Liver Problems in Pregnancy Flashcards
When does acute fatty liver of pregnancy usually occur?
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester (usually after 30 weeks) or the period immediately following delivery. Part of a spectrum of disorders related to pre-eclampsia.
What are the risk factors for acute fatty liver of pregnancy?
Male foetus
Twins
Older mothers
Primips
How does acute fatty liver of pregnancy present?
Abdominal pain Nausea & vomiting Headache Jaundice Thrombocytopenia Pancreatitis Hypoglycaemia PET also present in 30-60% of cases Can lead onto clotting disorder, coma and death ALT > 500
How should acute fatty liver of pregnancy be distinguished from HEELP and OC
Mild hypertension and proteinuria only Early coagulopathy Profound and persistent Hypoglycaemia Hyperuricaemia Fatty infiltration of liver
How should suspected acute fatty liver of pregnancy be investigated?
USS/CT – bright liver and ascites FBC LFT U&E BM Clotting screen
ALT is typically elevated e.g. 500 u/l
Swansea criteria used for diagnosis – 6 or more features in the absence of another diagnosis
How should acute fatty liver of pregnancy be managed?
HDU or ITU
Support care for liver and kidney failure
Treat hypoglycaemia aggressively
Treat coagulopathy with IV vitamin K and FFP
Once stabilised delivery is the definitive management
What is obstetric cholestasis?
Definition – slowing of bile acid within the liver, usually in the 3rd trimester of pregnancy. Diagnosis of exclusion.
What are the risk factors for obstetric cholestasis?
Family History
Previous Obstetric cholestasis
How does obstetric cholestasis present?
Pruritus without rash, typically worse palms, soles and abdomen
Worsening of rash at night
Clinically detectable jaundice occurs in around 20% of patients
Raised bilirubin is seen in > 90% of cases
Anorexia and malaise
Epigastric discomfort, steatorrhea and dark urine
How should you investigate a suspected case of obstetric cholestasis?
Liver function tests (LFTs) should be done to confirm the diagnosis, however, itch may precede derangement of LFTs by up to two weeks. So if normal repeat every 1-2 weeks. Usually see a 2-3 fold increase in ALT, AST, Gamma-GT and Alkaline Phosphatase (preg specific reference ranges should be used)
Clotting screen Bile acids USS of the liver and biliary tree Viral serology Autoimmune screen
What are the complications of obstetric choelstasis?
Foetal
Increased risk of still birth
Preterm Labour
Meconium
Maternal
Vitamin K deficiency and so post-partum haemorrhage
Acute Cholecystitis – treat and manage conservatively
How should obstetric cholestasis be managed?
Weekly LFTs
Induction of labour at 37 weeks is common practice but may not be evidence based
Ursodeoxycholic acid – widely used for pruritis but does not change any foetal outcomes
Vitamin K supplementation
Topical emollients
Monitoring with USS and CTG of foetus
What differentials should you consider before diagnosing obstetric cholestasis?
Gallstones
Acute or chronic viral hepatitis
Primary biliary cirrhosis (anti-mitochondrial antibodies)
Chronic active hepatitis (anti-smooth muscles antibodies)
