Liver disease in pregnancy (incl. obstetric cholestasis, acute fatty liver) Flashcards
What is the management of obstetric cholestasis antenatally?
Monitor - LFT and bile acids weekly until delivery
Conservative - wear cool, loose, cotton clothing, soak in cool bath, apply ice packs to affected areas, topical emollients e.g. Menthol 0.5% with aqueous cream
Medical -
- antihistamines e.g. chlorphenamine - improves sleep (sedative), but no impact on pruritus
- ursodeoxycholic acid - improves pruritus and LFTs but no protection against stillbirth
- vitamin K
What is the intrapartum management of obstetric cholestasis?
- Offer IOL at 37 weeks (aim to deliver no later than 40 weeks)
- Labour ward with continuous CTG monitoring
What is the prognosis of obstetric cholestasis for subsequent pregnancies and postnatally?
Recurrence is 45-90% in subsequent pregnancies.
Resolves after birth
What is the management of obstetric cholestasis postnatally?
Measure LFTs 6 weeks postnatal (to ensure resolution)
Why are women with obstetric cholestasis given IOL at 37 weeks?
Treatment (ursodeoxycholic acid) does not improve outcomes for the fetus/neonate
How common is obstetric cholestasis? When does it occur in pregnancy?
Affects ~1% of pregnancies (most common liver disease of pregnancy)
Usually in the third trimester
What are the clinical features of obstetric cholestasis?
- pruritus, often in the palms and soles
- no rash (although skin changes may be seen due to scratching)
- raised bilirubin
What are the complications of obstetric cholestasis?
- Increased rate of stillbirth.
- Spontaneous preterm birth
- Iatrogenic preterm birth
It is not generally associated with increased maternal morbidity although it may cause sleep deprivation in intense pruritus.
Given the complications, what should you advise patients in obstetric cholestasis?
Pay close attention to fetal movements and attend maternity triage in RFM
From graph the risk is about 0.3% compared to 0.05% in pregnancies not complicated by obstetric cholestasis.
Define AFLP.
An obstetric emergency characterized by maternal liver dysfunction +/- failure that can lead to maternal and fetal complications, including death.
How common is acute fatty liver of pregnancy? When does it usually occur?
Rare
May occur in the third trimester or the period immediately following delivery.
What is the pathophysiology of AFLP?
Defect in fetal-maternal fatty acid metabolism causing a build up in maternal blood and hepatocytes and damaging hepatocytes
What are the risk factors for AFLP?
- Fetal long-chain 3-hydroxyacyl CoA dehydrogenase deficiency
- Prior episode of AFLP
- Multiple gestation
- Preeclampsia or HELLP
- Male fetal sex
- Low body mass index (BMI <20 kg/m2)
- Nulliparity
What are the clinical features of acute fatty liver of pregnancy?
- abdominal pain
- malaise
- nausea & vomiting
- headache
- jaundice
- hypoglycaemia
- severe disease may result in pre-eclampsia
- influenza like symptoms
Many have HTN at presentation +/- proteinuria.
NB: liver failure can cause signs such as coagulopathy, encephalopathy and jaundice.
How is acute fatty liver of pregnancy diagnosed?
LFTs -
- ALT is typically elevated e.g. 500 u/l
- AST - >42 units/L, can be elevated up to 500 units/L compared with 60 units/L in pre-eclampsia, and 150 units/L in HELLP syndrome.
- Conjugated bilirubin - raised >14 micromol/L)
- ALP - profoundly elevated
Other:
- Hypoglycaemia - common feature
- FBC - may have persistent high WBC
- USS - exclude other diagnoses, variable results.
