Hepatology - Pregnancy and the liver Flashcards
What is acute cholestasis of pregnancy?
Intrahepatic cholestasis is defined as pruritus with elevated serum bile acids occurring in the second half of pregnancy, which resolves after delivery. It is associated with intrauterine growth retardation and premature birth.
Presentation is with itching and cholestatic or hepatitic LFTs. Ursodeoxycholic acid (15mg/kg) controls itch and prevents premature birth.
What is the most common cause of jaundice in pregnancy?
Viral hepatitis
The course of most viral hepatitis infections is unaltered by pregnancy - the exception is hepatitis E, where pregnant women who contract the disease exhibit fatality rates of 10-20%.
Other causes include:
- Pre-eclampsia associated with HELLP syndrome
- Acute fatty liver of pregnancy
- Hyperemesis gravidum
- Intrahepatic cholestasis of pregnancy
What is acute fatty liver of pregnancy?
This is more common in twin and first pregnancies. It typically presents between 31 and 38 weeks of pregnancy with vomiting and abdominal pain followed by jaundice. In severe cases, lactic acidosis, a coagulopathy, encephalopathy, hypoglycaemia and renal failure may occur.
It must be differentiated from toxaemia of pregnancy (which is more common) and can be made by the finding of high serum uric acid levels and the absence of haemolysis. Early delivery is the main management.
What is toxaemia of pregnancy and HELLP?
The HELLP syndrome (haemolysis, elevated liver enzymes, and low platelets) is a variant of pre-eclampsia affecting mainly multiparous women. It presents with hypertension and proteinuria; complications include DIC, hepatic infarction and rupture. Delivery leads to prompt resolution.
How should chronic liver disease be managed during pregnancy?
Chronic liver disease in pregnancy is associated with increased risk of foetal loss.
In patients with PBC, ursodeoxycholic acid can be safely continued in pregnancy, although cholestasis may worsen during pregnancy.
Neonates of mothers with marked hyperbilirubinaemia during pregnancy may require exchange transfusion at birth.
