overview of liver disease in pregnancies with few examples of case summaries

1. Liver Disease In Pregnancy
Dr Amita Suneja
Professor, OB & GYN
UCMS & GTBH

2. Challenging disease to manage
• Because of physiology of pregnancy
certain disorders take more ominous
course in pregnancy than in non pregnant
state and some are unique to pregnancy
• May have severe maternal & fetal effects
Therefore it is important to have accurate
diagnosis

3. Physiological changes in hepatic
parameters
NO CHANGE
• Hepatic blood flow
• Hepatic & splenic size
• Liver histopathology
• Bilirubin- direct or
indirect, AST, ALT,
GGTP, TBA
• PT/INR
WITH CHANGE
• Albumin - ↓ 20%-50%
• Globulin -↑
• Fibrinogen - ↑50%
• Ceruloplasmin & transerrin - ↑
• ALP - ↑2-4 fold
• LDH - ↑slight
• Cholesterol & TGL - ↑2fold
↑ AST, ALT,S Bb, TBA during
pregnancy indicate liver disease

4. Classification
Unique to pregnancy
• Hyperemesis Gravidarum
• Intrahepatic cholestasis of pregnancy
• Preeclampsia & liver - HELLP, INFARCTION & RUPTURE
• Acute fatty liver of pregnancy
concurrent with pregnancy
• Viral hepatitis A,B,C,E, herpes simplex
• Drug hepato toxicity
• Budd chiari syndrome
Pregnancy on Preexisting ch liver disease
• Cirrhosis & Portal HT
• Ch Hepatitis B, Ch Hepatitis C, Autoimmune hepatitis
• Primary biliary cirrhosis
• FNH & Hepatic adenoma
• Liver transplantation

5. Case report
• 36yrs, G2P1+0+0+1, 36wks, prev LSCS,↓FM
• c/o nausea, malaise & jaundice
• Treated as viral hepatitis x 3days in NH
• ANC - normal
• GPE – conscious, vitals & BP-n
icterus ++, no edema
• P/A–36wks, Vx, mild contractions, FHS-128/m
• P/V-early labor, unclotted blood in vagina

6. Investigations
Hb-10g%, TLC-11000/mm,
platelet-110,000/ul
Bb-11.8mg%: D-8mg%
AST-144U/L
ALT-197U/L
ALP-578U/L
PT,PTTK,TT ↑↑
INR 3.25
BUN-6mg/dl
Creatinine-1.5mg%
Co2-13mEq/L
Blood glucose- Normal
Viral markers-negative
Urine-normal
USG-normal

7. AFLP or HELLP
• AFLP
Normal BP
No haemolysis
Less thrombocytopenia
Marked coagulopathy
• HELLP
Can occur in normal BP
Had EL & LP
No hypoglycemia

8. Treatment
• 19U FFP & 10U cryoprecipitate
• LSCS 5hrs later for AFD, Male baby A&H
• Hysterectomy for PPH
• D2- moderate ascitis, thrombocytopenia,
coagulopathy, jaundice
• D3- marked icterus, semicomatose,
hypoglycemia, metabolic acidosis
- waiting list: cadaveric liver transplant
- deep coma, convulsions, cerebral edema
• D11- patient died, liver bx taken

9. Acute Fatty Liver Of Pregnancy
• Rare & fatal disorder
• 50% mortality, with early diagnosis & T/t
mortality is 20%
• More common in primi gravida & multiple
pregnancy
• Mildly raised enzymes, -ve viral markers,
dominantly hypoglycemia & coagulopathy,
• Normal USG
• Treatment is supportive management &
termination of pregnancy.
• Ac fulminant failure – liver transplant,

10. • If starts improving- full recovery
• LCHAD (long chain 3-hydroxyacyl-coenzyme A
dehydrogenase) deficiency in fetus →no
oxidation of Fatty acids in fetus
→maternal liver gets overwhelmed with
FA in heterzygous mother →AFLP
• Both parents r heterozygous for this defect

11. Case History II
• 24yrs,G2P1+0+0+1, 34 wks, intense pruritis
H/O pruritis & jaundice in previous pregnacy
ANC in this preg – N, no nausea or vomiting
• Examination
No icterus or hepatosplenomegaly or tenderness
scratch marks +ve, no evidence of scabies
Obstetric exam – uneventful
• Investigations
S Bb – 3mg%, Direct – 2mg%
AST – 200U/L, ALT 104 U/L, ALP – 400IU/L
PT - normal

12. Differential diagnosis
• IHCP
• Anicteric viral hepatitis
• Obstructive jaundice

13. Further investigations
• USG liver to rule out obsruction of the
biliary tract - normal
• Viral markers – normal
• If diagnosis is still in doubt due to unusual
features – confirmatory serum tests should
be total bile acids (TBA) which are raised

14. IHCP
• IIIrd trimester, Recurrent, Mild icterus (Bb is
not > 5 mg%)
• No prodrome, itching, ↑ALP, ↑TBA, n USG
• Counselling – maternal & fetal risk
• Relief of maternal symptoms- phenobarbitone
• Ursodeoxycholic acid – 300mg bd
• Addition of SAMe (S adnosylmethionine) to
UDCA – ? benefit;
• VIT K
• Terminate pregnancy at 37 weeks

15. • Etiology:
genetic – mutation of MDR3 gene
- hypersensitivity to oestrogens
Environmental
• Future pregnancy
Recurrence
No OCP
No progesterone in next pregnancy

16. IgM HAV +ve
• Similar course, ↑PTL, ↑
PPH, No perinatal
transmission
• IG to baby 0.02ml/kg IM if
infection within 2 weeks
of delivery or immediate
postpartum
• Vaccination to mother
when she moves to
endemic area
• IG to mother 0.02ml/kg
deep IM within 2 weeks of
exposure to index case
Anti HEV +ve
• Severe course in preg
• 20% fatal
• 50% of fulminant hepatitis
• No vaccine for it
• Supportive T/t
• Maternal outcome fatal if
fetus dies of hepatitis
• No carrier stage

17. Positive HBsAg, IgM anti HBc, HBeAg
• Course = non preg
• 10% carrier rate: 25%
have ch active hepatitis
& CA
• With HBeAg – highrisk
for ca
• PNT-20%
+ve HBeAg-90%
anti HBe ab-no
transmission
• Transplacental - 5%
vertical at TOD – 95%
& Breast Feeding
Infants born with HB are generally asymptomatic but
become carrier in 85%

18. Immunoprophylaxis for HBV
Neonate of HBsAg +ve
mother
• HBIG-0.5ml(250IU)
IM
TOD and 6 weeks
• HBV vaccine-different
site, IM
0,6,10,14, weeks vs.
0,1,6 months
Unimmunised Mother
• PEP within 48hrs
HBIG-500IU, IM
HBV vaccine 0,1,6
months at different
site

19. Hepatitis C & D & G
Hepatitis C
• IgM anti HCV +ve
• Course = non preg
• 85% develop ch
hepatitis
• Vertical transmission
only IgM +ve – 10%
PCR +ve - 30%
or HIV +ve
• No immunoprophylaxis
Hepatitis D
• Co infects with HBV
• Course = HB
• HC+HB is more severe
than HB alone
• 75% develop cirrhosis
• HB vaccine prevents
delta hepatitis
Hepatitis G
• HC coinfection
• Does not cause hepatitis

20. Fulminant hepatitis
• HE is commonest cause
• Jaundice, encephalopathy, coagulopathy, ARF
• Multiple organ failure
• DD: APLP,HELLP, Eclampsia
• Serological markers r helpful
• ICU care, supportive care, liver transplant facility
• Poor predictors: Bb>18mg%,INR>3.5,III-IV Enceph
• Vit K should be given, replacement of clotting factors
in absence of bleeding should not be done.
• Termination of pregnancy – role is doubtful. Should
be done id diagnosis is in doubt or for fetal survival
in 3rd trimester

21. • Chronic hepatitis
• Liver cirrhosis & portal hypertension
• Cholelithiasis in pregnancy
• Budd-Chiari syndrome
• Post liver transplantation pregnancy