Intra-Hepatic Cholestasis of Pregnancy and Its Consequences: A Review

Background: The most common cause of liver illness in pregnancy is intrahepatic cholestasis (IHCP). It has a varying incidence due to geographic variance; factors such as advanced age, multiple pregnancy, family history, and previous pregnancy cholestasis have demonstrated a higher prevalence in these patients. Cholestasis in pregnancy has an aetiology that is currently unknown. It usually occurs after ovarian hyperstimulation syndrome in early pregnancy and coincides with growing oestrogen levels in the second half of pregnancy [1]. The ABCB4 gene mutation is largely associated in a subtype of progressive familial intrahepatic cholestasis, where disease clustering in first-degree relatives increases hereditary predisposition. Itchy palms and soles with elevated liver enzymes and bile acids are the most common symptoms. Some of the reported maternal problems in these patients include preterm labour, HELLP syndrome, acute fatty liver of pregnancy, and postpartum haemorrhage [2]. There are no precise antenatal foetal monitoring tests that can predict foetal fatalities in the womb. To reduce perinatal death with expectant treatment beyond this gestation, it is recommended that a pregnancy be terminated near 36–37 weeks of pregnancy.

The association between acute fatty liver disease and nitric oxide during malaria in pregnancy

Background Liver disease is a common feature of malaria in pregnancy, but its pathogenesis remains unclear. Methods To understand the pathogenesis of liver disease during malaria in pregnancy, comparative proteomic analysis of the liver in a mouse model of malaria in pregnancy was performed. Results Decreased levels of mitochondrial and peroxisomal proteins were observed in the livers of pregnant mice infected with the lethal rodent malaria parasite Plasmodium berghei strain NK65. By contrast, increased levels of perilipin-2, amyloid A-1, and interferon (IFN)-γ signalling pathway-related proteins were observed in the livers of infected pregnant mice, suggesting that IFN-γ signalling may contribute to the development of liver disease during malaria in pregnancy. IFN-γ signalling is a potential trigger of inducible nitric oxide synthase (iNOS) expression. Liver disease associated with microvesicular fatty infiltration and elevated liver enzymes in pregnant wild-type mice infected with malaria parasites was improved by iNOS deficiency. Conclusions In this study, a causative role of iNOS in liver disease associated with microvesicular fatty infiltration during malaria in pregnancy was demonstrated. These findings provide important insight for understanding the role of iNOS-mediated metabolic responses and the pathogenesis of high-risk liver diseases in pregnancy, such as acute fatty liver.

Clinical Characteristics and Prognostic Analysis of Pregnancy-Related Acute Kidney Injury

Objective: To investigate the clinical characteristics and prognosis of pregnancy-related acute kidney injury (PR-AKI) and provide a basis for improving maternal and infant outcomes. Methods: Seventy pregnant women admitted to the surgical intensive care unit of Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine from January 2010 to December 2020 were included; 31 were screened out according to KDIGO-AKI criteria. We retrospectively analyzed their clinical characteristics and prognosis and analyzed risk factors for different pregnancy outcomes with logistic regression analysis. Results: A total of 31 PR-AKI patients were enrolled. The mean age of onset was 30.08±0.63 years, and the mean gestational age was 33.02±7.64 weeks. Six cases (19.45%) were in stage 1, six cases (19.35%) were in stage 2, and 19 cases (61.29%) were in stage 3. The continuous renal replacement therapy (CRRT) group comprised 13 cases (41.94%): one (7.69%) in stage 1, one (7.69%) in stage 2, and 11 (84.62%) in stage 3. The non-CRRT group comprised 18 cases (58.06%): five (27.78%) in stage 1, five (27.78%) in stage 2, and eight (44.44%) in stage 3. The mean time of commencing renal replacement therapy was 2.08±1.26 days after admission, and the serum creatinine (SCr) level at the beginning of treatment was 352.68±196.58 μmol/L. Renal function recovered completely in 18 cases (58.06%), comprising four (22.22%) in the CRRT group and 14 (77.78%) in the non-CRRT group, and three cases of partial renal function recovery occurred in the CRRT group. Eventually, seven patients (22.58%) died, of whom four (57.14%) were in the non-CRRT group, and all were in stage 3. The causes of death were postpartum hemorrhage, septic shock, and acute fatty liver during pregnancy. Three patients (42.86%) died in the non-CRRT group: two in stage 3 and one case in stage 1. The causes of death were severe preeclampsia and acute fatty liver during pregnancy. Multi-factor logistic regression analysis showed that gestational weeks (OR=0.456, P=0.023), platelet count (OR=0.989, P=0.02), hemoglobin (OR=1.017, P=0.022), and uric acid (OR=1.017, P=0.022) were associated risk factors for maternal adverse pregnancy outcomes of PR-AKI (P<0.05). Conclusions: The incidence of PR-AKI is high, the outcomes of maternal renal function are better, and the proportion of adverse fetal outcomes is higher. CRRT can effectively improve the prognosis of patients with PR-AKI, stabilize the internal environment, and affect hemodynamics slightly. It is currently one of the main ways to treat severe PR-AKI. Maternal and infant outcomes are related to the severity of PR-AKI.