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Clinical and Molecular Hepatology

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Clinical and Molecular Hepatology Volume 28   Number 1   January   2022       (1-119)pISSN 2287-2728      eISSN 2287-285Xhttps://doi.org/10.3350/cmh.2021.0359Clinical and Molecular Hepatology 2022;28:50-51Editorial Corresponding author : Ja Young KwonDepartment of Obstetrics and Gynecology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, KoreaTel: +82-2-2228-2245, Fax: +82-2-313-8350E-mail: jaykwon@yuhs.achttps://orcid.org/0000-0003-3009-6325Abbreviations: GDM, gestational diabetes; NAFLD, non-alcoholic fatty liver disease; OGTT, oral glucose tolerance test; PCOS, polycystic ovarian syndrome; PE, preeclampsia; PIH, pregnancy-induced hypertensionReceived : Nov. 16, 2021 /  Accepted : Nov. 17, 2021Editor: Seung Up Kim, Yonsei University College of Medicine, KoreaAccording to the current obstetrical practice, blood chemistry tests, such as liver function tests or cholesterol panel, are not in-cluded in the initial blood test at first prenatal visit.1 Moreover, el-evated serum cholesterol or triglyceride levels in pregnant women are not taken seriously but rather considered as normal alteration in lipid physiology caused by pregnancy hormones.2 Therefore, in practice, screening for non-alcoholic fatty liver disease (NAFLD) in pregnancy is easily overlooked and disease-related pregnancy complication are often underestimated.In the January 2022 issue of the Clinical and Molecular Hepatol-ogy, El Jamaly et al.3 reported a systemic review and meta-analy-sis to assess the association between NAFLD and adverse mater-nal and fetal outcomes, which provided compelling evidence to support that NAFLD is independently associated with gestational diabetes (GDM) as well as pregnancy-induced hypertension (PIH), including gestational hypertension, preeclampsia (PE), and eclamp-sia (odds ratio, 2.81, 1.83, 3.24, and 3.91, respectively).3 Certainly, such finding increases the awareness about NAFLD and adverse pregnancy outcome, but at the same time, raises questions in the context of obstetric care. Should we consider NAFLD in the risk stratification for GDM or PE? Who should be subjected to screen-ing for NAFLD during pregnancy or at postpartum? How should women with NAFLD, having such high metabolic risk, be man-aged differently during pregnancy? Is there a preventive strategy available for pregnancy-induced diabetes mellitus or hyperten-sion? More studies should follow to assess the potential benefit, or the lack of benefit, of screening a population for NAFLD when the diagnosis is made.Care should be taken in the interpretation of data herein. The participants were enrolled in this meta-analysis between 1992 and 2019, which is quite a wide time frame.3 During this period, new GDM screening strategy and diagnostic criteria were intro-duced. With the adoption of the International Association of the Diabetes and Pregnancy Study Groups diagnostic criteria for the 75-g oral glucose tolerance test (OGTT) in late 2000s, the diag-nostic yield for GDM increased by 12%.4 Meanwhile, the Ameri-can College of Obstetricians and Gynecologists continued to rec-Non-alcoholic fatty liver disease in pregnancy, paving the way for adverse pregnancy outcome risk assess-mentJa-Young KwonDepartment of Obstetrics and Gynecology, Institute of Women’s Medical Life Science, Yonsei University College of Medicine, Seoul, KoreaKeywords: Non-alcoholic fatty liver disease; Pregnancy outcome; Gestational diabetes; Preeclampsia Copyright © 2022 by Korean Association for the Study of the LiverThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.See Article on Page 5251Ja-Young KwonNAFLD as risk factor for adverse pregnancy outcomehttp://www.e-cmh.org https://doi.org/10.3350/cmh.2021.0359ommend Carpenter-Coustan or National Diabetes Data Group diagnostic threshold for the 100-g OGTT.5,6 Also, the diagnostic criteria for PE were revised in 2013 to encompass other features of end-organ dysfunction.7,8 As different criteria will identify dif-ferent degree of patients, the prevalence of adverse outcomes may differ significantly according to the study period.9 Therefore, the study period and diagnostic criteria may need to be consid-ered in the risk adjustment.Patients with conditions that predispose to insulin resistance (e.g., polycystic ovarian syndrome [PCOS])10 are considered at high risk for GDM and subjected to earlier GDM screening at the initial prenatal visit.11 We cannot argue with the fact that NAFLD is a manifestation of metabolic syndrome and presence of insulin re-sistance.12-14 Therefore, as with PCOS, a patient with NAFLD may also be a potential candidate for stringent GDM screening with the intent of optimizing gestational outcome. However, the cur-rent lack of consistency regarding the diagnosis of NAFLD in preg-nancy remains a major concern. While ultrasound is commonly employed, due to its low sensitivity and operator-dependency, there is no consensus on the ultrasound criteria to diagnose fatty liver.15-17 Therefore, building a consensus on the diagnostic criteria, or possibly developing a new ultrasonographic grading system based on the specific relationships to the risk of adverse pregnan-cy outcome, is warranted. Conflicts of InterestThe author has no conflicts to disclose.REFERENCES   1. Cunningham F, Leveno KJ, Bloom SL, Dashe JS, Hoffman BL, Casey BM, et al. Williams Obstetrics, 25e. New York: McGraw Hill, 2018: 160-179.  2. Lain KY, Catalano PM. Metabolic changes in pregnancy. Clin Obstet Gynecol 2007;50:938-948.   3. El Jamaly H, Eslick GD, Weltman M. Systematic review with meta-analysis: non-alcoholic fatty liver disease and the association with pregnancy outcomes. Clin Mol Hepatol 2022;28:52-66.  4. Shang M, Lin L. IADPSG criteria for diagnosing gestational diabetes mellitus and predicting adverse pregnancy outcomes. J Perinatol 2014;34:100-104.  5. ACOG practice bulletin No. 190: gestational diabetes mellitus. Ob-stet Gynecol 2018;131:e49-e64.  6. Harper LM, Mele L, Landon MB, Carpenter MW, Ramin SM, Reddy UM, et al. Carpenter-Coustan compared with National Diabetes Data Group criteria for diagnosing gestational diabetes. Obstet Gy-necol 2016;127:893-898.  7. Tranquilli AL, Dekker G, Magee L, Roberts J, Sibai BM, Steyn W, et al. The classification, diagnosis and management of the hyperten-sive disorders of pregnancy: a revised statement from the ISSHP. Pregnancy Hypertens 2014;4:97-104.   8. ACOG practice bulletin No. 202: gestational hypertension and pre-eclampsia. Obstet Gynecol 2019;133:1.  9. Reddy M, Fenn S, Rolnik DL, Mol BW, da Silva Costa F, Wallace EM, et al. The impact of the definition of preeclampsia on disease diagnosis and outcomes: a retrospective cohort study. Am J Obstet Gynecol 2021;224:217.e1-217.e11.10. Giannakou K, Evangelou E, Yiallouros P, Christophi CA, Middleton N, Papatheodorou E, et al. Risk factors for gestational diabetes: an umbrella review of meta-analyses of observational studies. PLoS One 2019;14:e0215372. 11. Palomba S, de Wilde MA, Falbo A, Koster MP, La Sala GB, Fauser BC. Pregnancy complications in women with polycystic ovary syn-drome. Hum Reprod Update 2015;21:575-592.12. Targher G, Bertolini L, Padovani R, Rodella S, Tessari R, Zenari L, et al. Prevalence of nonalcoholic fatty liver disease and its association with cardiovascular disease among type 2 diabetic patients. Diabe-tes Care 2007;30:1212-1218.13. Machado MV, Ferreira DM, Castro RE, Silvestre AR, Evangelista T, Coutinho J, et al. Liver and muscle in morbid obesity: the interplay of fatty liver and insulin resistance. PLoS One 2012;7:e31738. 14. Yki-Järvinen H. Non-alcoholic fatty liver disease as a cause and a consequence of metabolic syndrome. Lancet Diabetes Endocrinol 2014;2:901-910.15. Leoni S, Tovoli F, Napoli L, Serio I, Ferri S, Bolondi L. Current guide-lines for the management of non-alcoholic fatty liver disease: a systematic review with comparative analysis. World J Gastroenterol 2018;24:3361-3373.16. Mishra P, Younossi ZM. Abdominal ultrasound for diagnosis of nonalcoholic fatty liver disease (NAFLD). Am J Gastroenterol 2007;102:2716-2717.17. Saadeh S, Younossi ZM, Remer EM, Gramlich T, Ong JP, Hurley M, et al. The utility of radiological imaging in nonalcoholic fatty liver disease. Gastroenterology 2002;123:745-750.

Non-alcoholic fatty liver disease in pregnancy, paving the way for adverse pregnancy outcome risk assessment

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Non-alcoholic fatty liver disease in pregnancy, paving the way for adverse pregnancy outcome risk assessment

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