Liver disease pregnancy Flashcards
Risk of chronic carriage of Hep B if infected at delivery?
90%
subsequent cirrhosis and hepatocellular carcinoma
Risk of Hep B vertical transmission related to antigen status.
HBsAg +, HbeAg+ = 95%
HBsAg +, HBeAg- = 2-15%
Measurement of HBV DNA has replaced HBeAG as most sensitive test of viral activity.
Risk of HBV transplacental transmission?
5%
List significance of following ab/ag presence:
- HBsAb
- HBsAg
- HBcAb
- HBeAg
- vaccination or previous infection
- infected
- natural infection previously
- active viral replication
Risk of chronic infection after HBV exposure in adults?
10%. 25% of those develop chronic liver disease.
When is tenofovir indicated antenatally?
third trimester
HBV DNA >200,000IU/mL or 10^6 log copies/mL
What is the effect of antenatal tenofovir on infant infection?
RR 0.15 SS
Neonatal HBV immunisation consists of:
- HBIG <12 hrs after delivery
- DTAP <12 hours after delivery
- DTAP 6w, 3m, 5m
Reduces risk of infection RR0.08
Less effective if LBW or preterm.
Risk factors for hepatitis C?
80% of IVDU or blood product dependent patients
<5% sexually transmitted.
Course of hepatitis C infection in adults?
15-30% of untreated patients develop cirrhosis within 20 years
27% of those will develop hepatocellular carcinoma in 10 years.
Determinate of Hepatitis C vertical transmission ?
HCV viral load
1% RNA negative mothers
5% RNA positive mothers
Management of HCV in pregnancy
direct acting antivirals pre conceptually + treatment
DAA contraindicated antenatally
NIPT/MSS1 (no invasive tests if possible)
Avoid FSE/FBS
Bfing. Start DAA after finished + contraception.
No vaccines for HCV prevention.
No increase risk of congenital abnormalities, miscarriage or prematurity. Detection of infant infection reliable 3mo PP.
Prevalence of obstetric cholestasis?
0.7%
Risk factors for obstetric cholestasis?
family (autosomal dominant inheritance)
hep C carriage
gallstones
multiple pregnancy
Genetic pathology of obstetric cholestasis
MDR3 gene- hepatocellular transport system
lower oestriol circulates
bile salts accumulate—> vasoconstriction
dyslipidaemia
hyperbilirubinaemia
liver autoantibody screen?
anti-mitochondrial, anti-smooth muscle antibodies
Perinatal mortality/morbidity associated with obstetric cholestasis?
mortality = 1.1-3.5% (used to be 11%) stillbirth= 1.5% intrapartum fetal distress = 2-22% fetal arrhythmia preterm birth 25% meconium 44% vitamin K deficiency (intracranial haemorrhage)
Maternal intrapartum risks of obstetric cholestasis
LSCS fetal distress
PTB
PPH 2-22%
When would UCDA be prescribed for cholestasis?
non significant improvement in maternal itch scores. does not seem to effect any other perinatal/maternal outcomes.
Evidence for timing of delivery with peak BS <100
no difference in stillbirth rate compared with background population risk before 39 weeks gestation.
BS >100 individualise timing. HR 30.50 stillbirth. May be reasonable to consider timing ~36 weeks.
Delivery considerations of cholestasis?
What was the peak BS level LFTs BP monitoring CTG in induction/labour active management 3rd stage coagulation profile at start (vitamin K if PTT prolonged) IVL Neonatal vitamin K Avoid oestrogen OC's Repeat LFT >10/7.
Risk of AFLP in pregnancy?
1/7000-20,000
Risk factors AFLP
male fetus (3:1)
primigravida
multiple preganncy
homozygous genetic defect in child (LCHAD deficiency)
LCHAD function
catalyses step in beta oxidation of mitochondrial fatty acid
instead unmetabolised long-chain fatty acids spill into maternal circulation
leads to hepatotoxicity
LCHAD def also impairs placental vasopressinase enzyme degradation. Increases ADH= polydipsia, polyuria.
maternal mortality and perinatal mortality of AFLP?
maternal = 7% fetal = 15%
serum findings AFLP?
Abnormal coags lft deranged wcc elevated, plt low BSL low hypocholesterolaemia
Define HELLP syndrome
haemolysis
elevated liver ensyme
low platelets
unclear if on spectrum with PET or seperate
Prevalence of HELLP?
1%
5-20% of pregnancies with PET.
Difference of HELLP and HUS
HUS no jaundice, no neurological symptoms. AST/ALT normal. LDH elevated. Hypertension is not common. Severe AKI
HELLP
LDH may be elevated, but not profoundly
AST/ALT elevated
Liver complications of HELLP?
liver rupture
sub capsular haematoma
massive hepatic necrosis
Live birth rate after liver transplant?
92%
Increased PTB, FGR, NICU
Prevalence of asymptomatic gallstones and cholecystitis in pregnancy?
2.5-10%
1/1000 have cholecystitis.
What may prompt cholecystitis in pregnancy?
stones due to more bile cholesterol/less bile acid
gallbladder stasis
Swansea criteria? (8)
raised
- bilirubin
- urate
- WCC
- ALT/AST
- ammonia
- creatinine
low
- glucose
- coagulopathy
(cc wat bug)
