Pregnancy_Jaundice_Flashcards
What is intrahepatic cholestasis of pregnancy (ICP)?
Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis, is a liver disorder that occurs during pregnancy.
How common is intrahepatic cholestasis of pregnancy?
Intrahepatic cholestasis of pregnancy occurs in around 1% of pregnancies.
When is intrahepatic cholestasis of pregnancy generally seen?
Intrahepatic cholestasis of pregnancy is generally seen in the third trimester.
What are the features of intrahepatic cholestasis of pregnancy?
Features of intrahepatic cholestasis of pregnancy include pruritus (often in the palms and soles), no rash, and raised bilirubin.
What is a notable feature of intrahepatic cholestasis of pregnancy regarding skin changes?
In intrahepatic cholestasis of pregnancy, there is no rash, although skin changes may be seen due to scratching.
What is typically raised in intrahepatic cholestasis of pregnancy?
Bilirubin is typically raised in intrahepatic cholestasis of pregnancy.
How is intrahepatic cholestasis of pregnancy managed?
Management of intrahepatic cholestasis of pregnancy includes ursodeoxycholic acid for symptomatic relief, weekly liver function tests, and typically inducing women at 37 weeks.
What complications are associated with intrahepatic cholestasis of pregnancy?
Complications of intrahepatic cholestasis of pregnancy include an increased rate of stillbirth. It is not generally associated with increased maternal morbidity.
What is acute fatty liver of pregnancy?
Acute fatty liver of pregnancy is a rare complication that may occur in the third trimester or the period immediately following delivery.
When may acute fatty liver of pregnancy occur?
Acute fatty liver of pregnancy may occur in the third trimester or the period immediately following delivery.
What are the features of acute fatty liver of pregnancy?
Features of acute fatty liver of pregnancy include abdominal pain, nausea and vomiting, headache, jaundice, hypoglycaemia, and severe disease may result in pre-eclampsia.
What investigations are indicative of acute fatty liver of pregnancy?
Elevated ALT (e.g., 500 u/l) is indicative of acute fatty liver of pregnancy.
How is acute fatty liver of pregnancy managed?
Management of acute fatty liver of pregnancy involves supportive care and once stabilized, delivery is the definitive management.
Which syndromes may be exacerbated during pregnancy?
Gilbert’s syndrome and Dubin-Johnson syndrome may be exacerbated during pregnancy.
What does HELLP stand for in the context of pregnancy-related jaundice?
HELLP stands for Haemolysis, Elevated Liver enzymes, Low Platelets.
summarise pregnancy jaundice
Pregnancy: jaundice
Intrahepatic cholestasis of pregnancy
Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) occurs in around 1% of pregnancies and is generally seen in the third trimester. It is the most common liver disease of pregnancy.
Features
pruritus, often in the palms and soles
no rash (although skin changes may be seen due to scratching)
raised bilirubin
Management
ursodeoxycholic acid is used for symptomatic relief
weekly liver function tests
women are typically induced at 37 weeks
Complications include an increased rate of stillbirth. It is not generally associated with increased maternal morbidity
Acute fatty liver of pregnancy
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.
Features
abdominal pain
nausea & vomiting
headache
jaundice
hypoglycaemia
severe disease may result in pre-eclampsia
Investigations
ALT is typically elevated e.g. 500 u/l
Management
support care
once stabilised delivery is the definitive management
Gilbert’s, Dubin-Johnson syndrome, may be exacerbated during pregnancy
HELLP
Haemolysis, Elevated Liver enzymes, Low Platelets
A 28-year-old woman who is 32 weeks pregnant presents with itch.
On examination her abdomen is non tender with the uterus an appropriate size for her gestation. There is no visible rash, although she is mildly jaundiced. Her heart rate is 74/min, blood pressure 129/62mmHg, respiratory rate 20/min, oxygen saturations are 98% in air, temperature 36.8°C.
A set of blood results reveal:
Hb 110 g/l Na+ 139 mmol/l Bilirubin 54 µmol/l
Platelets 243 109/l K+ 4.1 mmol/l ALP 353 u/l
WBC 8.2 109/l Urea 4.6 mmol/l ALT 84 u/l
Neuts 5.7 109/l Creatinine 74 µmol/l γGT 207 u/l
Lymphs 1.8 * 109/l Albumin 34 g/l
What is the most likely cause of her symptoms?
Intrahepatic cholestasis of pregnancy
HELLP syndrome
Pre-eclampsia
Acute fatty liver of pregnancy
Biliary colic
Intrahepatic cholestasis of pregnancy
The answer here is intrahepatic cholestasis of pregnancy.
This is a common cause of itch in the third trimester of pregnancy. It will give a cholestatic picture of liver function tests (LFTs) with a high ALP and GGT, with a lesser rise in ALT. Patients may also be jaundiced with right upper quadrant pain and steatorrhoea. Ursodeoxycholic acid is a common treatment.
The cholestatic LFTs could indicate biliary colic, however the absence of abdominal pain here makes it very unlikely.
Acute fatty liver of pregnancy also occurs in the third term of pregnancy but a hepatic picture would be expected on LFTs, with a rise in ALT/AST greater than that of ALP, a raised white cell count and potential clotting abnormalities. This condition is rare and patients are likely to be unwell with nausea, vomiting, jaundice and possible encephalopathy.
In HELLP syndrome you would see a haemolytic anaemia, the mild anaemia seen here does not correlate with this and also low platelets not seen here.
This lady is not hypertensive and does not have any other features of pre-eclampsia so this is unlikely. In late pre-eclampsia a hepatic derangement of LFTs might be seen.
An overweight pregnant women is brought to the Emergency department with nausea, vomiting and lethargy. She is 36 weeks pregnant and this is her first pregnancy. On examination she is clinically jaundiced and has a temperature of 37.7ºC. Her blood pressure and heart rate is normal.
Her blood tests are as follows:
Bilirubin 80 µmol/l
ALP 240 u/l
ALT 550 u/l
AST 430 u/l
γGT 30 u/l
INR 1.8
Hb 110 g/l
Platelets 331 * 109/l
WBC 12.5 * 109/l
Acute viral hepatitis screen is negative. Urgent US doppler liver demonstrates steatosis with patent hepatic and portal vessels. What is the most likely diagnosis?
HELLP syndrome
Cholestasis of pregnancy
Acute fatty liver of pregnancy
Pre-eclampsia
Viral hepatitis
Acute fatty liver of pregnancy
The most likely diagnosis is acute fatty liver of pregnancy as demonstrated by jaundice, mild pyrexia, hepatitic LFTs, raised WBC, coagulopathy and steatosis on imaging. Clinically, acute fatty liver of pregnancy has predominantly non-specific symptoms (e.g. malaise, fatigue, nausea) whereas cholestasis of pregnancy is characterised by severe pruritis. With a normal haemoglobin, platelet count, and viral screen, the diagnosis of HELLP syndrome or viral hepatitis is unlikely. Finally, pre-eclampsia is characterised by hypertension and proteinuria.
Remember, serum ALP can be raised in pregnancy due to placental ALP.
