Acute liver disease

Question 1

Define acute liver disease in pregnancy.

Answer 1

Rare pregnancy associated disorder of fatty infiltration of liver.

Question 2

Explain the aetiology of acute liver disease in pregnancy.

Answer 2

Likely due to mitochondrial dysfunction of fatty acid oxidation.

Question 3

What are 4 risk factors for acute liver disease in pregnancy?

Answer 3

Nulliparity

Male fetus

Multiple pregnancies

Pre-eclampsia

Fetal long-chain 3-hydroxyacyl CoA dehydrogenase deficiency (LCHAD)

Question 4

Summarise the epidemiology of acute liver disease in pregnancy.

Answer 4

RARE
Occurs 30-38w

Question 5

4 symptoms of acute liver disease in pregnancy?

Answer 5

N+V
Abdominal pain
Malaise + Fatigue
Polyuria + polydipsia

Question 6

What are 4 signs of acute liver disease in pregnancy?

Answer 6

Jaundice

Ascites

Coagulopathies (petechiae/purpura/bruising)

50% have proteinuric HTN

Question 7

What is the main ddx for AFLP?

Answer 7

HELLP (haemolysis, elevated liver enzymes, low platelets)

Question 8

Which 4 signs are more consistent with AFLP than HELLP?

Answer 8

Hypoglycaemia
Encephalopathy
Ascites
Coagulopathy

Question 9

What investigations should be performed for acute liver disease in pregnancy?

Answer 9

FBC (high WCC, low Pl)

U+Es (high creatinine + urea)

Clotting (Alb, prolonged PT + APTT)

LFT (high transaminases + BR)

Glucose: hypoglycaemia

Question 10

Give 4 complications of AFLP if severe

Answer 10

Encephalopathy
DIC
AKI
Multi-organ failure

Question 11

What is the management for acute liver disease in pregnancy?

Answer 11

Admit to ITU
Continuous monitoring
Correct coagulopathy, electrolytes + hypoglycaemia
Expedite delivery (once mother stable/ ASAP if deteriorating)

Question 12

What is used to correct coagulopathy in AFLP?

Answer 12

FFP + vitamin K

Question 13

How can AFL of pregnancy be differentiated from OC?

Answer 13

No pruritus in AFLP

Question 14

What is the prognosis of acute liver disease in pregnancy?

Answer 14

Maternal mortality of 10-20%
Perinatal foetal mortality 20-30%

Question 15

What must be done for the neonate following AFLP delivery?

Answer 15

Screen for LCHAD deficiency
(Long chain 3 hydroxyacyl CoA dehydrogenase)

Question 16

What are 3 signs + symptoms of obstetric cholestasis?

Answer 16

Pruritus: worse on palms, soles + abdo
Jaundice in ~20%
Itching worse at night

Question 17

What negative feature characterises obstetric cholestasis?

Answer 17

No rash

Question 18

What investigations are used for obstetric cholestasis?

Answer 18

Bile acids/salts

LFTs

Hep A, B + C, EBV + CMV screening
Liver AI screen: anti-SM/ anti-mitochondrial

Coagulation screen

Question 19

List 5 risk factors for obstetric cholestasis

Answer 19

Non-caucasian
PHx/ FH
Multiple pregnancy
Hep C
>35y

Question 20

Describe monitoring for women with obstetric cholestasis

Answer 20

Transfer to consultant led care

Plan hospital birth with continuous monitoring

LFTs weekly until delivery

Question 21

What is the medical management of obstetric cholestasis?

Answer 21

Ursodeoxycholic acid: improves pruritus + LFTs

Vitamin K supplementation

Antihistamines e.g. Chlorphenamine: improves sleep

Question 22

What are the risks associated with obstetric cholestasis?

Answer 22

Stillbirth

Preterm birth

Meconium stained amniotic fluid

PPH

Question 23

When should delivery be planned for in women with obstetric cholestasis?

Answer 23

IOL at 37-38w
(though not evidence based)
Deliver in labour ward with continuous CTG monitoring

Question 24

What is the risk of recurrence of obstetric cholestasis?

Answer 24

45-90% in subsequent pregnancies.

Question 25

Why is vitamin K supplementation given in pregnancy?

Answer 25

Lack of bile in intestines leads to malabsorption of vitamin K + deranged coagulation

Question 26

What is conservative management in obstetric cholestasis?

Answer 26

Wear cool, loose, cotton clothes
Soak in a cool bath
Apply icepacks
Topical emollients e.g. Menthol with aqueous cream