Pregnancy LD

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    Pregnancy Related Liver Disease

    • Similar extra-hepatic findings as liver disease: Edema, palmar erythema, spider angiomas
      • Due to altered circulatory volume and hormones.
    • Characteristics of Pregnancy-Related Liver Diseases

       

      Disease

      Trimester

      Hepatic Aminotransferases (units/L)

      Bilirubin (mg/dL [µmol/L])

      Other Laboratory Changes

      Treatment

      Prognosis

      Hyperemesis gravidarum

      First

      <500

      <4 (68.4)

      Electrolyte abnormalities

      Antiemetics, intravenous fluids

      Good

      - Corrects with cessation of vomiting

      Intrahepatic cholestasis of pregnancy

      Second/third

      <500

      <6 (102.6)

      Elevated serum bile acids

      Ursodeoxycholic acid

      Good

      HELLP syndrome

      Third

      <500

      Elevated, unconjugated

      Low platelets, hemolytic anemia

      Delivery

      High maternal and fetal mortality; liver transplantation may be required

      AFLP

      Third

      100-1000

      Elevated

      Hypoglycemia, coagulopathy

      Delivery

      High maternal and fetal mortality; liver transplantation may be required

      AFLP = acute fatty liver of pregnancy; HELLP = Hemolysis, Elevated Liver enzymes, and Low Platelets.

    Hyperemesis Gravidarum

    • First trimester, associated with prolonged vomiting (fluid and electrolyte abnormalities)
    • Elevated enzymes seen in half patients.
    • Usually return to baseline with resolution of vomiting.
    • VERY rarely associated with liver failure.

    Intrahepatic Cholestasis of Pregnancy

    • ICP presents Second/Third trimester
    • Occurs: 1:300 to 1:1000 pregnancies, more commonly seen in scandinavian, S. American, or S. Asian origin.
    • ICP results from cholestatic effects of pregnancy hormones.
      (Sometimes seen in non-pregnant women supplemented with hormones).
    • Symptoms:
      • Puritis, Jaundice (10-25%)
    • Diagnosis: Elevated serum bile acids are diagnostic.
    • Treatment:
      • Ursodeoxycholic Acid (UDCA) is effective.
      • Poor fetal outcomes (i.e. early labour, intrauterine death etc..) are increased
      • Early induction 36-38w at gestation.

    HELLP

    • Hemolysis, Elevated Liver enzymes Low Platelets
    • Presents in 3rd trimester, advanced complication of pre-eclampsia.
    • Symptoms:
      • New onset abdominal pain, nausea/vomiting, pruritis, jaundice.
    • Management:
      • Admit to a high-risk obstetric care unit (maternal mortality: 20%)
        • Careful monitoring of BP, fluids, coagulopathy prior to delivery.
      • Delivery is definitive therapy, mother's condition can deteriorate immediately post-partum.
        (usually resolves in 46days post-delivery)
      • Liver transplant (rare, but fulminant hepatic failure can develop).

    Acute Fatty Liver of Pregnancy

    • AFLP is a rare but dangerous condition in 3rd trimester.
    • May be hard to differentiate from HELLP.
      • Hypoglycemia and coagulopathy tend to be worse
    • Management:
      • Involve hepatology for possible liver transplant.
      • Prompt delivery! --> usually stabilizes, and improves over 48-72h.
      • Can be associated with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (L-CHAD),
        • Screen women and their children
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