Sex Hormones and Bile Acids in IntrahepaticCholestasis of Pregnancy

See Article on Page 544

Fifty years ago, 2 clinical studies from Alvar Svan-borg and Leif Thorling, in Sweden, identified thefirst series of patients with the basic features of a

peculiar disease of pregnancy that had yet to be identifiedunder a standard name.1,2 The first papers were publishedin journals that were difficult to access, in an era when theInternet and PubMed were not even dreams. Index Me-dicus gave them an official recognition and then started achain of perseverant (sometimes inadvertent) research ef-forts that spread worldwide. Decades later, the topic hasgained recognition in the fields of hepatology and obstet-rics. It is difficult to trace this “new” disease before 1950or to define whether it corresponded with a case of recur-rent jaundice in late pregnancy (without a mention ofpruritus, that currently is considered a sine qua non symp-tom of the disease) that had been locally reported in 1882by F. Ahlfeld in Germany. Data collected in Europe,North America, Australia, New Zealand, and Chile delin-eate a disease with clinical and laboratory characteristicsthat can, at present, be considered diagnostic requisites(Table 1) (reviewed in Bacq et al.,3 Reyes et al.,4 Lammertet al.,5 and Arrese et al.6). Although some patients maydiffer slightly (for example, early onset in the second orfirst trimester), most characteristics should be fulfilled if aproper differential diagnosis is to be made, particularlywith an unsuspected underlying chronic liver disease thatwill become evident sometime after delivery.7-9 For clini-cal needs, such as for the selection of treatment, the sur-veillance of the fetal status, and eventually its activemanagement, the diagnosis of intrahepatic cholestasis ofpregnancy can certainly be made during the pruritic epi-sode before delivery, but for research purposes it is indis-pensable to have a follow-up to document a completeclinical and laboratory improvement after delivery.

The disease has been named “intrahepatic cholestasisof pregnancy” (ICP), or “obstetric cholestasis” in the Brit-ish Commonwealth. It has been diagnosed in differentethnic groups and geographic locations. The prevalenceranges from 1 case in 1000 to 1 case in 10,000 deliveries inNorth America, Asia, and Australia. Between 1950 and1980, a 10-fold to 100-fold higher prevalence had beenreported in Chile (particularly in the native southernAraucanian-admixed population) and in Sweden andother Baltic countries. After 1980, the prevalence of ICPhas markedly decreased in Chile and currently rangesfrom 1.5%-4% of all pregnancies. Changes in environ-mental factors have been proposed for this epidemiologi-cal phenomenon, supported also by the higher prevalenceof this disease in winter as has been observed in Chile,Finland, and Sweden.6 ICP may recur in 40%-70% ofsubsequent pregnancies, but no maternal mortality hasbeen attributed to it during pregnancy or after delivery.The only maternal consequences so far recognized are ahigher risk of developing cholestatic hepatitis if thewoman receives high doses of estrogens or progesterone innonpregnant periods, a higher prevalence of cholesterolgallstones, and the fact that episodes of ICP tend to coex-ist with urinary tract infections. In contrast, the babiesface a higher risk of fetal distress, with premature deliver-ies and even stillbirths. This is the main reason to searchfor therapeutic agents to improve the disease in the moth-ers: to improve the babies’ prognosis. In recent years, oraladministration of ursodeoxycholic acid (UDCA) has be-come the best alternative for both outcomes, mainly inpatients in whom the disease starts before week 35 ofpregnancy, those with hyperbilirubinemia, or those withhigh fasting serum total bile acids (�40 �mol/L).10-12

The cause of the disease remains unknown. Its patho-genesis has been connected with female sex hormones,either through abnormalities in synthesis and metabolismgenerating cholestatic compounds, or through an abnor-mal response to the physiologic overload of these hor-mones in pregnancy. A search for an abnormalmetabolism of female sex hormones has been a majorapproach, and the maternal liver has been the focus ofmost research efforts. But it should be kept in mind thatduring pregnancy the synthesis and metabolism of femalesex hormones is not limited to the maternal liver, ovaries,and adrenals: there is a bidirectional flux to the fetal pla-cental unit and the fetus also synthesizes hormonal com-pounds. In fact, about half of the progesterone

Abbreviations: CA, cholic acid; CDCA, chenodeoxycholic acid; DCA, deoxy-cholic acid; ICP, intrahepatic cholestasis of pregnancy; UDCA, ursodeoxycholicacid.

Address reprint requests to: Dr. Humberto Reyes, Departamento de MedicinaOriente, Facultad de Medicina, Universidad de Chile. Casilla 16038, Santiago deChile. E-mail: hreyes@med.uchile.cl; fax: (56) (2) 274 1628.

Copyright © 2008 by the American Association for the Study of Liver Diseases.Published online in Wiley InterScience (www.interscience.wiley.com).DOI 10.1002/hep.22139Potential conflict of interest: Nothing to report.

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metabolism occurs in extrahepatic sites. This gives rise toa large number of complex molecules whose identificationrequires sophisticated, expensive, and time-consumingtechniques that are currently out of the reach of clinicaldiagnostic laboratories.

Serum levels and urinary excretion of estrogens andtheir metabolites do not differ during ICP than in normalpregnancies at the same gestational age.4,5,13 However,multiple pregnancies (twins, triplets) that have a higherload of female sex hormones than singletons also have ahigher incidence of ICP. Changes in the metabolism ofestrogens could lead to retention of conjugated metabo-lites, mainly precursors of D-ring glucuronides that cancause cholestasis in rodents,14 but these metabolites havenot yet been related to cholestasis in humans.

In 1970, Jan and Karin Sjovall reported differences inprogesterone metabolism: patients with ICP have higherserum levels of sulfated metabolites of progesterone thanpatients with normal pregnancies.15 Other investigatorsfound similar changes in new studies. Twenty years later,L.J. Meng in Sjovall’s laboratory, by employing gas chro-matography and mass spectrometry to separate and mea-sure different bile acids and steroidal compounds inserum and urine, clarified that the synthesis of bile acidsappeared to be reduced in patients with ICP, probablydue to bile secretory failure and retention of bile acids inhepatocytes, resulting in their increase in serum andurine.16-18 In patients with ICP, fasting serum total bileacid concentration is typically higher than in healthypregnant women (�10 �mol/L). Primary bile acids are90% of total bile acids, and cholic acid (CA) becomes thepredominant primary bile acid in serum (80%) in con-trast with normal pregnant and nonpregnant women, inwhom its proportion is almost similar to chenodeoxy-cholic acid (CDCA). A low serum level of deoxycholic

acid (DCA, a secondary bile acid) reflects an impairedenterohepatic circulation with a low dehydroxylation ofCA by bacterial enzymes in the intestinal lumen. Treat-ment with UDCA in those patients decreased the totalconcentration of bile acids and also changed the propor-tion of conjugated bile acids (CA:CDCA:DCA) to valuessimilar to those in normal pregnancies.

These studies also revealed that in healthy pregnantwomen, monosulfated and disulfated progesterone me-tabolites are increased in serum, and most of them disap-pear about a week after delivery. But in ICP patients, thesemetabolites increase 4-fold to 10-fold more whereas glu-curonidated metabolites do not change, either by preg-nancy or ICP. The most significant and probably specificchange was the increased ratio of 3�- to 3�-hydroxys-teroid sulfates in serum. Giusti et al. reported that thesedifferences were not observed in pregnant patients withviral hepatitis, thus supporting a specific connection withICP.19

In ICP patients treated with UDCA (1 g/day for 3weeks), pruritus was ameliorated, standard serum livertests indicative of cholestasis improved, and the concen-tration of progesterone metabolites in blood and theirurinary excretion also tended to normalize. Sjovall et al.proposed that “patients with ICP have a selective defect inthe excretion of steroid metabolites into bile, affectingonly the excretion of sulphated steroids. These changesmay be corrected by the administration of UDCA”.4

Several abnormalities in the metabolism of female sexhormones may coexist and interact; therefore, a role ofestrogen metabolites is not excluded by these results. Fur-thermore, during enterohepatic circulation both proges-terone and estrogen metabolites may be transformed intocholestatic compounds. This could be exaggerated in pa-tients with ICP in whom an increased intestinal perme-ability (“leaky gut”) has been detected during and afterpregnancy.20

An experimental study by Vallejo et al. showed that aglucuronidate estrogen metabolite (estradiol 17�-D-glucuronide) and a sulfated progesterone metabolite (5�-pregnan-3�-ol-20-one sulfate) are both secreted into bile,and they reduce bile flow and bile acid output in isolatedperfused rat liver. These effects were not obtained by in-fusing the parent sulfated progesterone. Both metabolitesalso inhibited the bile salt export pump and impairedmitochondrial activity and bile acid efflux in frog oocytes,thus favoring intracellular toxicity of accumulated bileacids.21 A cholestatic effect of these metabolites in hu-mans has not yet been reported.

The recent study by Glantz et al. adds valuable infor-mation on the effects of UDCA in steroid hormones andtheir metabolites in patients with ICP.22 In a study of 40

Table 1. Cardinal Features for the Diagnosis of IntrahepaticCholestasis of Pregnancy

1. Pruritus “sine materia” appeared in late pregnancy, starting in the palmsand soles and then extended to other zones of the body surface.

2. Abnormal serum liver tests:● Alanine and/or aspartate aminotransferases 2-fold to 10-fold over normal(in all the patients).

● Fasting total bile salts �10 �mol/L (in all the patients).● Alkaline phosphatases (total) with variable increase.● Gamma-glutamyl transferase mildly increased (in 15% of patients).● Conjugated hyperbilirubinemia (in 10% of patients, with mild jaundice in afew of them).

3. Pruritus and the biochemical abnormalities persist during the remaining timeof pregnancy, with spontaneous fluctuations in severity.

4. Pruritus disappears after delivery and the biochemical abnormalities improveto normal values within 3 weeks.

5. No past history, physical signs, or biochemical, virologic, or autoimmuneabnormalities that could reveal other acute or chronic liver diseases.

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patients, they showed at baseline a typical increase in se-rum bile acids with �50% CA. The pattern of steroidhormone metabolites in urine was dominated by disul-fates of pregnanediols. In 13 patients randomized to re-ceive UDCA (1 g/day for 3 weeks), they observed asignificant fall in fasting total serum bile acids, starting at1 week, with an enrichment with isoUDCA (a main iso-mer of UDCA) and a significant reduction of CA andCDCA; urinary excretion of steroid hormone metabolitesalso diminished significantly. Pruritus was amelioratedsimultaneous to these metabolic changes. An importantcontribution of this study is that the improvement inpruritus correlated with the reduction in urinary excre-tion of pregnanediol disulfate, whereas pruritus did notcorrelate with changes in serum total bile acids or individ-ual CA or CDCA levels. The beneficial effects obtained byUDCA were significantly better than the minimalchanges obtained in 14 patients that received oral dexa-methasone (12 mg/day for 1 week). The authors also in-terpreted the pattern of progesterone metabolites in ICPas “most likely due to impaired hepatobiliary secretion ofspecific isomeric metabolites, which is improved by oraladministration of UDCA”. Minor differences with theresults reported by Meng et al. could be due to differentmethods used to identify isomers of progesterone metab-olites.16-18 Besides, Glantz et al. measured progesteronemetabolites only in urine whereas Meng and coworkersdid it in serum and urine samples obtained simulta-neously. The studies by Glantz and coworkers furtherstimulate research in membrane receptors and transport-ers of steroid hormones and their metabolites.

Hormonal and other metabolic factors that may beinvolved in the pathogenesis of ICP are becoming moreprecisely known, but their intimate action and the mech-anisms of the beneficial effect of UDCA are still hypothet-ical. Stimulated by findings in other different familialcholestatic disorders (mainly seen in childhood) somemutations have been proposed as causally related toICP.23-27 Nevertheless, the number of patients in whomthey have been found is quite small. It is also disturbingthat some patients in whom putative mutations have beendescribed do not fulfill the diagnostic requisites of a clas-sical case of ICP, and therefore, they may have differentdiseases unveiled by pregnancy. If a mutation were caus-ally related to ICP, it should be found in all or in a largeproportion of patients with an unequivocal phenotype.Homozygous patients would be expected to have a moresevere and recurrent disease, with familial clustering, thanthe heterozygous individuals; the mutation should be ab-sent or exceptional in proper control patients (multipa-rous women with several pregnancies not affected by ICP)and it should be present in different populations but with

a higher prevalence in ethnic groups where ICP is alsomore prevalent.

Clinical and epidemiological characteristics of ICPsupport the proposal that its pathogenesis is multifacto-rial: a genetic abnormality determines a susceptibility todevelop the disease while, simultaneously, environmentalfactors may influence the onset of the disease and modu-late its severity and its prevalence worldwide.

Acknowledgment: The author is grateful to ProfessorEmeritus Jan Sjovall, who pioneered research on steroidmetabolism in pregnant women and in patients with ICP,leading his group and stimulating others to follow a soundline of research. This editorial is dedicated, on his 81stbirthday, to Irwin Arias, Founding Editor of HEPATOL-OGY, a mentor and friend whose endless scientific andintellectual curiosity is a dreamt example to numerousformer Fellows in the international community.

HUMBERTO REYES, M.D.Department of Medicine (Eastern Campus) and Institute

of Biomedical SciencesUniversity of Chile School of MedicineSantiago de Chile

References1. Svanborg A. A study of recurrent jaundice of pregnancy. Acta Obstet

Gynecol Scand 1954;33:434-444.2. Thorling L. Jaundice in pregnancy. A clinical study. Acta Med Scand

1955;151(Suppl 302):1-119.3. Bacq Y, Sapey T, Brechot M-C, Pierre F, Fignon A, Dubois F. Intrahepatic

cholestasis of pregnancy: a French prospective study. HEPATOLOGY 1997;26:358-364.

4. Reyes H, Sjovall J. Bile acids and progesterone metabolites in intrahepaticcholestasis of pregnancy. Ann Med 2000;32:94-106.

5. Lammert F, Marschall H-U, Glantz A, Matern S. Intrahepatic cholestasisof pregnancy: molecular pathogenesis, diagnosis and management. J Hepa-tol 2000;33:1012-1021.

6. Arrese M, Reyes H. Intrahepatic cholestasis of pregnancy: a past andpresent riddle. Ann Hepatol 2006;5:202-205.

7. Engstrom J, Hellstrom K, Posse N, Sjovall J. Recurrent cholestasis ofpregnancy. Treatment with cholestyramine of one case with an unusuallyearly onset. Acta Obstet Gynecol Scand 1970;49:29-34.

8. Olsson R, Tysk C, Aldenborg F, Holm B. Prolonged post-partum courseof intrahepatic cholestasis of pregnancy. Gastroenterology 1993;105:267-271.

9. Leevy CB, Koneru B, Klein KM. Recurrent familial prolonged intrahepaticcholestasis of pregnancy associated with chronic liver disease. Gastroenter-ology 1997;113:966-972.

10. Zapata R, Sandoval L, Palma J, Hernandez I, Ribalta J, Reyes H, et al.Ursodeoxycholic acid in the treatment of intrahepatic cholestasis of preg-nancy, A 12-year experience. Liver Int 2005;25:548-554.

11. Kondrackiene J, Beuers U, Kupcinskas L. Efficacy and safety of ursodeoxy-cholic acid versus cholestyramine in intrahepatic cholestasis of pregnancy.Gastroenterology 2005;129:894-901.

12. Glantz A, Marschall H-U, Lammert F, Mattsson L-Å. Intrahepatic cho-lestasis of pregnancy: a randomized controlled trial comparing dexameth-asone and ursodeoxycholic acid. HEPATOLOGY 2005;42:1399-1405.

13. Reyes H, Simon FR. Intrahepatic cholestasis of pregnancy: an estrogen-related disease. Semin Liver Dis 1993;13:289-301.

378 REYES HEPATOLOGY, February 2008

14. Meyers M, Slikker W, Vore M. Steroid D-ring glucuronides: characteriza-tion of a new class of cholestatic agents in the rat. J Pharmacol Exp Ther1981;218:63-73.

15. Sjovall J, Sjovall K. Steroid sulphates in plasma from pregnant women withpruritus and elevated plasma bile acid levels. Ann Clin Res 1970;2:321-338.

16. Meng LJ, Reyes H, Palma J, Hernandez I, Ribalta J, Sjovall J. Profiles ofbile acids and progesterone metabolites in the urine and serum of womenwith intrahepatic cholestasis of pregnancy. J Hepatol 1997;27:346-357.

17. Meng LJ, Reyes H, Axelson M, Palma J, Hernandez I, Ribalta J, et al.Progesterone metabolites and bile acids in serum of patients with intrahe-patic cholestasis of pregnancy: effect of ursodeoxycholic acid therapy.HEPATOLOGY 1997;26:1573-1579.

18. Meng LJ, Reyes H, Palma J, Hernandez I, Ribalta J, Sjovall J. Effects ofursodeoxycholic acid on conjugated bile acids and progesterone metabo-lites in serum and urine of patients with intrahepatic cholestasis of preg-nancy. J Hepatol 1997;27:1029-1040.

19. Giusti G, Piccinino F, Ricciardi I, Delrio G, Sagnelli E, Manzillo G.Abnormal steroid sulphate in plasma of women with intrahepatic cholesta-sis of pregnancy. Acta Hepatogastroenterol 1979;26:203-206.

20. Reyes H, Zapata R, Hernandez I, Gotteland M, Sandoval L, Jiron MI, et al.Is a leaky gut involved in the pathogenesis of intrahepatic cholestasis ofpregnancy? HEPATOLOGY 2006;43:715-722.

21. Vallejo M, Briz O, Serrano MA, Monte MJ, Marın JJG. Potential role oftrans-inhibition of the bile salt export pump by progesterone metabolites in

the etiopathogenesis of intrahepatic cholestasis of pregnancy. J Hepatol2006;44:1150-1157.

22. Glantz A, Reilly S-J, Benthin L, Lammert F, Mattsson L-Å, MarschallH-U. Intrahepatic cholestasis of pregnancy: amelioration of pruritus byUDCA is associated with decreased progesterone disulphates in urine.HEPATOLOGY 2007. DOI: hep.21987.

23. Dixon PH, Weerasekera N, Linton KJ, Donaldson O, Chambers J, Egg-inton E, et al Heterozygous MDR3 missense mutation associated withintrahepatic cholestasis of pregnancy: evidence for a defect in protein traf-ficking. Hum Mol Genet 2000;9:1209-1217.

24. Lucena JF, Herrero JI, Quiroga J, Sangro B, Garcıa-Foncillas J, ZabaleguiN, et al. A multidrug resistance 3 gene mutation causing cholelithiasis,cholestasis of pregnancy, and adult biliary cirrhosis. Gastroenterology2003;124:1037-1042.

25. Savander M, Ropponen A, Avela K, Weerasekera N, Cormand B, HirviojaML, et al. Genetic evidence of heterogeneity in intrahepatic cholestasis ofpregnancy. Gut 2003;52:1025-1029.

26. Pauli-Magnus C, Lang T, Meier Y, Zodan-Marin T, Jung D, Breymann C,et al. Sequence analysis of bile salt export pump (ABCB11) and multidrugresistance p-glycoprotein 3 (ABCB4, MDR3) in patients with intrahepaticcholestasis of pregnancy. Pharmacogenetics 2004;14:91-102.

27. Wasmuth HE, Glantz A, Keppeler H, Simon E, Bartz C, Rath W, et al.Intrahepatic cholestasis of pregnancy: the severe form is associated withcommon variants of the hepatobiliary transporter gene ABCB4. Gut 2007;56:265-270.

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