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Midwifery emergencies > Obstetric Cholestasis & Acute Fatty Liver of pregnancy > Flashcards

Obstetric Cholestasis & Acute Fatty Liver of pregnancy Flashcards

1
Q

Name the five functions of the liver

A

Synthesis and storage

Detoxification

Blood Circulation and Filtration

Bile drainage

Blood glucose regulation

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2
Q

What does the liver synthesis and store?

A

Amino acids

Proteins

Vitamins

Fats

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3
Q

What are the 11 components that compose the anatomy of the liver?

A

CYSTIC DUCT

PANCREAS

LIVER

GALLBLADDER

RIGHT HEPATIC DUCT

PANCREATIC DUCT

COMMON HEPATIC DUCT

DUODENUM

SPHINCTER OF ODDI

LEFT HEPATIC DUCT

COMMON BILE DUCT

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4
Q

List the changes in the liver in pregnancy.

A
  • Displaced by the uterus.
  • Unchanged – fat & glycogen storage
  • Changed – Production of plasma proteins, enzymes, lipids and bilirubin.
  • Changes are response to increased blood volume and increase in oestrogen.
  • LFT’s in pregnancy can mimic liver disease.
  • Increase – albumin levels.
  • Decrease – Cholesterol, fibrinogen, alk phosphate & liver proteins
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5
Q

List the ways in which the Gall bladder is affected in pregnancy

A
  • Increased progesterone – causes hypotonic gall bladder.
  • Bile storage is increased.
  • Rate of emptying slows.
  • Bile becomes more diluted.
  • Cholesterol conversion is decreased.
  • Cholesterol based gall stones more likely – especially in 2nd & 3rd trimester.
  • Bile salts are retained
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6
Q

Definition of Obstetric Cholestasis or Intraheptitic Cholestasis?

A

A potential serious liver disorder that can develop in pregnancy. It usually occurs when the bile acids do not flow properly and build up in the body.

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7
Q

What facts can you mention about OC.

A
  • Most common disorder of the liver in pregnancy.
  • Incidence 1:200 to 1:2000, 0.7% in multi-ethnic population in England
  • Poorly recognised by HCP’s.
  • Usually presents after the 30th week of pregnancy

.•Exact cause is still unknow

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8
Q

What are the 7 suspected causes (pathophysiology) of OC?

A
  • Genetic predisposition possible.
  • Sensitivity to oestrogen – over-production by placenta.
  • Metabolic defect in hepatocytes.
  • Disturbance in enterohepatic circulation.
  • Accumulation of bile salts.
  • Absorption of fat soluble vitamins such as Vitamin K is impeded.
  • Coagulation is disturbed
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9
Q

What are the 5 risk factors for OC?

A
  • OC in a previous pregnancy.
  • Genetic - OC in a 1st degree blood relative & also in certain ethnic groups.
  • Twin pregnancy.
  • Environmental factors.
  • Symptoms can recur with use of contraceptives containing oestrogen.
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10
Q

What signs and symptoms would you look at for when identifying OC?

A
  • Presenting Signs & Symptoms of OC
  • Pruritus of the trunk and limbs (often worse at night) and without a rash.
  • Epigastric pain.
  • Mild jaundice.
  • Pale stools.
  • Dark urine and/or UTI.
  • Nausea and/or vomiting.
  • Irritability.
  • Exhaustion from disturbed sleep/Malaise
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11
Q

What are the MATERNAL complications associated with OC?

A
  • Incidence of gallstones increased.
  • Increased risk of PPH due to deranged clotting.
  • Emotional/psychological wellbeing affected
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12
Q

What are the FETAL complications associated with OC?

A
  • Increased risk of preterm labour.
  • Increased risk of fetal distress.
  • Increased risk of still birth.
  • Increased risk of haemorrhagic disease
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13
Q

How would you diagnose a woman with OC?

A
  • Diagnosis by exclusion.
  • Pruritus.
  • Abnormal LFTs
  • Raised alkaline phosphate
  • Raised bile acids
  • Raised liver enzymes
  • Raised total bilirubin
  • Raised bile acids.
  • Exclusion of other hepatic dysfunction causes
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14
Q

What are the investigations that you would undertake to a woman that shows signs OF OC?

A
  • Bloods.
  • LFT’s
  • Clotting screen
  • Bile acids
  • Viral Serology (EBV, CMV, Hep A, B & C)
  • Auto-immune screen (Antimitochondrial and anti-smooth muscle antibodies)
  • Liver ultrasound
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15
Q

How can aqueous cream with menthol help women with OC?

A

Can soothe Pruitus

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16
Q

What is the dosage of Oral Chlorpheniramine (Piriton) and how can it help women with OC?

A

4mg up to 4 times a day, causes sedation but does not completely eliminate pruritus.

17
Q

What is the dosage of Oral Ursodeoxycholic acid (URSO) and how can it help women with OC?

A

10mg/kg, once a day, displaces bible salts.

18
Q

What is the dosage of Vitamin K and how can it help women with OC?

A

10mg once a day, prevents Vitamink K deficiency and reduces risk of PPH.

19
Q

When should an early delivery be offered and why?

A

37-38 weeks to reduce risk of still birth

20
Q

As a midwife what are the ways in which you would care for a woman with OC postnatally?

A
  • Reassure that symptoms resolve quickly in most cases.
  • Ensure the woman understand implications for future pregnancies.
  • Ensure the woman is aware of the possibility of other family members being at increased risk of OC.
21
Q

As an obstetrician what are the ways in which you would care for a woman with OC postnatally?

A
  • Ensure LFTS have returned to normal - arrange GP appt for > 10 days PN.
  • Advise to avoid oestrogen based contraceptives.
22
Q

What is acute Fatty Liver of Pregnancy?

A

A development of a type of fatty live, usually in the last three months of pregnancy this is rare and potential fatal.

23
Q

What facts can you mention about Acute Fatty Liver of pregnancy.

A
  • very rare affecting approximately 1:10,000 pregnancies.
  • Occurs usually in the 3rd trimester.
  • Serious condition with very rapid deterioration.
  • It has a maternal mortality rate of 18%, but higher if diagnosis is delayed.
  • It has a fetal mortality rate of 23%
24
Q

What are the 3 suspected causes (pathophysiology) of AFLP?

A
  • There are links to pre-eclampsia (PET) & pregnancy induced hypertension (PIH).
  • Possible due to the effect of female hormones, i.e. the action of oestrogen on the mitochondria of the liver.
  • Possible due to a mitochondrial abnormality in the fetus
25
Q

What are the 5 risk factors of AFLP?

A
  • Primigravida
  • Multiple pregnancy
  • Raised BMI
  • Male fetus
  • Hypertension and/or pre-eclampsia
26
Q

What are considered to be the signs and symptoms of AFLP?

A
  • Nausea & Vomitting
  • Flu-like symptoms, inc. fever, headache & fatigue
  • Confusion
  • Jaundice
  • Loss of appetite
  • Pruritus
  • Upper right quadrant abdominal pain
  • Symptoms of PET, PIH and/or diabetes
27
Q

What are the complications associated with AFLP?

A
  • Severe jaundice
  • Renal and hepatic failure
  • Pancreatitis
  • Infection – sepsis
  • Haemorrhage & DIC
  • Still birth
  • Respiratory distress syndrome (RDS)
  • Death
28
Q

What are the investigations and diagnosis of AFLP?

A
  • Differentiation from HELLP syndrome essential by the presence of normal platelet count.
  • Eliminate other causes for jaundice.
  • Bloods to be taken for FBC, LFTs, Clotting, U&Es, Urate, ABG.
  • Liver USS/Biopsy – but not if this causes delay in treatment or if there is coagulopathy.
  • SWANSEA criteria
  • 6 or more criteria should be met to diagnose AFLP in the absence of another cause. (Further reading)
29
Q

What is are the 9 ways in which AFLP can be managed?

A
  • Management must be on a HDU/ITU with an MDT (ensure hepatic specialist involvement).
  • Swift response is essential
  • Treat hypoglycaemia.
  • Correct coagulopathy with Vitamin K and FFP.
  • Strict fluid balance.
  • Stabilise then deliver (usually via GA due to deranged clotting).
  • Continuous fetal monitoring.
  • Notify NNU.
  • Avoid episiotomy
30
Q

What are the 10 things you can do when caring for a woman with AFLP postnatally.

A
  • PN care for the woman should be on HDU/ITU.
  • Closely observe biochemistry and renal function via a urometer.
  • Broad spectrum antibiotics and anti-fungals should be advised.
  • Close observation of lochia needed as haemorrhage common.
  • Debrief and counselling should be offered to the woman.
  • Hepatic consultant follow.
  • Observe any wounds closely as infection much more likely.
  • May require a blood transfusion.
  • Babies of AFLP mums are at higher risk of SIDS – advice should be reiterated several times.
  • Monitoring of baby’s B

Midwifery emergencies (8 decks)

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