2. Yellow discoloration
of skin, conjunctiva,
sclera and mucosa
associated with rise
in serum bilirubin
above 2mg/dl
( normal 0.2-01mg/dl)
Latent jaundice:1-2mg/dl
4. Mechanisms:
↑ production of bilirubin
↓ hepatocyte transport or conjugation
Impaired excretion of bilirubin
Impaired delivery of bilirubin into intestine
--“surgically relevant jaundice” or obstructive
jaundice
“Cholestasis” refers to the latter two, impaired
excretion and obstructive jaundice.
5. Physiological changes in liver
during pregnancy
Liver is not palpable during pregnancy.
Sr. protein decrease by 20%. Bilirubin also decrease
In 3rd trimester ALP level increase up to 2-4 times the
normal. It returns to normal in 2-3 month of post
delivery.
ALT and AST level normal, but increase during labour
and normalize in 1-2 days postpartum.
6. 5’ nucleotides is significantly raised but GGT
slightly decrease.
Increase sr. triglyceride and VLDL. Cholesterol
increases up to 2 times the normal.
10-15% normal pregnant may have bilirubin level
of over 1mg% d/t delayed excretion of bilirubin
that may leads to increase incidence of purities in
pregnancy.
7. Incidence: 1 to 4/1000 deliveries.
Maternal mortality 12% in our country
Grade of jaundice:
Mild: bilirubin <6mg%
Moderate 6-15mg%
Severe >16mg%
8. Cause of jaundice during
pregnancy
Liver disease unique to
pregnancy
Coincidental
occurrence of liver
disease in pregnancy
Acute fatty liver of
pregnancy.
Intrahepatic cholestasis of
pregnancy.
Pre-eclampsia, eclampsia,
HELLP syndrome.
Hyperemesis gravidarum
Acute viral hepatitis.
Hemolytic jaundice.
Cholelithiasis.
Drug induced
Obstructive jaundice
9. Jaundice develop during pregnancy
on chronic liver disease:
A. Cirrhosis of liver.
B. Chronic hepatitis
10. Liver disease probably related to
pregnancy:
Portal HTN.
Cholecystitis.
Pancreatitis.
Wilsons ds.
Gilbirts syndrome.
Budd chiari syndrome.
11. Acute fatty liver of pregnancy
Acute hepatic failure in absence of viral hepatitis, IHC,
etc.
Manifest usually in 3rd trimester sometimes present
after delivery.
Incidence: 1 in 7000-15000 pregnancies.
More common in primipara and associated with pre-
eclampsia, multiple pregnancy, having male fetus.
12. Etiology:
may be mitochondrial dysfunction.--- >LCHAD
def.
--->defect in oxidation pathway of fatty acid.
↑estrogen in 3rd trimester leads to ↓ mitochondrial
oxidation.
13. Table 4 . Swansea criteria for diagnosis of acute fatty liver of
pregnancy
Six or more criteria required in the absence of another cause
Vomiting
Abdominal pain
Polydipsia/polyuria
Encephalopathy
Elevated bilirubin >14 μ mol/l
Hypoglycaemia <4 mmol/l
Elevated urea >340 μ mol/l
Leucocytosis >11×10 6 cells/l
Ascites or bright liver on ultrasound scan
Elevated transaminases (AST or ALT) >42 IU/l
Elevated ammonia >47 μ mol/l
Renal impairment; creatinine >150 μ mol/l
Coagulopathy; prothrombin time >14 s or APPT>34 s
Microvesicular steatosis on liver biopsy
14. Clinical features and diagnosis
Clinical features: Anorexia, nausea, vomiting,
headache, fatigue, altered mental status,
polydypsia with or with out polyuria.
Jaundice 90%,
Right upper quadrant pain.
Puritus and ascites 50% cases.
Hepatic encephalopathy seen in latter.
Clinical improvement occurs 1-4 weeks after
delivery..
15. Conjugated hyperbilirubinimia up to 5-15 mg/dl.
↑ALT but <1000iu/ml.
↑ALP 3-4times. Prolonged PT.
↑BUN and amonia level..
↓sr. fibrinogen,hypoglycemia. Hyperurecemia,
leukocytosis,
USG, CT, MRI demonstrate fatty infiltration.
liver biopsy is gold standered.
--microvesicular fatty infiltration
--portal inflamation with cholestasis.
16. Prognosis
Maternal mortality:10-15% d/t
Hepatic encephalopathy, DIC, ARDS, Renal failure, Acute
pancreatitis, PPH.
Fetal mortality: 15-20% d/t
IUD , prematurity.
Full clinical and laboratory remission occurs over 1-4
weeks post delivery..
Prenatal diagnosis in next can be done by CVS or
amniocentesis
Recurrence in future pregnancy 15-25% in those have
LCHAD deficiency.
17. Management
Supportive and directed towards management of
liver insufficiency and complication.
Optimal management is prompt delivery.. Transfer
to high dependency unit.
FFP, platelets, blood transfusion to correct
coagulopathy.
iv glucose to maintain normoglycemia.
monitor LFT with PT.
In fulminant hepatic failure liver transplantation
is only treatment.
18. Intrahepatic cholestasis of
pregnancy
Typically occurs in late pregnancy. Affecting 1.5-2% of
pregnancies.
Disappears spontaneously, recurs in subsequent
pregnancy.
ETIOLOGY:
i. Hereditary hepatic ↑ sensitivity of pregnancy
hormone → affects gallbladder function →slow or
stop the bile flow →build up of bile acid in liver.
ii. Genetic mutation in the hepatocellular phospholipid
transporter MDR3 in 15% case.
iii. Familial.
iv. Selenium deficiency in diet.
v. Previous liver damage.
19. Intrahepatic cholestasis of
pregnancy
Typically manifest in 3rd trimester but can occure as
early as 10 weeks.
Puritus in 2nd half of pregnancy which is otherwise
unexplained is most charecteristic manifestation 70%
cases.
Puritus on palm and sole, intensity more in night.
Severe puritus leads to insomnia, fatigue, depression
,mental disturbance.
Dark colour urine.
Jaundice seen in 10% cases usually mild ,develop 1-4
wks after puritus.
20. Jaundice usually disappears with in weeks following
delivery.
Puritus begins to decline a few hours after delivery and
disappears with in few days. Purities as a rule persist
longer than jaundice.
Biochemical abnormalities normalize in few weeks
following delivery.
If persist more than three month after delivery,
investigate to rule out chronic liver disease.
21. Sr.bile acid is earliest and most consistent change.
Fasting sr. total bile acid concentration is specific test.
10-100 fold rise in sr. cholic acid.
↑ALP, ↑5’ nucleotidase by 2 fold..
AST &ALT mildly increase.
↑conjugated bilirubin 20% cases. But level between 2-
5mg/dl.
PT usually normal.
Serum cholesterol increases 2-4 fold
Sr. viral marker negative.
22. management
a. Ursodeoxycholic acid(UDCA):10-20mg/kg/day, even in high
dose(1.5-2gm/d) It relieves purities by decreasing the
concentration of bile acid.
- -improve hepato-cellular secretion by stimulation of
canilicular expression of transport protein.
--- restore the impaired maternal-placental bile acid
transport across the trophoblast.
---liver function test should be repeated weekly until
delivery and at 6weeks postpartum to ensure
return to normal baseline.
23. b . Corticosteroids: dexamethasone 12mg/day for 1 week.
---improves biochemical abnormalities but does
not improve puritus.
c. S-adenosyl methionine: it improve puritus by decreasing
the negative effects of estrogen on bile acid secretion.
d. Cholestyramine: relives puritus.
- binds to bile acids in gut.
- It increases the risk of vit-k deficiency, thus ↑ risk of
PPH.
-therefore monitoring of PT .
e. Vit-k: 10 mg daily.
24. Prognosis
Fetal risk:
-- morbidity increase if bile acid more than 40micmol/l,. Perinatal
mortality 35-70/1000 live birth
-preterm delivery 15-60%
-intrapartum fetal distress. - meconium aspiration.
-fetal respiratory distress. -IUFD 0.4-4.1%.
Maternal risk:
-↑caesarean section rate 25-36%.
-PPH 20-22%.
-developing gallstones subsequent to pregnancy.
- recurrence in next pregnancy.
25. HELLP syndrome
Coined by Dr.Louis weinstein in 1982.
0.5-0.9% of all pregnancies, and 10-20% case with
preeclampsia.
characterized by haemolysis, elevated liver enzyme ,low
platelet.
More common in multiparous and older pregnant
women.
Develops during antepartum periods in 70% cases with
frequency between 27th and 37th wks GA.
Majority with HELLP syndrome have HTN and
proteinuria, but it may absent in10-20% cases.
26. Pathogenesis: as in preeclampsia activation of
complement and coagulation cascade→increse
vascular tone,platlet aggregation , alteration in
TXA2 and prostacycline ratio. Leade to
--micro angiopathic hemolytic anemia.
--elevated liver enzyme(d/t periportal
hepatic necrosis)
--thrombocytopenia.
Clincal picture: nausea, vomiting, malaise,
headache,weight gain, upper abdominal pain,
HTN,
27. DIAGNOSIS
Peripheral smear: features of hemolysis i.e
schizocytes, Burr cells,↑reticulocytes, ↑LDH.
↑Uncojugated bilirubin
-- thrombocytopenia.
Elevated liver enzyme--↑ALT and AST.
Diagnostic criteria: Mississippi classification.
CT or USG if subcapsular hematoma is suspected.
29. Management
Stabilizes maternal condition.
Control HTN.
Antiseizure prophylaxis with mgso4.
Correct coagulopathy. Assessment of fetal wellbeing.
Definitive therapy is delivery irrespective of
gestation.
Mode of delivery: vaginal delivery prefered.
If CS has to be done 10 units of platlets should be
arranged if count <40000/cmm,
Intensive monitoring for 48 hrs,
Dexamethasone therapy to continue untill
postpartum resolution of disease occurs.
30. Prognosis
Maternal mortality 2-25%.
Perinatal mortality 33% .
Recurrence in subsequent pregnancy 25%..
Most patient have rapid, early resolution of
HELLP syndrome after delivery, with
normalization of platlets 5-7 postpartum day.
31. Hyper emesis gravidarum
Extreme of spectrum of morning sickness.
c/b intractable nausea, vomiting ,dehydration, metalic
acidosis or alkalosis, electrolyte imbalance, weight
loss.
Incidence less than 1 in 1000 pregnancy.
Limited in 1st trimester, more in 1st pregnancy , recur in
next pregnancy, more in multiple pregnancy with
hydatidiform mole.
Etiology:
a) Hormonal: hCG, estrogen, progesterone.
b) Psychological(neurosis)
32. Pathology:
Liver: centri lobular hepatic infiltration with out
necrosis.
Heart: small heart , occasonal sub endocardial
hemorrhage.
Brain: small hemorrhage in hypothalamic region
giving the manifestation of wernick’s
encephalopathy
34. Management
Hospitalization in severe case,
Restriction of oral fluid, and iv fluid given to
correct dehydration.
Anti emetics and vitamins.
Hydrocortisone use in severe case.
Nutritional support with vit b1, vitb6, vit b12, vitc.
35. Acute viral hepatitis
MC cause of jaundice in pregnancy.
Caused by hepatiti A,B,C,D and E VIRUS.
36. Hepatitis A:
Occurs in area of crowding or poor sanitation
Transmitted by feco oral route, with IP 28-30 days.
c/b initial period of fever, anorexia , nausea, vomiting,
jaundice, subsides 2-4 weeks
In acute stage IgM, and IgG promotes immunity.
Self limited, no carrier state, no vertical transmission,
Not teratogenic, but ↑ risk of preterm birth.
Post exposure immunoglobin and vaccine may be
given to seronagative.
Infant born of seropositive mother may be given active
and passive immunization.
38. Hepatitis B
Prevalance in india 0.2-7.7% in pregnant women.
Transmitted by parenteral route , IP 30-180 days.
Routine screening in early pregnancy should be
done.
Diagnosed by HBV DNA, HBsAg(Ab), HBcAb,
HBeAg(Ab).
Vertical transmission 10-90%.
5-10% may go to carrier state,
Post exposure immunoglobin and vaccination
should be given to sero negative pregnant women.
All infant born of sero positive mother must be
given active and passive immunization
39. Hepatitis B .
22. Active–passive immunoprophylaxis with hepatitis B immune
globulin and the HBV vaccination series should be administered
to all infants born to HBV-infected mothers to prevent
perinatal transmission (strong recommendation, low level of
evidence).
23. Women chronically infected with HBV and high viral load
(>200,000 U/ml or >10 6 log copies/ml and higher) should be
off ered antiviral medication with tenofovir or telbivudine in
the third trimester to reduce perinatal transmission of HBV
(strong recommendation, low level of evidence).
24. C-section should not be performed electively in HBV-positive
mothers to prevent fetal infection (strong recommendation,
very low level of evidence).
25. Women chronically infected with HBV should be allowed to
breastfeed as recommended for infant health (strong recommendation,
very low level of evidence).
40. Hepatitis C
Prevalance in pregnancy 2.3-17%.
Transmitted by parenteral route, IP 30-60days
Vertical transmission 3-6%.
Diagnosed by HC antibody and RNA-PCR.
NO vaccination is available.
Routine screening not mandatory.
All infants born of HCV positive mother should be
follow up.
41. All pregnant women with risk factors for HCV should
be screened with anti-HCV antibody. Screening should
not be performed in women without risk factors for
HCV acquisition (strong recommendation, low level of
evidence).
27. Invasive procedures (e.g., amniocentesis, invasive fetal monitoring)
should be minimized in infected mothers and their
fetus to prevent vertical transmission of hepatitis C (strong
recommendation, very low level of evidence).
28. C-section should not be performed electively in HCV-positive
mothers to prevent fetal infection (strong recommendation,
very low level of evidence).
29. Women chronically infected with HCV should be allowed to
breastfeed as indicated for infant health (strong recommendation,
very low level of evidence).
30. Hepatitis C therapy should not be off ered to pregnant
women to either treat HCV or decrease the risk for vertical
transmission (strong recommendation, very low level of
42. Autoimmune hepatitis
31. Pregnant women with autoimmune hepatitis (AIH) should
be continued on their treatment with corticosteroids and/or
azathioprine (AZA) (strong recommendation, very low level
of evidence).
32. Pregnant women with primary biliary cirrhosis (PBC) should
be continued on their treatment with UDCA (strong recommendation,
very low level of evidence).
33. Pregnant women with Wilson’s disease (WD) should be
continued, with dose reduction if possible, on their treatment
with penicillamine, trientine, or zinc (strong recommendation,
very low level of evidence).
34. Pregnant women with suspected portal hypertension should
undergo screening with upper endoscopy for esophageal
varices in the second trimester (strong recommendation, low
level of evidence).
35. Pregnant women who are found to have large esophageal
varices should be treated with beta-blockers and/or band
ligation (conditional recommendation, very low level of
evidence).
36. Pregnant women with a history of liver transplantation
should continue their immunosuppression except for
mycophenolic acid (strong recommendation, moderate level
43. Hepatitis D
Delta virus; defective RNA virus.
Must co-infect with HBV.
Transmission similar to HBV.
Chronic co-infection with HBV and HDV is more
severe.
Neonatal transmission is unusual.
44. Hepatitis E
Transmitted by feco-oral route.
Fulminant varity is most common among all types.
HEV specific IgM and IgG can be detected.
Chance of vertical transmission.
Chronic infection is uncommon but may occurs.
Hepatitis E vaccine(Hecolin) .
Maternal mortality 15-20%.
45. Clinical features of viral hepatitis
Prodromal phase: nausea, vomiting, pyrexia, loss of
appetite, upper abdominal pain, myalgia, artthralgia,
dark urine, clay colour stool. Palpable liver.
Icteric phase: appears 1-2 weeks after symptom.
Recovery phase: jaundice recedes, liver enlargement
regress, it takes 6-12 weeks for complete recovery.
Investigation:
---LFT
---liver biopsy.
46. •Effects on pregnancy and fetus.
• ↑incidence of abortion, pre term labour, still birth,
• ↑incidence of primary pulmonary hypertention ,
hemorrhagic manifestation, hepatic coma,
47. Management
Preventive:
--disposable syringe & needle are used
--blood transfusion with due care.
--sanitation and clean water supply,
--health personnel should be provided with the
guidelines while dealing with pregnant women and
during delivery.
--active and passive immunization.
48. Therapeutic:
- bed rest until jaundice disappears.
- isolation as far as possible.
-diet rich in carbohydrate.
-vit B-complex .
49. Acute
Hepatitis
ICP HELLP AFLP
Trimester Any Trimester Third Third Third
Presenting
symptoms
Fever, Jaundice Pruritus HTN, Nausea,
Vomiting,Pain
Nausea,
Vomiting,Pain
ALT & AST Markedly high Normal to Mild
rise
Moderately
high
Moderately
high
Alkaline
Phospatase
Normal to mild
rise
High Normal Normal
Platelets Normal Normal Low Normal
Fetal
Complications
Infection with
HBV & HCV
Prematurity,
IUGR, FD
IUGR,
Prematurity
Prematurity
Maternal
Complications
Acute liver
failure(HEV)
None Thrombocytope
nia, septicemia,
DIC
Acute liver
failure
51. Sickle cell anaemia with pregnancy :
Pregnancy is high risk in sickle cell disease (mostly SS
Haemolytic crisis causes rapidly developing anemia with
jaundice.
Vaso-occlusive crisis causes osteonecrosis, infarction of
kidney, lung. Hepato-splenomegaly, heart failure are
common.
Increased incidence of maternal pre-eclampsia, PPH,
infection. Increased morbidity and mortality due to CVA,
pulm infarction, CHF, embolism etc.
Increased risk of abortion, prematurity, IUGR, fetal loss,
perinatal mortality.
52. Management includes :
• Pre-conceptional councelling
• During pregnancy: Regular ANC, Prophylactic folic
acid 1 mg daily, Iron supplementation etc. Infection or
appearance of unusual symptoms needs
hospitalization
• During labour: Oxygen inhalation, Adequate
hydration, Antibiotics . Epidural anesthesia preferred.
Caesarian section should be performed for obstetric
indication only.
• Contraception: Sterilization even with low parity. OC
pills, IUCD contraindicated. Barrier method is ideal.
53. Malaria
Malaria is imp. cause of jaundice in our country.
Effects on mother: Anemia, Hypoglycemia, Metabolic
acidosis, Hepatic dysfunction with jaundice, Renal
failure, Pulmonary edema, Convulsions, coma etc.
Effects on the fetus: Abortion, Preterm labour, Pre-
maturity, IUGR, IUFD etc.
Congenital malaria is rare (<5%) unless placenta is
damaged (with Plasmodium falciparum in 2nd half of
pregnancy ).
Effects of pregnancy on malaria: Risk and severity of
infection increases, Complications are high.
54. Management:
Management:
• Prevention from mosquito bite.
• Chemoprophylaxis: Cloroquine ( 300mg base weekly, 2
weeks before travel, covering the period of exposure and 4
weeks after leaving the endemic zone). Mefloquine
250mg/week in cloroquine resistant cases.
• Treatment:
i. Cloroquine- 10mg base/kg followed by 10mg/kg base at
24 hr and 5mg/kg at 48 hr.
ii. Cloroquine resistant cases: Quinine- 10mg salt/kg p.o
,every 8 hr for 7 days.
iii. Complicated malaria: Artesunate IV 2.4mg/kg at 0, 12, 24
hr, then daily for 5 days. Oral therapy ( 2mg/kg) when
the pt is stable.
55. Symptoms/signs:
weakness, Dark urine, anemia,
Icterus, splenomegaly
Lab:
UB without bilirubinuria
fecal and urine urobilinogen
hemolytic anemia
hemoglobinuria (in acute intravascular hemolysis)
Reticulocyte counts
57. Clinical picture:nausea, vomiting, abdominal pain,
jaundice and puritus, sign of liver failure, cerebral
oedema, encephalopathy.
Morphological change:
Hepatitis, cholestasis, fatty liver, granulomatous
hepatitis.
Clinical diagnosis: regression of symptom when
treatment is interrupted and recurrence when it is
administered again.
May be confirmed by biopsy.
58. o Pregnancy is relative hyper coagulable state.
o Thrombosis of one or more hepatic veins and IVC.
o Resulting injaundice, ascitis, oedema and
coagulopathy.
o Liver is enlarged and tender.
oDiagnosis by
---- doppler USG of IVC and hepatic vein.
----hepatic venous angiography.
Hepatic venous outflow
obstruction
59. Pregnancy and chronic liver
disease
CLD has mainly two types of manifestation
Firstly ,those related to portal HTN such as
oesophageal and gastric varices. The varices may
be low or high grade
secondly ,features of liver failure such as
ascites, jaundice, coagulopathy, hepatorenal
syndrome, hepatic encephalopathy.
60. CLD with well preserved liver function
--cirrhosis is not contraindication to pregnancy.
--pregnancy may be uneventful.
--all pregnant patient should screen for varices in second
trimester.
--low grade varices should be observed, high risk varices should
receives primary prophylasix either beta blockers or
endoscopic variceal ligation.
--vasopressin is contraindicated in pregnancy as it may causes
placental ischemia, necrosis and amputation of fetal digit.
--coagulation should be corrected before induction or cs.
--vaginal delivery prefered, should be assited and second stage
shortened.
--early termination of pregnancy should be consider when
hepatic decompensation is present.
61. CLD with decompensation of liver function
Most women are amenorrhoeic and unable to
conceive because of associated hypothalamic-
pituitary dysfunction.
It is high risk pregnancy with maternal and fetal
complication 50% with increase fetal loss .
62. Obstructive jaundice
Intrahepatic-Liver cell Damage/Blockage of Bile
Canaliculi
Drugs or chemical toxins
Dubin-Johnson syndrome
Estrogens or Pregnancy
Infiltrative tumors
Intrahepatic biliary hypoplasia or atresia
Primary biliary cirrhosis
63. Extrahepatic-Obstructive of bile Ducts
Compression obstruction from tumors
Congenital choledochal cyst
Extrahepatic biliary atresia
Intraluminal gallstones
Stenosis-postoperative or inflammary
64. Cholestasis
Clinical features:
Pain due to gallbladder disease, malignancy,
or stretching of the liver capsule
Fever due to ascending cholangitis
Palpable and / or tender gallbladder
Enlarged liver, usually smooth.
Scratch marks: excoriation
Finger clubbing
Loose, pale, bulky, offensive stools
Dark orange urine
66. Imaging for Obstructive Jaundice
RUQ Ultrasound
See stones, CBD diameter
CT scan
Identify both type & level of obstruction
ERCP
Direct visualization of biliary tree/panc ducts
Procedure of choice for choledocholithiasis
Diagnostic –AND- therapeutic (unlike MRCP)
PTC useful of obstruction is prox. to CBD
Endoscopic Ultrasound or EUS
67. Treatment
If Medical, then treat the etiology
If Obstructive Jaundice:
Should r/o ascending cholangitis,
For cholangitis: IVF, IV Antibiotics, Decompression
Stones (remove stones vs stent vs drainage)
Done via ERCP or PTC or open (surgery)
Benign stricture (stent vs drainage catheter)
Cancer (Stent vs drainage +/- resect the CA)
The key principle is decompression, either
externally(drainage) or internally(stenting) the duct
open to allow better drainage
68. Cholelithiasis
Pregnancy alters bile composition and gall bladder
emptying slows in the second trimester increasing the risk
of gall stones.
Risk factors are multiparity and previous gallbladder
disease.
Choledocholithiasis accounts for approximately 7% of
patients with jaundice in pregnancy but jaundice occurs in
only 5% of cholelithiasis.
Treatment involves laparoscopic cholecystectomy.
Uncomplicated cholecystectomy is safer in first and second
trimesters with fetal loss about 5%
But with common bile duct exploration and if with
pancreatitis then 15 % maternal and 60% fetal mortality
69. Jaundice in pregnancy should be evaluated thoroughly
with proper history, clinical examination, laboratory
investigation to identify the underlying cause.
Proper management may improve maternal and
fetal outcome.