Three possibilities need to be borne in mind when treating a pregnant woman with a liver abnormality:
- Worsening of pre-existing chronic liver or biliary disease
- Acute liver disease, not intrinsically related to pregnancy.
- Genuine pregnancy-associated liver disease
In general, if liver abnormality is found in early part of pregnancy, it is more likely to be caused by either pre-existing liver disease or non-pregnancy-related acute liver disease.
Management:
- Supportive care
- Consideration for early delivery of the fetus
- Joint management between hepatologists and obstetricians is essential.
Pre-existing liver disease
- Cirrhosis: pregnancy is uncommon, because cirrhosis causes relative infertility.
- complications of portal hypertension: enlargement of varices in pregnancy
- ascites: treated with amiloride rather than spironolactone.
- penicillamine for Wilson’s disease & azathioprine for autoimmune liver disease should be continued during pregnancy.
- Chronic HBV, HCV
- Autoimmune hepatitis: improvement during pregnancy, flare up during postpartum.
Intercurrent liver disease
- Incidental: viral, autoimmune and drug-induced hepatitis must be excluded in the presence of an elevated ALT.
- Acute hepatitis A: no effect on the fetus.
- Chronic hepatitis B:
- Immunoglobulin/ vaccination given to the fetus at birth prevents transmission of hepatitis B to the fetus if the mother is infected.
- Hepatitis C: Maternal transmission occurs in 1% of cases, the mode of delivery does not affect this.
- Hepatitis E: can progress to acute liver failure with a 20% maternal mortality.
- Gallstones: cholecystitis or biliary obstruction.
- diagnosis by ultrasound, MRCP
- treatment of biliary obstruction: therapeutic ERCP can be safely performed with lead protection for the fetus.
Pregnancy-associated liver disease
| Acute fatty liver of pregnancy (AFLP) |
- Third trimester; first pregnancies & multiple pregnancies, male fetuses.
- Genetic defect:
- inherited deficiency of the enzyme long-chain acyl-CoA dehydrogenase (LCHAD) in the baby.
SAQ. A woman is 34 weeks pregnant, admitted with anorexia, nausea, vomiting. She is started with IV fluids & ranitidine. 6 hrs later, her vomiting persists & she becomes confused. On exam, she is afebrile, BP 160/90 mm Hg, Pulse 120/min. precordium & chest exam both normal. Her abdomen is tender in the right upper quadrant, no focal signs. Hb 12 g/dl, TC – 20,000 mm3, Platelet- 160,000/mm3, PBF shows schistocytes, Creatinine 130 µmol/l, Urea 13 mmol/l, Bilirubin 40 μmol/l, ALP 201 U/L, ALT 520 U/1, Albumin 3.2 mg/dl, RBS 3.9 mmol.l, Urine 2+ protein.
( 6 or more than 6 হলেই AFLP ডায়াগনোসিস হবে। HELLP এর ফিচার থাকতেই পারে। Don’t be confused)
Q-1.What is your diagnosis? Reasoning behind Dx?
- Diagnosis: Acute Fatty Liver of Pregnancy (AFLP)
- Reasoning: Box above
Q-2. Mention 1 important non invasive investigation. Mention 3 D/D.
- Investigation: USG of abdomen: Ascites or bright echogenic liver.
- D/D:
- HELLP syndrome, Pre-eclampsia, TTP, Obstetric cholestasis
Q-3. Your plan of management?
- Supportive management:
- Mx of fluid & electrolyte imbalance,
- Mx of AKI, ALF,
- Coagulopathy, Hypoglycemia, HTN
- Delivery of the baby
- Obstetric referral.
SAQ. A 35 years old lady with 36 weeks of gestation comes with vomiting and abdominal pain. On Examination patient is icteric, abdomen is tender over right hypochondrium CBC shows HB 10g/dl, WBC-12000 cells/cmm, Platelet count-3,50000 cells/cmm, serum bilirubin- 20 micromol/L, SGPT-50 U/L, serum creatinine-1.8 mg/dl.
- What is the most likely diagnosis
- Acute fatty liver of pregnancy
| HELLP syndrome |
Clinical features
- anemia, jaundice, low platelet,
- abnormal liver function test: elevated enzyme
- সাথে HTN, edema, proteinuria থাকতে পারে। ( ডায়াগনোসিস HELLP-ই হবে, pre-eclampsia হবে না)
D/D:
- AFLP
- Pre eclampsia
SAQ. A 27 year old lady with 8 months pregnancy is admitted due to jaundice and suspected pre-eclampsia. On examination, the patient is moderately anemic and moderately icteric, BP 160/100 mmHg, bilateral pitting edema. Investigations: Hb 8.2 g/dl, WBC 12000/cmm, Platelet 110000/cmm, PBF- fragmented RBC, S. Bilirubin 118 micromol/L, SGPT 120 U/L, ALP 320 U/L, S. Creatinine 1.1 mg/dl.
Q.1. What is your diagnosis?
Q.2. Name 2 complications.
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Q.3. Treatment options.
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SAQ. A 32-wks pregnant lady is admitted to hospital with nausea, vomiting, headache, and right upper abdominal pain. On exam, oedema ++, BP 155/100 mmHg. Urinary protein +++, Hb 10.3 g/dl. Platelets 120000/mm³, PT 35 secs, FDP↑
1). What’s your complete diagnosis?
2). Mention 2 D/D?
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3). Mention 3 Mx principles.
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| Obstetric cholestasis / Acute Cholestasis of Pregnancy |
Pathology: Cholestatic effect of high estrogen levels.
Presentation: Third trimester with pruritus, particularly affecting the soles and palms.
Investigations:
- Bile acid: high (increased risk of fetal mortality, when >100 µmol/L)
- LFTs: Abnormal ALT, AST, ALP, albumin, PT INR
- USG, CBC: Exclusion of other causes of liver dysfunction and pruritus
Treatment:
-
- Ursodeoxycholic acid (UDCA): 250 mg twice daily,
- Rifampicin: additional therapy if UDCA is ineffective
- Vitamin K: if clotting is abnormal.
- Aqueous cream with menthol: effective in soothing pruritus
- Fetal delivery before 40 weeks (early delivery)
Prognosis:
- The risk of recurrence in future pregnancies is high
| Viral hepatitis |
HBV infection:
- risk of vertical transmission: up to 90% in women who are hepatitis B e-antigen-positive.
- Vaccinations and immunoglobulin should be given to the newborn at birth; and
- Antiviral agents should be given to the mother after delivery.
HCV infection:
- Vertical transmission rates:
- low in the absence of HIV infection and so no action is required for the infant,
- co-infection with HIV: antiviral drugs should be considered.
HEV infection:
- Pregnant women are at greater risk of contracting hepatitis E
- Cause fulminant hepatic failure in up to 20% of pregnant women