الفهرس 
Normal hepatic physiological changes in pregnancyOnly 14 pages are availabe for public view
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Abstract
Severe liver disease in pregnancy is rare. Pregnancy-related liver disease is
the most frequent cause of liver dysfuncteion in pregnancy and provides a real
threat to fetal and maternal survival. A rapid diagnosis diff erentiating between
liver disease related and unrelated to pregnancy is required in women who present
with liver dysfunction during pregnancy. Research has improved our
understanding of the pathogenesis of pregnancy-related liver disease, which has
translated into improved maternal and fetal outcomes. Here, we provide an
overview of liver diseases that occur in pregnancy, an update on the key
mechanisms involved in their pathogenesis, and assessment of available treatment
options.
Abnormal liver tests occur in 3%-5% of pregnancies, with many potential
causes, including coincidental liver disease (most commonly viral hepatitis or
gallstones) and underlying chronic liver disease. However, most liver dysfunction
in pregnancy is pregnancy-related and caused by 1 of the 5 liver diseases unique to
the pregnant state: these fall into 2 main categories depending on their association
with or without preeclampsia. The preeclampsia-associated liver diseases are
preeclampsia itself, the hemolysis (H), elevated liver tests (EL), and low platelet
count (LP) (HELLP) syndrome, and acute fatty liver of pregnancy. Hyperemesis
gravidarum and intrahepatic cholestasis of pregnancy have no relationship to
preeclampsia. Although still enigmatic, there have been recent interesting advances
in understanding of these unique pregnancy-related liver diseases. Hyperemesis
gravidarum is intractable, dehydrating vomiting in the first trimester of pregnancy;
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50% of patients with this condition have liver dysfunction. Intrahepatic cholestasis
of pregnancy is pruritus and elevated bile acids in the second half of pregnancy,
accompanied by high levels of aminotransferases and mild jaundice. Maternal
management is symptomatic with ursodeoxycholic acid; for the fetus, however,
this is a high-risk pregnancy requiring close fetal monitoring and early delivery.
Severe preeclampsia itself is the commonest cause of hepatic tenderness and liver
dysfunction in pregnancy, and 2%-12% of cases are further complicated by
hemolysis (H), elevated liver tests (EL), and low platelet count (LP)-the HELLP
syndrome. Immediate delivery is the only definitive therapy, but many maternal
complications can occur, including abruptio placentae, renal failure, subcapsular
hematomas, and hepatic rupture. Acute fatty liver of pregnancy is a sudden
catastrophic illness occurring almost exclusively in the third trimester;
microvesicular fatty infiltration of hepatocytes causes acute liver failure with
coagulopathy and encephalopathy. Early diagnosis and immediate delivery are
essential for maternal and fetal survival.
Classification of liver diseases in pregnancy
Quoted from ( Deepak J et al., 2010)
Pregnancy-related liver diseases
· Hyperemesis gravidarum
· Intrahepatic cholestasis of pregnancy
· Pre-eclampsia and eclampsia
· HELLP syndrome
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· Acute fatty liver of pregnancy
Pregnancy-unrelated liver diseases
Pre-existing liver diseases
· Cirrhosis and portal hypertension
· Hepatitis B and C
· Autoimmune liver disease
· Wilson’s disease
Liver diseases co-incident with pregnancy
· Viral hepatitis
· Biliary disease
· Budd-Chiari syndrome
· Liver transplantation
· Drug-induced hepatotoxicity
When to refer for a specialist opinion This would normally include (patients
with:
2. Unexplained liver abnormalities more than 1.5 times normal on two
occasions, a minimum of 6 weeks post pregnancy.
3. Unexplained liver disease with evidence of hepatic dysfunction
(hypoalbuminaemia, hyperbilirubinaemia, prolonged prothrombin time or
international normalised ratio).
4. Known liver disease where treatment beyond the withdrawal of the
implicating agent is required. What tests to do before referral (Minuk G
et al., 1998).
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Consider the following:
1. Screen for viral hepatitis: IgM antihepatitis A virus, HbsAg, antihepatitis C
virus.
2. Antinuclear antibodies.
3. Caeruloplasmin in patients younger than 40 years.
4. Ultrasound of the liver especially where fatty infiltration is suspected (obese
individuals, diabetics and/or hyperlipidaemic patients).