Acute liver disease Flashcards
Define acute liver disease in pregnancy.
Rare pregnancy associated disorder of fatty infiltration of liver.
Explain the aetiology of acute liver disease in pregnancy.
Likely due to mitochondrial dysfunction of fatty acid oxidation.
What are 4 risk factors for acute liver disease in pregnancy?
Nulliparity
Male fetus
Multiple pregnancies
Pre-eclampsia
Fetal long-chain 3-hydroxyacyl CoA dehydrogenase deficiency (LCHAD)
Summarise the epidemiology of acute liver disease in pregnancy.
RARE
Occurs 30-38w
4 symptoms of acute liver disease in pregnancy?
N+V
Abdominal pain
Malaise + Fatigue
Polyuria + polydipsia
What are 4 signs of acute liver disease in pregnancy?
Jaundice
Ascites
Coagulopathies (petechiae/purpura/bruising)
50% have proteinuric HTN
What is the main ddx for AFLP?
HELLP (haemolysis, elevated liver enzymes, low platelets)
Which 4 signs are more consistent with AFLP than HELLP?
Hypoglycaemia
Encephalopathy
Ascites
Coagulopathy
What investigations should be performed for acute liver disease in pregnancy?
FBC (high WCC, low Pl)
U+Es (high creatinine + urea)
Clotting (Alb, prolonged PT + APTT)
LFT (high transaminases + BR)
Glucose: hypoglycaemia
Give 4 complications of AFLP if severe
Encephalopathy
DIC
AKI
Multi-organ failure
What is the management for acute liver disease in pregnancy?
Admit to ITU
Continuous monitoring
Correct coagulopathy, electrolytes + hypoglycaemia
Expedite delivery (once mother stable/ ASAP if deteriorating)
What is used to correct coagulopathy in AFLP?
FFP + vitamin K
How can AFL of pregnancy be differentiated from OC?
No pruritus in AFLP
What is the prognosis of acute liver disease in pregnancy?
Maternal mortality of 10-20%
Perinatal foetal mortality 20-30%
What must be done for the neonate following AFLP delivery?
Screen for LCHAD deficiency
(Long chain 3 hydroxyacyl CoA dehydrogenase)
What are 3 signs + symptoms of obstetric cholestasis?
Pruritus: worse on palms, soles + abdo
Jaundice in ~20%
Itching worse at night
What negative feature characterises obstetric cholestasis?
No rash
What investigations are used for obstetric cholestasis?
Bile acids/salts
LFTs
Hep A, B + C, EBV + CMV screening
Liver AI screen: anti-SM/ anti-mitochondrial
Coagulation screen
List 5 risk factors for obstetric cholestasis
Non-caucasian
PHx/ FH
Multiple pregnancy
Hep C
>35y
Describe monitoring for women with obstetric cholestasis
Transfer to consultant led care
Plan hospital birth with continuous monitoring
LFTs weekly until delivery
What is the medical management of obstetric cholestasis?
Ursodeoxycholic acid: improves pruritus + LFTs
Vitamin K supplementation
Antihistamines e.g. Chlorphenamine: improves sleep
What are the risks associated with obstetric cholestasis?
Stillbirth
Preterm birth
Meconium stained amniotic fluid
PPH
When should delivery be planned for in women with obstetric cholestasis?
IOL at 37-38w
(though not evidence based)
Deliver in labour ward with continuous CTG monitoring
What is the risk of recurrence of obstetric cholestasis?
45-90% in subsequent pregnancies.
Why is vitamin K supplementation given in pregnancy?
Lack of bile in intestines leads to malabsorption of vitamin K + deranged coagulation
What is conservative management in obstetric cholestasis?
Wear cool, loose, cotton clothes
Soak in a cool bath
Apply icepacks
Topical emollients e.g. Menthol with aqueous cream
