Jaundice

Question 1

What are the physiological liver changes in pregnancy

Answer 1

Increased liver metabolism
Fall in serum albumin (20-40%)
No significant change in bilirubin
Increased fibrinogen level
Raised ALP
Fall in the upper limit of AST, ALT

Question 2

What are the causes of jaundice in pregnancy

Answer 2

Viral hepatitis (most common)
Acute fatty liver of pregnancy
Obstetric cholestasis
HELLP
Hyperemesis gravidarum

Question 3

How is vertical transmission of hepatitis B prevented

Answer 3

Testing in all women
Babies who are born to acutely/chronically infected mothers:
- Vaccination (birth, 1 month, 6 months → serological test for HBV at 12 months)
- HBV IVIG within 12 hours of birth

Question 4

What is the risk of vertical transmission of hepatitis B

Answer 4

20%
If HBeAg +ve - 90%
C-section will not reduce this transmission
Hepatitis will not be transmitted via breastfeeding

Question 5

How is vertical transmission of hepatitis C prevented and what is the treatment consideration

Answer 5

Detect anti-HCV antibodies
Confirm with PCR for the virus
Treatment contraindicated in pregnancy (ribavirin + interferon

Question 6

What is the risk of hepatitis E and how is it prevented

Answer 6

Causes a severe reaction if contracted in the third trimester - fulminant hepatitis
Pregnant mothers should stay away from pork and shellfish

Question 7

What is acute fatty liver of pregnancy and its epidemiology

Answer 7

Rare obstetric emergency characterized by fatty infiltration of the liver
Rare - 1 in 7000-15000

Question 8

What is the cause of acute fatty liver of pregnancy

Answer 8

Likely mitochondrial disorder affecting fatty acid oxidation
Free fatty acids normally increase in pregnancy (especially late)
Accumulation of microvesicular fat in hepatocytes, periportal sparing, small yellow liver on gross examination

Question 9

What are the risk factors for acute fatty liver of pregnancy

Answer 9

Foetal long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) deficiency
Previous episode of AFLP
Multiple pregnancy
Pre-eclampsia or haemolysis, or elevated liver enzymes and a low platelet count syndrome
Obesity or Low BMI < 20kg/m2)
Male foetus
Common in primigravida

Question 10

What are the symptoms of acute fatty liver of pregnancy

Answer 10

Presents AFTER 30 weeks (3rd trimester)- typically between 30-38 weeks or immediately following delivery
Nausea + vomiting
Abdominal pain
Malaise
Headache
Anorexia
Jaundice

Question 11

What are the signs of acute fatty liver of pregnancy on examination

Answer 11

Signs of liver failure: jaundice, ascites, encephalopathy, DIC, hypoglycaemia
AKI which can rapidly progress to multiorgan failure
Hypertension (maybe)
Proteinuria (maybe)
Hypoglycaemia: drowsiness

Question 12

What investigations should be done for acute fatty liver of pregnancy

Answer 12

Bedside: BM (?hypoglycaemia), urine dip, urine protein:creatinine ratio
Bloods: FBC, U&Es, LFTs, clotting screen, LDH, uric acid, glucose
- FBC: raised WCC (Plt normal)
- Elevated transaminases >500 (AST/ ALT > ALP)
- total bilirubin raised >40 (much more than in HELLP)
- PT: prolonged
- Uric acid: raised
- Glucose: profound hypoglycaemia
Other: liver USS, biopsy
- USS: non-specific change
- biopsy: confirms diagnosis, rarely needed

Question 13

What is the Swansea criteria for acute fatty liver of pregnancy

Answer 13

Patient with GI symptoms → third trimester → assess PMHx liver disease, BP, LFTs, coagulation
AFLP:
- no PMHx liver disease
- BP variable
- LFTs: Elevated enzymes
- Coagulation: APTT and PT prolonged

Question 14

What is the management for acute fatty liver of pregnancy

Answer 14

This is a LIFE-THREATENING EMERGENCY
1. Supportive care → stabilisation then delivery
- Magnesium sulphate- in pregnancies <32 weeks of gestation, magnesium sulphate is administered until delivery
- Foetal monitoring
- Glucose replacement if needed
- Plasmapheresis for coagulopathy
2. Initial/ Immediate
- PROMPT delivery of foetus regardless of gestational age

3. Delivery: Route of delivery depends on maternal-foetal compromise
4. Postnatal
   - Monitoring of mother and baby
   - MDT, specialist centre
   - Six-hourly LFTs, renal function and haematological parameters should be performed within the first 24–48 hours after delivery.

Question 15

What are the complications of acute fatty liver of pregnancy

Answer 15

Fatal to mother and baby
Maternal: haemorrhage (secondary to DIC), renal failure, hepatic encephalopathy, sepsis, pancreatitis, risk of recurrence in future pregnancies
Foetal: death is secondary to maternal decompensation and/or preterm delivery
Maternal mortality: 10-20%
Perinatal mortality: 20-30%

Question 16

What is HELLP syndrome and what other syndrome is it related to

Answer 16

Haemolysis, Elevated Liver enzymes, and a Low Platelet count
Significant overlap with severe pre-eclampsia in terms of the features
10-20% of patients with severe preeclampsia will go on to develop HELLP

Question 17

What are the clinical features of HELLP

Answer 17

nausea & vomiting
right upper quadrant pain
Lethargy

Question 18

What investigations should be done for HELLP

Answer 18

Bloods: FBC, LFTs, coagulation screen, haptoglobins
Coagulation: PT and APTT NORMAL

Question 19

What is the management for HELLP

Answer 19

Immediate delivery of baby