Kolestazlı gebelerde vitamin D düzeylerinin olumsuz neonatal sonuçlarla ilişkisi
Relationship of low vitamin D levels in cholestasis of pregnancy with negative neonatal outcomes
Yazar: EMRE CANVERENLER
Danışman: PROF. DR. GÜRSEN GÜNDEM
Ege Üniversitesi / Tıp Fakültesi / Cerrahi Tıp Bilimleri Bölümü / Kadın Hastalıkları ve Doğum Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2014
Konu: Kadın Hastalıkları ve Doğum = Obstetrics and Gynecology
Dizin: Enzime bağlı immünosorbent testi = Enzyme-linked immunosorbent assay ; Fetal tehlike = Fetal distress ; Fetüs = Fetus ; Gebelik = Pregnancy ; Kolestaz = Cholestasis ; Neonatal tarama = Neonatal screening ; Neonatoloji = Neonatology ; Vitamin D = Vitamin D

Özet:
Gebelik kolestazlı kadınlarda, D vitamini düzeyleri sağlıklı gebe topluma göre istatistiksel olarak anlamsız biçimde düşük bulunmuştur. Bu durum D vitamini düzeyi referans aralıklarının çok geniş olması, çalışma grubu ile kontrol grubunun her anlamda homojen olmaması ve hasta sayısının kısıtlı olması nedenli olabilir. D vitamini eksikliği olan hastaların çoğunluğu ALT düzeyi 200 U/L'den yüksek olan kolestazlı gebelerin grubunda bulunmuştur. Yani D vitamini eksikliği ağır kolestazlı hastalarda daha düşük oluyor gibi görünmektedir. D vitamini düzeylerinin olumsuz neonatal sonuçlar için bir fetal distres belirteci olarak rutin kullanıma girip girmeyeceğini anlamak için  daha yüksek hasta populasyonlu randomize kontrollü çalışmalara ihtiyaç vardır.

Abstract:
The aim of the study is to search lower vitamin D levels are associated with negative perinatal outcomes in statement of intrahepatic cholestasis of pregnancy. İn this cases maternal vitamin D levels may be used as an indirect marker of fetal distress.
The hospitalized pregnant women with elevated liver enzyme levels and itching symptoms, gastroenterology consultation is requested. İn order to rule out possible factors, viral and autoimmune hepatitis markers are routinely searched , and  cholestasis of pregnancy is diagnosed as a  exclusion diagnosis . In our study, the patients blood plasma 25-hydroxy-cholecalciferol (vitamin D) levels are studied by ELISA method in Ege University,Laboratory of Clinical Biochemistry. Then, the routine analysis of the fetus was evaluated by ultrasonography and nonstress test. After the birth,  newborn was evaluated whether amniotic fluid is stained with meconium or not, whether in  cord arterial blood gas analysis acidosis occurs or not and was searched with APGAR scores for fetal distress. These data and the mother's vitamin D levels were studied to catch a relation with other routine biochemical parameters.
Patients in first arrival , symptoms of itching (72.7%) and jaundice (13.6%) were mostly identified. The mean time of diagnosis is average  34.2 +2.2 gestational weeks. İn working group, five of cases (18.2%) had fetal distress, and three of these patients amniotic fluid is stained with meconium . İn the control group there was not any fetal distress, and meconium-stained amniotic fluid . In 17.6% of cases, amniotic fluid is stained with meconium passage. No cases of mortality occurred during the perinatal period. There was no significant difference in  1 and 5 minutes APGAR scores and newborn cord blood gases analysis between the working group and the control group. Patients with mean ALT levels were higher than 200 U/L, mean Vitamin D levels were found 38 ng/ml, patients with mean ALT levels were lower than 200 U/L, mean Vitamin D levels were found 54 ng/ml. In all patients with cholestasis of pregnancy the average value of vitamin D levels were 48 ng / ml. 30% (9/31)  of those with vitamin D deficiency (<30ng/ml) were found in the patient group. 6 of 9 patients with vitamin D deficiency and one patient with severe vitamin D deficiency were in group with patients mean ALT levels higher than 200 U / L.
Women with cholestasis of pregnancy, vitamin D levels were lower than  healthy pregnant women of the community which was statistically insignificant. This can be induced from the large magnitude of reference levels of vitamin D, condition of not being homogenous in every sense between working group and the control group and the limited number of patients. The majority of patients with vitamin D deficiency were in group with mean ALT levels  higher than 200 U / L . It seems that  vitamin D deficiency in patients with severe cholestasis appears to be lower . In order to understand Vitamin D levels will attempt to use routinely as a marker of fetal distress for negative neonatal outcomes , higher patient population randomized controlled studies are needed.