Bhuvan Pathak

Cholestasis of Pregnancy

Intrahepatic cholestasis (ICP) of pregnancy is a disease that is likely multifactorial in etiology and has a prevalence that varies by geography and ethnicity. The diagnosis is made when patients have a combination of pruritus and abnormal liver-function tests. It is associated with a high risk for adverse perinatal outcome, including preterm birth, meconium passage, and fetal death. As of yet, the cause for fetal death is unknown. Because fetal deaths caused by ICP appear to occur predominantly after 37 weeks, it is suggested to offer delivery at approximately 37 weeks. Ursodeoxycholic acid appears to be the most effective medication to improve maternal pruritus and liver-function tests; however, there is no medication to date that has been shown to reduce the risk for fetal death.

Pregnancy outcomes during an era of aggressive management for intrahepatic cholestasis of pregnancy.

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.

Sudden Fetal Death in Intrahepatic Cholestasis of Pregnancy

BACKGROUND: Intrahepatic cholestasis of pregnancy is associated with an increased risk of fetal death. The mechanism of death is unknown. CASES: The first case involved a young primipara with pruritus and a bile acid concentration of 79 &mgr;mol/dL. While undergoing fetal heart rate monitoring, the fetus had a prolonged deceleration resulting in intrauterine death. The second case involved a young multipara with cholestasis who received ursodeoxycholic acid. Her bile acid concentration improved to13 &mgr;mol/dL. At 34 weeks of gestation, she had uterine contractions with prolonged decelerations resulting in delivery of her fetus with Apgar scores of 0, 0, and 5 at 1, 5, and 10 minutes, respectively. CONCLUSION: Fetal death from intrahepatic cholestasis of pregnancy can be abrupt and not reliably predicted by the characteristics of the fetal heart rate tracing.

The mechanical PR interval in fetuses of women with intrahepatic cholestasis of pregnancy

OBJECTIVE The purpose of this study was to evaluate the fetal mechanical PR interval in intrahepatic cholestasis of pregnancy (ICP). STUDY DESIGN Fetal echocardiography was performed for women with ICP and control subjects. Clinical characteristics, total bile acids, and liver profile tests were compared between groups. RESULTS Fourteen women with ICP and 7 control subjects were enrolled. Total bile acids (28.3 vs 6.2 μmol/L; P < .001), aspartate aminotransferase (53 vs 23 IU/L; P = .002), alanine aminotransferase (63 vs 19 IU/L; P = .002), and the PR interval (124 vs 110 msec; P = .006) were significantly higher in fetuses with ICP than in control fetuses. On multivariable linear regression analysis, only the presence of ICP was associated significantly with an increase in the PR interval (95% confidence interval, 4-24 msec; P = .01). CONCLUSION The fetal cardiac conduction system is altered in ICP. Further investigation is needed to determine whether fetal echocardiography can help to predict which fetuses are at risk for death that is associated with ICP.

Amniopatch as a Treatment for Rupture of Membranes following Laser Surgery for Twin-Twin Transfusion Syndrome

Objective: The risk of iatrogenic rupture of membranes (IROM) is 5–30% after operative fetoscopy. The aim of this study was to describe outcomes of patients with IROM following selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS) who were subsequently treated with amniopatch therapy. Methods: A review of patients who underwent treatment for mid-trimester TTTS between March 2006 and February 2008 with IROM within 7 days of SLPCV was performed. IROM patients without evidence of preterm labor or chorioamnionitis were offered expectant management, pregnancy termination, or amniopatch therapy. Results: Ninety-three patients were treated with SLPCV, of which three (3.2%) had IROM within 7 days. All three opted for amniopatch therapy which was performed at 18 2/7, 23 1/7, and 22 6/7 weeks’ gestation in patients 1, 2 and 3, respectively. In patients 1 and 2, amniopatch therapy sealed membranes within 7 days. A second amniopatch was required for patient 3 before IROM resolved. Gestational ages at delivery were 38 2/7, 37 5/7 and 30 2/7 weeks, respectively. Conclusion: Amniopatch is a viable treatment option for iatrogenic ROM following SLPCV.

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

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. Fishers exact, &khgr;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). Table 1 Characteristics. Between Severe Intrahepatic Cholestasis of Pregnancy (Total Bile Acids 40 Micromoles/L or Greater) Compared With Mild Intrahepatic Cholestasis Of Pregnancy (Sheibani, p. 78-9S) Table 2 Outcomes Between Severe Intrahepatic Cholestasis of Pregnancy (Total Bile Acids 40 Micromoles/L or Greater) Compared With Mild Intrahepatic Cholestasis of Pregnancy (Sheibani, p. 78-9S) CONCLUSION: When compared with patients with mild intrahepatic cholestasis of pregnancy, those with severe intrahepatic cholestasis of pregnancy did not have a higher risk of fetal heart rate decelerations. This supports previous findings that fetal demise in the setting of intrahepatic cholestasis of pregnancy is a sudden event that can occur with previously normal antenatal testing.

Postoperative Middle Cerebral Artery Peak Systolic Velocity Changes Confirm Physiological Principles of the Sequential Laser Technique for Twin-Twin Transfusion Syndrome

Introduction: Treatment of the twin-twin transfusion syndrome (TTTS) via sequential selective laser photocoagulation of communicating vessels (SQLPCV) mandates ablation of donor-to-recipient arteriovenous anastomoses first. It is hypothesized that SQLPCV facilitates intraoperative transfusion to the donor, thereby minimizing donor hypovolemia and anemia. We sought to determine if postoperative changes in fetal middle cerebral artery-peak systolic velocities (MCA-PSV) support this hypothesis. Materials and Methods: Patients undergoing preferential SQLPCV for TTTS had MCA-PSV measured 1 day before surgery and on postoperative day 1 (POD-1). Fetal anemia was defined as an MCA-PSV ≧1.5 multiples of the median (MoM). Exclusions included: POD-1 demise, missing MCA-PSV data, or gestational age <18 weeks. Results: Study criteria were met by 139 patients. Mean MCA-PSV in recipients increased from 0.97 to 1.15 MoM postoperatively (p < 0.0001). Donor mean MCA-PSV remained stable at 1.00 MoM preoperatively and 0.98 MoM postoperatively (p = 0.272). Nine fetuses, 6 donors and 3 recipients, had preoperative anemia; SQLPCV was not attempted in the 3 anemic recipients. Postoperatively, the proportion of donors with anemia remained stable (increase 3.6%, p = 0.419), and the proportion of recipients with anemia increased (increase 12.2%, p = 0.009). Discussion: Our findings confirm the presumed physiological basis for the SQLPCV treatment of TTTS.

Neonatal Outcomes by Mode of Delivery in Preterm Birth.

OBJECTIVE We set out to test the hypothesis that infants born vaginally at ≤ 30 weeks gestation have less respiratory distress syndrome (RDS) than those born by cesarean delivery. STUDY DESIGN We conducted a retrospective cohort study of 652 infants born between 24 and 30 (6/7) weeks gestation from March 31, 1996 to May 31, 2014. Comparisons of neonatal outcomes by intended and actual mode of delivery were made using chi-square and t-tests (α = 0.05). Multiple logistic regression was performed to control for confounding variables. RESULTS Neonates born by cesarean delivery were more likely to have RDS (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.10-2.90), require intubation (OR, 1.80; 95% CI, 1.12-2.88), and have longer neonatal intensive care unit stay (70.0 ± 37.1 vs. 57.3 ± 40.1 days, p = 0.02). CONCLUSION Compared with cesarean delivery, vaginal delivery is associated with a significant reduction in RDS among infants born at ≤ 30 weeks gestation.

Umbilical Artery Hypoplasia in Twin-Twin Transfusion Syndrome Complicated by Discordant Umbilical Artery Doppler Findings in the Donor Twin: A Diagnostic Dilemma

Fetal Doppler assessment is a useful tool in diagnosing and staging mono-chorionic twins complicated by twin-twin transfusion syndrome (TTTS). 1 Umbilical artery absent or reversed end-diastolic velocity (UA-AREDV) is a poor prognostic factor in TTTS 2 , 3 and is associated with increased risk of in utero fetal death of the donor twin. 4 The etiology of donor twin UA-AREDV has primarily been attributed to 2 placental factors: unequal individual placental territories and the presence of arterioarterial anastomoses. 5 However, umbilical artery (UA) hypoplasia, which can result in UA-AREDV, has not to our knowledge been reported in association with TTTS. We present a case with donor twin umbilical artery absent end-diastolic velocity (UA-AEDV) caused by a hypoplastic UA, with emphasis on the diagnostic and management challenges associated with discordant UA Doppler findings in the setting of TTTS.