Dr Abdullah Ansari MBBS, MD Medicine Aligarh Muslim University The physiological changes in the liver during pregnancy The possibilities of liver diseases LFT in pregnancy Intercurrent and pre-existing liver disease: viral hepatitis, autoimmune hepatitis, gall stones Pregnancy associated liver disease: Hyperemesis Gravidarum, Acute cholestasis of pregnancy, Acute fatty liver of pregnancy, HELLP syndrome

1. PREGNANCY
&
LIVER DISEASES
Dr Abdullah Ansari
MBBS, MD Medicine
Aligarh Muslim University

2. PHYSIOLOGICAL CHANGES IN THE LIVER
DURING PREGNANCY
Increased
 ALP rise 3-4 fold due to placental production
 Fibrinogen rise by 50 %, with other clotting factors
Decreased
 Gallbladder contractility
 Albumin and total protein

3. No change
 Liver size
 Liver blood flow despite increased blood volume
and cardiac output
 Liver aminotransferase levels, may decrease
 Bilirubin level
 Prothrombin time

4. THE POSSIBILITIES OF LIVER DISEASES
1. A worsening of pre-existing chronic liver or biliary
disease (may not have previously been
diagnosed)
2. A genuine first presentation of liver disease that is
not intrinsically related to pregnancy
3. A genuine pregnancy-associated liver injury
process

5. THE GENERAL RULE
 The earlier in pregnancy the liver abnormality
presents, the more likely it is to represent either
preexisting liver disease or non-pregnancy-related
acute liver disease

6. LFT IN PREGNANCY
 ALT levels and albumin normally fall in pregnancy
 ALP levels can rise due to contribution of placental
ALP

7. INTERCURRENT AND PRE-EXISTING
LIVER DISEASE
Viral hepatitis
 Acute hepatitis A: no effect on fetus
 Chronic hepatitis B: requires identification to
reduce perinatal transmission
 Chronic hepatitis C: perinatal transmission 1%
 Acute hepatitis E: progresses to fulminant hepatic
failure, with 20% maternal mortality

8. Autoimmune hepatitis
 Improves during pregnancy and flare-up
postpartum
 Azathioprine to be continued during pregnancy
Gallstones
 More common during pregnancy,
 May present with cholecystitis or biliary obstruction
 ERCP safely performed with lead protection

9. Cirrhosis
 Pregnancy uncommon as cirrhosis causes relative
infertility
 Ascites or polyhydramnios treated with amiloride
rather than spironolactone
Wilson’s disease
 Penicillamine to be continued during pregnancy

10. PREGNANCY-ASSOCIATED LIVER DISEASE
 Predominant in the third trimester and resolve post-
partum
 Maternal and fetal mortality and morbidity
prevented by early delivery
 Hyperemesis Gravidarum is a disease of 1st
trimester

11. HYPEREMESIS GRAVIDARUM
 0.3-2% of all pregnancies
 Presents with persistent vomiting, leading to
dehydration with associated ketosis and weight
loss of >5%
 Risk factors include previous pregnancies with
hyperemesis gravidarum, multiple gestations,
trophoblastic disease, nulliparity
 Hormonal peaking of HCG and estradiol probably
plays role

12.  Mild elevation of transaminase in 50% cases,
Bilirubin may rise to 4 mg/dl
 Amylase elevated in 10%
 A transient hyperthyroidism associated in 50-60%
cases
 Complications include electrolyte imbalance,
esophageal rupture, retinal hemorrhage, renal
failure

13.  Initial management is conservative
 The only FDA-approved drug for treating nausea
and vomiting in pregnancy is doxylamine/pyridoxine
 However, antihistamines, antiemetics of the
phenothiazine class, and promotility agents (eg,
metoclopramide) are used
 In refractory cases, ondansetron and steroids may
be considered

14. ACUTE CHOLESTASIS OF PREGNANCY
 20% of jaundice in pregnancy
 Presents with itching
 Associated with IUGR, premature birth and IU fetal
death (if pregnancy >36 weeks)
 Cholestatic LFT and elevated serum bile salts

15.  Delivery leads to resolution and pregnancy should
not be continued beyond term
 UDCA (15 mg/kg daily) effective in itching and
probably prevents premature birth
 UDCA requires long time for effective levels in bile
pool, hence of little use in late pregnancy
 Recurs in 60% subsequent pregnancies

16. ACUTE FATTY LIVER OF PREGNANCY
 More common in twins, first pregnancies and male
fetus
 Presents with vomiting and abdominal pain followed
by jaundice
 Fulminant hepatic failure in severe cases
 Defect in beta-oxidation of fatty acids in
mitochondria, leads to fat droplets formation in
hepatocyte (microvesicular fatty liver)

17.  Differentiates from toxaemia of pregnancy by high
levels of serum uric acid and absence of hemolysis
 Maternal and perinatal mortality 1% and 7%
respectively
 Delivery regardless of gestational age is the only
treatment

18. HELLP SYNDROME
 Hemolysis, elevated liver enzymes and low
platelets, a variant of pre-eclampsia
 Presents with hypertension, proteinuria and fluid
retention
 Jaundice only in 5% cases
 Blood tests shows low haemoglobin, with
fragmented red cells, markedly elevated serum
transaminases and raised D-dimers

19.  Complications include hepatic infarction and
rupture, DIC and placental abruption
 Maternal and perinatal mortality 1% and 30%
respectively
 Delivery leads to prompt resolution
 Recurs < 5% subsequent pregnancies

20. Thank You