Liver Disease in Pregnancy

Question 1

Define Obstetric Cholestasis.

Answer 1

Pruritus in pregnancy, resolves on delivery, associated with abnormal liver function in the absence of other identifiable pathology.

• 1% of pregnancies in 2nd half of pregnancy

Question 2

What are the causes of obstetric cholestasis?

Answer 2

Likely genetic (defect in membrane phospholipid) and hormonal (oestrogen impairing sulphation) factors)

Question 3

What are the risk factors for obstetric cholestasis?

Answer 3

• Previous OC
• FHx
• Ethnicity (South Asia, Chilean, Bolivian)
• Multiple pregnancy
• Pruritis on COCP

Question 4

What are the signs and symptoms of obstetric cholestasis?

Answer 4

• Pruritus with excoriations - palms and soles → worst at night
• Raised bilirubin (and jaundice in 20%)
• No rash

Question 5

What are the appropriate investigations for suspected obstetric cholestasis?

Answer 5

• Raised bile acids
• LFTs - raised bilirubin
• CTG (check baby)
• Coagulation screen - may be high if vitamin K deficient
• High fasting serum cholesterol
• Hepatitis C serology - increased risk of OC in hepatitis C

Question 6

What is the management of obstetric cholestasis?

Answer 6

• Symptomatic relief
  
  • Ursodeoxycholic Acid – reduces itching and improves LFTs
  • Vitamin K supplementation
  • Sedating antihistamines
  • Topical emollient and wear loose cotton clothes
• Antenatal Monitoring
  
  • Weekly LFTs until delivery
  • Twice-weekly Doppler and CTG until delivery
  • Consultant-led care
• Delivery
  
  • Offer induction of labour at 37 weeks
• Postnatal follow-up to ensure LFTs have returned to normal

Question 7

What are the complications of obstetric cholestasis?

Answer 7

• Premature birth
• PPH (due to low vitamin K)
• Intrauterine death (intracranial haemorrhage)
• Meconium passage
• Severe liver impairment
• Foetal distress

Question 8

What is the pathophysiology of fatty liver in pregnancy?

Answer 8

Rare pregnancy associated disorder characterised by fatty infiltration of the liver

• Accumulation of microvesicular fat in hepatocytes, periportal sparing, small yellow liver on gross examination
• Likely mitochondrial disorder affecting fatty acid oxidation

Question 9

What are the risk factors for acute fatty liver of pregnancy?

Answer 9

• Nulliparity
• Multiple pregnancies
• Obesity
• Male foetus
• Pre-eclampsia

Question 10

What diagnosis should always be considered in pregnant women with liver issues?

Answer 10

• HELLP
  
  • Haemolysis
  • Elevated liver enzymes
  • Low platelets

Question 11

What are the signs and symptoms of fatty liver of pregnancy?

Answer 11

• Normally 3^rd trimester
• Nausea
• Vomiting
• Abdominal pain/Liver tenderness
• Jaundice
• Ascites
• Manifestations of coagulopathy/Bleeding
• 50% have proteinuric hypertension

Question 12

What are the appropriate investigations for suspected fatty liver of pregnancy

Answer 12

• LFTs → ALT is typically very elevated
  
  • ALP may be raised due to placental ALP (doesn’t always need to mean obstruction)
  • Low blood glucose
  • Elevated uric acid
• USS → fatty liver (hypoechogenic)

Question 13

What is the management of fatty liver of pregnancy?

Answer 13

• Supportive care - stabilisation
• Delivery is the definitive management to prevent deterioration

Question 14

What are the complications of fatty liver of pregnancy?

Answer 14

• Maternal → death, haemorrhage (secondary to DIC), renal failure, hepatic encephalopathy, sepsis, pancreatitis
• Foetal → death
• Prognosis:
  
  • Maternal mortality = 10-20%
  • Perinatal mortality = 20-30%