Liver

Question 1

Hyperemesis gravidarum
- Differential diagnosis
- Investigations
- Management

Answer 1

What: severe protracted vomiting resulting in fluid, electrolyte and nutritional disturbance often with abnormal LFTs. Weight loss of 5% or more.

DDx
- Uncomplicated early pregnancy
- Molar pregnancy
- Twins/multiples
- Other causes of N+V eg infections, thyrotoxicosis, peptic ulceration, cholecystitis

Investigations
- STI/MSU/Ketones/Smear
- CBC, U&E, ext electrolytes, thyroid function, LFTs, early pregnancy serology
- TVUSS for dating

Risks
- Wernickes enccephalopathy
- Hyponatraemia seizures and resp arrest
- MW tear
- IUGR, PTB, thrombosis

Management
- Admit, IVL, normal saline
- IV emetics (metroclopramide, cyclizine, ondansetron)
- Folic acid, iodine, VB6, thiamine
- Dietition
- Steroids
- NG feeding or TPN
- Psychological effects
- CLexane

Question 2

Hepatitis
- Differential diagnosis
- Investigations
- Management

Answer 2

Symptoms:

DD:
- Infective: Viral A, B, C, D, E (bad in pregnancy), CMV, EBV, HSV (generally a result of primary HSV 2 infection)
- Autoimmune
- Alcohol or obesity
- Drugs

Investigations
- Normal bloods plus serology for above, liver antibodies
- Hep B: HbeAg, HbeAb, HBV-DNA, LEFTS, PT and liver USS
- Hep C: viral load, HCA RNA< antiHCV ab, HIV

Risks
- MTCT
- Worsening disease - not significant
- Delayed treatment

Management
- MDT team
- Consider antepartum procedures and inform paeds
- Hep B: Antiviral therapy if active disease, cirrhosis or during third trimester if high viral loads. Neonatal Ig and HBV vaccine within 24hours.
- Hep C: treatment outside of pregnancy recommended, vertical transmission not super common, avoid procedures during labour and definitive testing requires HCV RNA and anti HCV ab by 18months.

Question 3

Obstetric cholestasis
- Differential diagnosis
- Investigations
- Management

Answer 3

Ddx
- Atopic eruption, PEP,
- Cholestasis, gall bladder disease

Investigations
- LFTs, liver screen (viral and liver autoantibodies) and USS and bile salts, coag if severe liver derangement

Risks
- Vit K deficiency
- PPH
- Fetal meconium, fetal distess, SB, ICH, PTB

Management
- Weekly LFT and bile salts
- Consider early IOL at 38 weeks if bile salts >40
- Give antihistamines, vitK, UDCA
- Recommend CTG in labour, Vit K to neonate
- Next pregnancy counselling

Question 4

Acute fatty liver
- Differential diagnosis
- Investigations
- Management

Answer 4

DD: (nausea, anorexia, malaise, vomiting, abdominal pain, less so HTN and proteinuria)
- PET/HELLP
- TTP/Cholecystitis/pancreatitis
- Can occur with DI

Investigations
- PET bloods, LDH, bilirubin, ABG, ammonia, coags, liver USS (sometimes shows hepatic steatosis)
- BSL

Risks
- Maternal and perinatal mortality
- DIC
- Liver failure

Management
- Delivery, correction of coagulopathy (vit K and FFP), glucose, abx, N-acetylcystine, desmopressin for DI
- Tx to liver unit
- Think VTE, contraception, EDS PP
- Consider testing women postpartum for LCHAD deficiency

Question 5

HELLP Syndrome
- Differential diagnosis
- Investigations
- Management

Answer 5

PET + vomiting, epigastric pain, abruption, coagulopathy.

Ddx
- AFLP, PET, DIC, TPP, HUS

Investigations
- Haemolysis with LDH, bilirubin

Risks
- Same as above (abruption, PPH, AKI, liver rupture)

Management
- Delivery after stabilisation
- Think of correct HTN, coagulopathy with platelets, steroids, MgSo4, FFP, vit K
- Think fluid balance, VTE contraception PP

Question 6

Pre-existing liver disease
- Differential diagnosis
- Investigations
- Management

Answer 6

NAFLD
- Common
- Assoc with obesity, T2DM, hyperlipidaemia

Autoimmune CAH
Primary biliary cirrhosis
Sclerosing cholangitis

Cirrhosis
- Severe hepatic impairment is assoc with infertility and pregnancy should be discouraged.
- Bleeding from oesophageal varices can occur
- B blockers should be continued in portal HTN

Liver transplants
- PP pregnancy 18months
- Increased risks of PTB, FGR and NICU

Question 7

Gall bladder disease
- Differential diagnosis
- Investigations
- Management

Answer 7

DDx
- Pancreatitis, appendix, peptic ulcer, AFLD, viral hepatisi
- All the epigastric things
(Sx epigastric pain, vomiting, nausea, fever)

Investigations
- Bloods for LFTS, liver USS, lipase/amylase

Management
- Conservative: IV fluid, abx, analgesia, NBM
- Surgery in 2nd trimester is best