RUQ pain in pregnancy

Question 1

Hx/Exam/Ix

Answer 1

Key ddx = PET, AFLP, Infections (e.g. hepatitis), ICP

Hx
- pain location/radiation/N&V
- headache/visual/peripheral/central swelling
- polyuria/polydipsia (diabetes insipidus)
- jaundice/grey stool/dark urine/bleeding/pruritis
- sick contacts/fever
- FM/APH/SROM/TPL
- AN hx - serology/NIPT/morph/G/S
- OGHx - ?hx of PET/ICP, CST, STI
- PHx - liver disease ?HBV ?fatty liver ? liver USS
- Med/Surghx - gall stones /SHx - etoh, drug use

Exam
- vitals, cardio-resp, general appearance
- abdo pelvic hepatosplenomegaly
- reflexes/clonus, fundal height, CTG
- RTS, urine dipstick, random BSL

Ix
- FBE (plt)/UEC (raised Cr/Uric acid)/CRP/LFT (transaminitis)
- Coag (prolonged PT, ?DIC)/Bile acids (ICP)
- +/- LDH (HELLP) +/- lipase/amylase +/- BSL (AFLD)
- urine PCR, hepatitic screen - HCV/HBV/EBV
- Liver USS

Question 2

Mx of AFLP

Answer 2

• multi-D - MFM, obs med, ICU, Haematology, Gastro, anaesthetic
• maternal stabilization - strict fluid balance +/- desmopressin, glucose (dextrose infusion), correct coagulopathy (FFP + Vit K)
• fetal well-being -> urgent delivery by CS once coagulopathy corrected
• postpartum -> high risk for PPH & coagulopathy -> ICU +/- invasive supportive treatments such as dialysis / plasmapheresis / NAC infusion / liver transplant