The objective of this study is to determine factors associated with poor outcomes and the need for surgical treatment in neonates with meconium peritonitis (MP).. We evaluated the association between prenatal ultrasound features, maternal characteristics, and the likelihood of surgery, mortality, and serious morbidity in 49 neonates with a prenatal diagnosis of MP, who were born in Guangzhou Women and Children's Medical Center between January 2011 and December 2016.. Thirty of 49 neonates (61.2%) required surgical treatment, and 17 (34.7%) had a poor outcome. Independent predictors of need for surgical treatment were polyhydramnios, maternal intrahepatic cholestasis of pregnancy (associated with lower risk), and persistence of peritoneal fluid. The model correctly predicted 70.0% of the neonates who required surgery (at a 10% false-positive rate; area under the curve [AUC]: 0.86 [95% CI, 0.75-0.97]). For poor outcomes, independent predictors were low gestational age at birth, persistence of peritoneal fluid, and polyhydramnios. For the latter, the model only achieved a detection rate of 52.9% (10% false-positive rate, AUC: 0.82 [95% CI, 0.70-0.94]).. A combination of prenatal ultrasound features and maternal characteristics correctly predicted 70.0% the need for neonatal surgery. Prediction of poor outcome-based prenatal ultrasound features and gestational age did not perform well.

Topics: Adult; Cesarean Section; China; Cholestasis, Intrahepatic; Female; Gestational Age; Humans; Infant, Newborn; Male; Meconium; Peritonitis; Pregnancy; Pregnancy Complications; Retrospective Studies; Treatment Outcome; Ultrasonography, Prenatal

To identify laboratory data that correlates with poor perinatal outcomes.. A retrospective chart review of women with intrahepatic cholestasis of pregnancy (ICP), admitted for delivery between January 1, 2013 and December 31, 2017, was performed. Chi-square, student's t-test, and ANOVA statistical analysis was performed. The receiver-operator characteristic curves were plotted for the prediction of each category of perinatal outcome and the areas under the curves were determined. All p-values were two-sided, and p < 0.05 was considered statistically significant.. Analysis of the 61 ICP cases showed no occurrence of the intrauterine fetal demise (IUFD), stillbirth, abruption, or neonatal demise. ROC curve analysis revealed a statistically significant correlation between bile acid and AST levels and perinatal outcomes. A bile acid (BA) level equal to or greater than 37μmol/L strongly predicted spontaneous preterm labor in women affected by ICP with a sensitivity of 100% and specificity of 60.70% (p = 0.002). A BA level equal to or greater than 42μmol/L strongly predicted meconium-stained amniotic fluid with a sensitivity of 85.70% and specificity of 66.70% (p = 0.006). AST levels equal to or greater than 62 IU/L strongly predicted NICU admission with a sensitivity of 81.30% and specificity of 62.20% (p = 0.002). AST levels equal to or greater than 75 IU/L strongly predicted hyperbilirubinemia in the neonates with a sensitivity of 87.50% and specificity of 69.80% (p = 0.001).. There is a statistically significant correlation between elevated BA and elevated AST levels and adverse perinatal outcomes.

Topics: Adult; Amniotic Fluid; Aspartate Aminotransferases; Bile Acids and Salts; Cholestasis, Intrahepatic; Female; Hospitalization; Humans; Infant, Newborn; Intensive Care Units, Neonatal; Liver Function Tests; Meconium; Obstetric Labor, Premature; Predictive Value of Tests; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Prognosis; Specimen Handling

Intrahepatic cholestasis of pregnancy (ICP) is the commonest gestational liver disease. The risk of adverse fetal outcome has been associated with the severity of maternal hypercholanemia after diagnosis.. To investigate whether there is a relationship between the severity and timing of onset of hypercholanemia and the risk of meconium-stained amniotic fluid (MSAF) and adverse neonatal events.. The study included 382 pregnancies complicated by ICP managed at a referral hospital in Buenos Aires (Argentina) between June 2009 and December 2013. The patients were classified into three groups according to the severity of hypercholanemia at diagnosis; mild (10-19.9 μmol/L), moderate (20-39.9 μmol/L) and severe (≥40 μmol/L). Their clinical characteristics and pregnancy outcomes were investigated in a prospective observational study.. Higher risk of MSAF was observed when ICP appeared early in gestation or when hypercholanemia was more severe. Taking both parameters into account an MSAF risk factor (MRF) was defined. Based on a model of positive/negative predictive values, a cut-off point of MRF = 3 was selected, which prioritized sensitivity versus specificity. In ICP patients with MRF>3, the probability of MSAF was enhanced 4-fold. An increase in the frequency of MSAF was also associated with higher serum levels at diagnosis of alanine transaminase, alkaline phosphatase and direct bilirubin.. The risk of MSAF is associated not only with the magnitude of hypercholanemia at diagnosis but also with the early gestational onset of raised maternal serum bile acids.

Topics: Alanine Transaminase; Alkaline Phosphatase; Amniotic Fluid; Bilirubin; Cholestasis, Intrahepatic; Female; Humans; Infant, Newborn; Male; Meconium; Pregnancy; Pregnancy Complications; Risk Factors; Severity of Illness Index; Time Factors; Young Adult

Meconium-stained amniotic fluid (MSAF) is rarely observed in preterm pregnancies, and its clinical significance is undetermined. We evaluated the correlation between MSAF and obstetrical and perinatal complications prior to 34 weeks' gestation.. Pregnancies complicated with MSAF between 24 and 34 weeks of gestation were compared with same gestational age-matched controls. The variables measured were: obstetrical complications: clinical chorioamnionitis, Intrahepatic Cohlestasis of Pregnancy - ICP, Intra Uterine Growth Restriction - IUGR, preeclampsia, gestational diabetes; nonobstetrical complications; and perinatal complications: cord around neck/body, Apgar <7 at 5 min, cord pH, Neonatal Intensive Care Unit - NICU admission, complications during NICU hospitalization, and composite outcome.. Higher incidence of clinical chorioamnionitis (15% versus 4.3%; p = 0.041) and higher incidence of cord around the neck/body were found in the MSAF group in comparison with the clear AF group (27.4% versus 18.4%; p = 0.04). No significant differences between the study's groups were found in nonobstetrical complications or other perinatal complications investigated in our study.. MSAF in preterm pregnancy is an ominous sign for the occurrence of chorioamnionitis and for in utero cord compression. Therefore, MSAF in preterm pregnancies should be considered as a non-reassuring sign.

Topics: Adult; Amniotic Fluid; Biomarkers; Case-Control Studies; Cholestasis, Intrahepatic; Chorioamnionitis; Constriction; Female; Gestational Age; Humans; Infant, Newborn; Infant, Premature; Intensive Care Units, Neonatal; Male; Meconium; Nuchal Cord; Pregnancy; Pregnancy Complications; Retrospective Studies; Risk Factors; Umbilical Cord

To establish a prediction model of fetal meconium-stained amniotic fluid in re-pregnant women with intrahepatic cholestasis of pregnancy (ICP).. Clinical data of 180 re-pregnant women with ICP delivering in Women's Hospital, Zhejiang University School of Medicine between January 2009 to August 2014 were collected. An artificial neural network model (ANN) for risk evaluation of fetal meconium-stained fluid was established and assessed.. The sensitivity, specificity and accuracy of ANN for predicting fetal meconium-stained fluid were 68.0%, 85.0% and 80.3%, respectively. The risk factors with effect weight >10% were pregnancy complications, serum cholyglycine level,maternal age.. The established ANN model can be used for predicting fetal meconium-stained amniotic fluid in re-pregnant women with ICP.

Topics: Amniotic Fluid; Cholestasis, Intrahepatic; Female; Fetus; Humans; Infant, Newborn; Meconium; Neural Networks, Computer; Pregnancy; Pregnancy Complications; Sensitivity and Specificity

Our objective was to examine whether delivery at 37 weeks of gestation alters adverse pregnancy outcomes in Latina patients with intrahepatic cholestasis of pregnancy (ICP). We conducted a retrospective chart review of Latina patients who delivered at our institution coded with ICP between 2000 and 2007. During this time period it was our practice to offer delivery to patients with ICP at 37 weeks of gestation. Subjects were classified into three groups according to total bile acid (TBA) concentration: < 20 micromol/L (mild ICP), > or = 20 micromol/L and < 40 micromol/L (moderate ICP), and > or = 40 micromol/L (severe ICP). Meconium passage was observed in no births in patients with mild IC, but was found in 18% of deliveries with moderate/severe ICP. The risk of meconium passage increased linearly, with a 19.7% increased risk for each 10 mumol/L increase in TBA concentration ( P = 0.001). There was no association with higher TBA concentration and other adverse outcomes. There was no difference in adverse outcomes between moderate and severe ICP. We concluded that in our Latina population with ICP, an association existed between meconium passage and moderate/severe ICP. Delivering at 37 weeks was associated with a low risk of adverse outcomes due to ICP among all patients, including those with higher TBA concentrations.

Topics: Adult; Bile Acids and Salts; Cholestasis, Intrahepatic; Cross-Sectional Studies; Female; Hispanic or Latino; Humans; Infant, Newborn; Los Angeles; Meconium; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Retrospective Studies

Obstetric cholestasis is associated with maternal morbidity and adverse foetal outcomes. No information on local incidence is available. We present our experience with eight consecutive cases of obstetric cholestasis diagnosed between January 2003 and December 2005 in a regional hospital in Hong Kong. Three patients presented with pruritus without rash, three with impaired liver function, and two with elevated blood pressure postpartum. Meconium-stained liquor was present in five patients and four had spontaneous preterm delivery (between 34 and 36 weeks). The higher the bile acid level, the more marked the prematurity (correlation coefficient, -0.771; P=0.025). All those presenting with itchiness delivered preterm. Two patients developed pre-eclampsia. The rates of labour induction and abdominal delivery were both 38%. Heightened awareness among clinicians is required to recognise patients with obstetric cholestasis. Affected pregnancies are associated with meconium passage and prematurity. In our locality, affected women may also have an increased risk of pre-eclampsia. In affected women, the bile acid level is useful in assessing the risk of prematurity.

Topics: Adult; Bile Acids and Salts; Cesarean Section; Cholestasis, Intrahepatic; Female; Hong Kong; Hospitals; Humans; Hypertension; Incidence; Infant, Newborn; Liver Function Tests; Meconium; Obstetric Labor, Premature; Postpartum Period; Pre-Eclampsia; Pregnancy; Pregnancy Complications; Premature Birth; Pruritus

Conservative management of intrahepatic obstetric cholestasis is associated with a high stillbirth rate despite monitoring of fetal well-being with non-stress test and amniotic fluid volume assessment. Most cases of stillbirth are associated with meconium passage. We prospectively evaluated the effect of a management protocol inclusive of surveillance for presence of meconium and induction of labor at 37 weeks.. Between January 1989 and December 1997, all women with obstetric cholestasis underwent transcervical amnioscopy after 36 weeks for assessment of amniotic fluid color, in addition to standard monitoring of fetal well-being (semi-weekly non-stress test and amniotic fluid volume determinations). Amniocentesis for fetal lung maturity and amniotic fluid color assessment was performed before 36 weeks in severe cases. Labor was induced at 37 weeks or earlier in the presence of non-reassuring fetal testing, meconium, or severe maternal symptoms unresponsive to therapy with mature fetal lungs. The obstetric outcome of the group with cholestasis was compared with that of the general obstetric population at our Institution during the study period. The rate of fetal death in the study group was compared with that of series published within the last 20 years, which used expectancy and conventional monitoring of fetal well-being. Statistical analysis utilized Fisher's exact test, Chi-square, and Student's t-test with P value <0.05 or an odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant.. Obstetric cholestasis was diagnosed in 206/20,815 pregnant women (1%) at a median gestational age of 34 weeks (range 20-40). Delivery was prompted by non-reassuring fetal testing in four cases (2%). Meconium passage was documented in 33 cases (16%), in 11 of which before onset of labor and in 10 before 37 weeks. The rate of meconium passage before 37 weeks (17.9 versus 2.9%, OR=7.3; 95% CI 3.3, 16.0) was significantly higher in obstetric cholestasis than in the general obstetric population, whereas the cesarean section rate was similar in the two groups (15.1 versus 16.0%, OR=0.9; 95% CI 0.6, 1.4). The fetal death rate was significantly lower in the group managed with the current strategy than in the published series of obstetric cholestasis (0/218 versus 14/888, P=0.045).. In pregnancies complicated by obstetric cholestasis, a protocol inclusive of search for meconium and elective delivery at 37 weeks, in addition to standard monitoring of fetal well-being, can significantly reduce the stillbirth rate without increasing the cesarean delivery rate.

Topics: Adult; Alanine Transaminase; Amniotic Fluid; Aspartate Aminotransferases; Bile Acids and Salts; Bilirubin; Cholagogues and Choleretics; Cholestasis, Intrahepatic; Cholestyramine Resin; Female; Fetal Death; Fetal Monitoring; Fetoscopy; Gestational Age; Humans; Labor, Induced; Meconium; Middle Aged; Odds Ratio; Pregnancy; Pregnancy Complications; S-Adenosylmethionine; Ursodeoxycholic Acid

Data on meconium bile acid composition in newborn babies of patients with intrahepatic cholestasis of pregnancy (ICP) are relatively scant, and changes that occur on ursodeoxycholic acid (UDCA) administration have not been evaluated.. To investigate bile acid profiles in meconium of neonates from untreated and UDCA treated patients with ICP. Maternal serum bile acid composition was also analysed both at diagnosis and delivery to determine whether this influences the concentration and proportion of bile acids in the meconium.. The population included eight healthy pregnant women and 16 patients with ICP, nine of which received UDCA (12.5-15.0 mg/kg body weight/day) for 15+/-4 days until parturition. Bile acids were assessed in the meconium by gas chromatography-mass spectrometry and in maternal serum by high performance liquid chromatography.. Total bile acid and cholic acid concentrations in the meconium were increased (p<0.01) in newborns from patients with ICP (13.5 (5.1) and 8.4 (4.1) micromol/g respectively; mean (SEM)) as compared with controls (2.0 (0.5) and 0.8 (0.3) micromol/g respectively), reflecting the total bile acid and cholic acid levels in the maternal serum (r = 0.85 and r = 0.84, p<0.01). After UDCA administration, total bile acid concentrations decreased in the mother ( approximately 3-fold, p<0. 05) but not in the meconium. UDCA concentration in the meconium showed only a 2-fold increase after treatment, despite the much greater increase in the maternal serum (p<0.01). Lithocholic acid concentration in the meconium was not increased by UDCA treatment.. UDCA administration does not influence the concentration and proportion of bile acids in the meconium, which in turn are altered by ICP. Moreover, this beneficial treatment for the mother does not increase meconium levels of potentially toxic metabolites of UDCA such as lithocholic acid.

Topics: Bile Acids and Salts; Cholagogues and Choleretics; Cholestasis, Intrahepatic; Cholic Acid; Female; Humans; Infant, Newborn; Maternal-Fetal Exchange; Meconium; Pregnancy; Pregnancy Complications; Ursodeoxycholic Acid

The sensitivity of meconium stain in amniotic fluid for prediction of fetal well-being in intrahepatic cholestasis of pregnancy(ICP) was evaluated. The study consisted of an ICP group(n = 30), and a control group (n = 30) and the umbilical arterial pH value(< 7.2) was used as a standard. The positive and negative predicttive valus of meconium-stained amniotic fluid in ICP group were 80.0%; the positive and negative predictive values in control group were 60.0% and 92.0% respectively. There was no significant difference (P > 0.05) between the two groups in positive and negative predictive values. However, the positive and negative predictive values of the two groups were high, which indicated that meconium-stained amniotic fluid related to fetal hypoxia. Moreover, the incidence of meconium-stained amniotic fluid in ICP was higher than that in control (40.0%: 16.70%, P < 0.05). Therefore, we suggest that the amniotic fluid of patients with ICP should be observed very closely. When meconium-stained amniotic fluid is discovered, delivery by cesarean section is imminent.

Topics: Adult; Amniotic Fluid; Cholestasis, Intrahepatic; Female; Fetal Blood; Fetal Hypoxia; Fetal Monitoring; Humans; Hydrogen-Ion Concentration; Meconium; Pregnancy; Pregnancy Complications; Prospective Studies

1. We studied 202 pregnant women who were porter of pregnancy intrahepatic cholestasis (CIE). They were attended at the High Risk Fetus Unity (FAR) at the Hospital Salvador Maternity. They were compared with a control group that was composed by 404 patients with normal pregnancy. 2. The patients with CIE presented three times more risk of having a newborn infant of preterm than the other group (p < 0.01) omitting the cesarean factor. 3. The patients with CIE but without an associated pathology, also didn't present a greater risk of having a newborn infant of below weight (< 2,500 g) neither a newborn infant with Apgar 1' > 7, at any gestational age and any way of delivery, than the control group. 4. The risk of having meconium is three times greater in the patients with CIE. This risk increases (Odds ratio = 4.87 with p < 0.01) when they present an associated pathology. 5. Analyzing separately the group of patients with CIE and meconium and comparing with the control group, we didn't find any difference between both groups in relation with the risk of below weight (< 2,500 g), Apgar 1' < 7 and strangely preterm delivery. 6. The presence of meconium in patients with CIE and without an associated pathology, disposing adequate monitoring of pregnancy and delivery, is postulate that it isn't in relation with bad new born infant prognostic.

Topics: Case-Control Studies; Chi-Square Distribution; Chile; Cholestasis, Intrahepatic; Confidence Intervals; Female; Humans; Infant, Newborn; Infant, Premature; Meconium; Odds Ratio; Pregnancy; Pregnancy Complications; Retrospective Studies; Risk Factors

Topics: Child; Chlorides; Cholestasis, Intrahepatic; Humans; Infant, Newborn; Infant, Newborn, Diseases; Male; Meconium; Peritonitis; Sweat; Syndrome

Topics: Amniotic Fluid; Apgar Score; Cholestasis, Intrahepatic; Estriol; Female; Humans; Infant, Low Birth Weight; Infant, Newborn; Meconium; Obstetric Labor Complications; Pregnancy; Pregnancy Complications; Risk