Intrahepatic cholestasis of pregnancy: changes in maternal-fetal bile acid balance and improvement by ursodeoxycholic acid

Intrahepatic cholestasis of pregnancy (ICP) is a disease characterized by generalized pruritus and biochemical cholestasis that appears typically during the last trimester of gestation. The most predictive and accurate markers for diagnosis and follow-up of ICP are increased total bile acid levels (above 11,0 micromol/L), enhanced cholic acid percentage (above 42%) and decreased glycine/taurine bile acid ratio (below 1.0). Although essentially benign for the mother, evidence associates ICP with fetal poor prognosis resulting from increased transfer of bile acids from mother to fetus, who showed reduced ability to eliminate bile acids across the placenta. Those conditions lead to an accumulation of bile acids in the cord blood serum, meconium and amniotic fluid that may account for a diminished fetal well-being and sudden intra-uterine death by ICP. Ursodeoxycholic acid (UDCA) treatment was shown to reduce the bile acid content in the fetal compartment, while restoring the ability of the placenta to carry out vectorial transfer of these compounds towards the mother, decreasing bile acid levels in maternal serum and its passage to the fetus. In addition, UDCA administered to the mother also lowers the amount of bile acids present in colostrum without either increasing the UDCA concentration or causing major changes in lithocholic acid levels, further supporting the safety of UDCA in late pregnancy. Therefore, it is tempting to indicate UDCA as a first choice therapy for ICP as much as relevant aspects of fetal outcome may also be improved. This review focuses on the altered bile acid profiles in maternal and fetal compartments during ICP and its recovery by UDCA administration. Further elucidation of the precise mechanisms of action of UDCA and its therapeutic potential in improving fetal prognosis could result in the approval of UDCA for ICP treatment.     

Prenatal ultrasound diagnosis of clubfoot

Five cases of congenital clubfoot diagnosed prenatally by ultrasound are reported. The incidence of clubfoot may be higher within an affected family and may be associated with other structural anomalies or chromosomal abnormalities. Identifying a clubfoot in utero should therefore alert the sonographer that other anomalies may be present and should lead to a detailed structural survey.     

Bilirubin toxicity to human erythrocytes: a review

Neonatal jaundice, a physiologic condition reflecting the interplay between developmentally modulated changes in bilirubin production and metabolism, affects virtually all newborn infants. Usually, it is an entirely benign process that is resolved at the end of the first week of life without treatment or sequelae. However, in a small percentage of neonates, unconjugated hyperbilirubinemia can pose a neurotoxic risk especially in the presence of aggravating conditions such as a diminished albumin binding capacity and/or affinity, acidosis, displacing drugs and prematurity. Although neuronal cells are considered the main target for unconjugated bilirubin (UCB) toxicity, circulating cells are also affected during neonatal hyperbilirubinemia. Moreover, the UCB ability to cause hemolysis shall further aggravate neonatal jaundice through a vicious circle. In this review, we summarize the most relevant data obtained by our group regarding UCB toxicity and the role of some risk factors for kernicterus. In order to improve the risk assessment of neurotoxicity it is essential to understand the underlying mechanisms of UCB pathophysiology.