Liver disease in pregnancy

Liver disease in pregnancy

• Abormalities in FBE, blood film and coags mark severe lift-threatening disease

Acute fatty liver of pregnancy

• • Usually third trimester after 32 weeks. Higher risk in twin, male and primipara pregnancies.
  • Possible relationship to pre-eclampsia - mild HTN, oedema and proteinuria
  • Presentation
    • Vomiting, polydipsia, epigastric or RUQ pain, malaise, fatigue, pruritis, rapidly progressive jaundice to liver failure
  • Investigation
    • Transaminases generally 300-500, with raised bilirubin and ALP
    • USS has poor sensitivity in identifying acute fatty liver but is necessary to exclude differentials
    • FNA could confirm diagnosis, but not normally done because it wastes time
  • Cured by delivery - that reduces mortality to about 20%, but mum's condition can worsen post-delivery
  • Liver transplant may be required
  • No chronic disease following recovery
  • Recurrent disease with future pregnancies is not expected, but has been reported

Cholestasis of pregnancy

• • Strong genetic predisposition
  • Itch is predominant feature, along with jaundice
  • Cholestatic LFTs but mother is otherwise well. Can sometimes see a significant rise in transaminases.
  • May be a history of similar problems in previous pregnancies or with oral contraception
  • Associated with increased rate of fetal loss
  • Ursodeoxycholic acid helps with maternal symptoms and appears to reduce fetal mortality
  • Recurrence in future pregnancies is likely

Pre-eclampsia/HELLP

• • HTN, proteinuria and hyper-reflexia
  • Liver disease occurs in about 10% of pre-eclampsia
  • Transaminases can go above 500. jaundice is often mild.
  • Most maternal deaths are cerebral, but liver can contribute through infarction, haemorrhage or haematoma
  • Cured by delivery
  • HELLP = haemolysis, elevated LFTs, low platelets (microangiopathic haemolytic anaemia) - needs urgent delivery