Liver Disease In Pregnancy

Dr Amita Suneja

Professor, OB & GYN

UCMS & GTBH

Challenging disease to manage

• Because of physiology of pregnancy

certain disorders take more ominous

course in pregnancy than in non pregnant

state and some are unique to pregnancy

• May have severe maternal & fetal effects

Therefore it is important to have accurate

diagnosis

Physiological changes in hepatic

parameters

NO CHANGE

• Hepatic blood flow

• Hepatic & splenic size

• Liver histopathology

• Bilirubin- direct or

indirect, AST, ALT,

GGTP, TBA

• PT/INR

WITH CHANGE

• Albumin - ↓ 20%-50%

• Globulin -↑

• Fibrinogen - ↑50%

• Ceruloplasmin & transerrin - ↑

• ALP - ↑2-4 fold

• LDH - ↑slight

• Cholesterol & TGL - ↑2fold

↑ AST, ALT,S Bb, TBA during

pregnancy indicate liver disease

ClassificationUnique to pregnancy

• Hyperemesis Gravidarum

• Intrahepatic cholestasis of pregnancy

• Preeclampsia & liver - HELLP, INFARCTION & RUPTURE

• Acute fatty liver of pregnancy

concurrent with pregnancy

• Viral hepatitis A,B,C,E, herpes simplex

• Drug hepato toxicity

• Budd chiari syndrome

Pregnancy on Preexisting ch liver disease

• Cirrhosis & Portal HT

• Ch Hepatitis B, Ch Hepatitis C, Autoimmune hepatitis

• Primary biliary cirrhosis

• FNH & Hepatic adenoma

• Liver transplantation

Case report

• 36yrs, G2P1+0+0+1, 36wks, prev LSCS,↓FM

• c/o nausea, malaise & jaundice

• Treated as viral hepatitis x 3days in NH

• ANC - normal

• GPE – conscious, vitals & BP-n

icterus ++, no edema

• P/A–36wks, Vx, mild contractions, FHS-128/m

• P/V-early labor, unclotted blood in vagina

Investigations

Hb-10g%, TLC-11000/mm,

platelet-110,000/ul

Bb-11.8mg%: D-8mg%

AST-144U/L

ALT-197U/L

ALP-578U/L

PT,PTTK,TT ↑↑

INR 3.25

BUN-6mg/dl

Creatinine-1.5mg%

Co2-13mEq/L

Blood glucose- Normal

Viral markers-negative

Urine-normal

USG-normal

AFLP or HELLP

• AFLP

Normal BP

No haemolysis

Less thrombocytopenia

Marked coagulopathy

• HELLP

Can occur in normal BP

Had EL & LP

No hypoglycemia

Treatment

• 19U FFP & 10U cryoprecipitate

• LSCS 5hrs later for AFD, Male baby A&H

• Hysterectomy for PPH

• D2- moderate ascitis, thrombocytopenia, coagulopathy, jaundice

• D3- marked icterus, semicomatose, hypoglycemia, metabolic acidosis

- waiting list: cadaveric liver transplant

- deep coma, convulsions, cerebral edema

• D11- patient died, liver bx taken

Acute Fatty Liver Of Pregnancy

• Rare & fatal disorder

• 50% mortality, with early diagnosis & T/t mortality is 20%

• More common in primi gravida & multiple pregnancy

• Mildly raised enzymes, -ve viral markers, dominantly hypoglycemia & coagulopathy,

• Normal USG

• Treatment is supportive management & termination of pregnancy.

• Ac fulminant failure – liver transplant,

• If starts improving- full recovery

• LCHAD (long chain 3-hydroxyacyl-coenzyme A

dehydrogenase) deficiency in fetus →no oxidation of Fatty acids in fetus →maternal liver gets overwhelmed with FA in heterzygous mother →AFLP

• Both parents r heterozygous for this defect

Case History II

• 24yrs,G2P1+0+0+1, 34 wks, intense pruritis

H/O pruritis & jaundice in previous pregnacy

ANC in this preg – N, no nausea or vomiting

• Examination

No icterus or hepatosplenomegaly or tenderness

scratch marks +ve, no evidence of scabies

Obstetric exam – uneventful

• Investigations

S Bb – 3mg%, Direct – 2mg%

AST – 200U/L, ALT 104 U/L, ALP – 400IU/L

PT - normal

Differential diagnosis

• IHCP

• Anicteric viral hepatitis

• Obstructive jaundice

Further investigations

• USG liver to rule out obsruction of the

biliary tract - normal

• Viral markers – normal

• If diagnosis is still in doubt due to unusual

features – confirmatory serum tests should

be total bile acids (TBA) which are raised

IHCP• IIIrd trimester, Recurrent, Mild icterus (Bb is

not > 5 mg%)

• No prodrome, itching, ↑ALP, ↑TBA, n USG

• Counselling – maternal & fetal risk

• Relief of maternal symptoms- phenobarbitone

• Ursodeoxycholic acid – 300mg bd

• Addition of SAMe (S adnosylmethionine) to

UDCA – ? benefit;

• VIT K

• Terminate pregnancy at 37 weeks

• Etiology:

genetic – mutation of MDR3 gene

- hypersensitivity to oestrogens

Environmental

• Future pregnancy

Recurrence

No OCP

No progesterone in next pregnancy

IgM HAV +ve

• Similar course, ↑PTL, ↑

PPH, No perinatal

transmission

• IG to baby 0.02ml/kg IM if

infection within 2 weeks

of delivery or immediate

postpartum

• Vaccination to mother

when she moves to

endemic area

• IG to mother 0.02ml/kg

deep IM within 2 weeks of

exposure to index case

Anti HEV +ve

• Severe course in preg

• 20% fatal

• 50% of fulminant hepatitis

• No vaccine for it

• Supportive T/t

• Maternal outcome fatal if

fetus dies of hepatitis

• No carrier stage

Positive HBsAg, IgM anti HBc, HBeAg

• Course = non preg

• 10% carrier rate: 25%

have ch active hepatitis

& CA

• With HBeAg – highrisk

for ca

• PNT-20%

+ve HBeAg-90%

anti HBe ab-no

transmission

• Transplacental - 5%

vertical at TOD – 95%

& Breast Feeding

Infants born with HB are generally asymptomatic but

become carrier in 85%

Immunoprophylaxis for HBV

Neonate of HBsAg +ve

mother

• HBIG-0.5ml(250IU)

IM

TOD and 6 weeks

• HBV vaccine-different

site, IM

0,6,10,14, weeks vs.

0,1,6 months

Unimmunised Mother

• PEP within 48hrs

HBIG-500IU, IM

HBV vaccine 0,1,6

months at different

site

Hepatitis C & D & G

Hepatitis C

• IgM anti HCV +ve

• Course = non preg

• 85% develop ch

hepatitis

• Vertical transmission

only IgM +ve – 10%

PCR +ve - 30%

or HIV +ve

• No immunoprophylaxis

Hepatitis D

• Co infects with HBV

• Course = HB

• HC+HB is more severe

than HB alone

• 75% develop cirrhosis

• HB vaccine prevents

delta hepatitis

Hepatitis G

• HC coinfection

• Does not cause hepatitis

Fulminant hepatitis

• HE is commonest cause

• Jaundice, encephalopathy, coagulopathy, ARF

• Multiple organ failure

• DD: APLP,HELLP, Eclampsia

• Serological markers r helpful

• ICU care, supportive care, liver transplant facility

• Poor predictors: Bb>18mg%,INR>3.5,III-IV Enceph

• Vit K should be given, replacement of clotting factors

in absence of bleeding should not be done.

• Termination of pregnancy – role is doubtful. Should

be done id diagnosis is in doubt or for fetal survival

in 3rd trimester

• Chronic hepatitis

• Liver cirrhosis & portal hypertension

• Cholelithiasis in pregnancy

• Budd-Chiari syndrome

• Post liver transplantation pregnancy