Medical and Surgical Complications in Pregnancy
Intrahepatic cholestasis treatment in pregnancy...(AIPG 2010)
Pregnancy and the liver
Liver disease in pregnancy may be intercurrent, pregnancy-associated or pre-existing.
1. Intercurrent liver disease
a. When elevated serum transaminases are present, acute viral hepatitis (particularly in IIIrd trimester, runs a severe course and can go in to fulminant hepatic failure) and occur during pregnancy.
b. Gallstones are more common during pregnancy.
2. Pregnancy-associated liver disease
a. These conditionals only occur during pregnancy, may recur in subsequent pregnancies, and resolve after delivery of the baby
3. Intrahepatic cholestasis of pregnancy
a. This usually occurs in the third trimester of pregnancy but can occur earlier;
b. It is associated with intrauterine growth retardation and premature birth, increase fetal mortality.
c. The condition characteristically presents with profound itching and cholestatic LFTs. But the bilirubin may be normal and the liver biochemistry may show raised liver enzymes.
d. Placental bile salt deposition contribute to progressive uteroplacental insufficiency.
e. Resolves typically within two weeks of termination of pregnancy but can reoccur in next pregnancy or with the use of OC.
f. Treatment is ursodiol.
4. Acute fatty liver of pregnancy
a. This is more common in twin and fist pregnancies.
b. It typically presents between 31 and 38 weeks of pregnancy with Vomiting pain following by lactic acidosis, a coagulopathy, encephalopathy and renal failure.
c. Hypoglycemia can occur.
d. The features are characteristic of a defect in beta-oxidation of fatty acids in the mitochondria that leads to the formation of small fat droplets in liver cells (known as microvesicular fatty liver). Some women are heterozygous for long –chain 3-hydroxy-CoA dehydrogenate deficiency (LCHAD).
e. Only treatment is termination of pregnancy.
5. Toxanemia of pregnancy and HELLP syndrome
a. The HELP syndrome is a variant of pre-eclampsia that tends to affect multiparous women and comprised hemolysis, elevated liver enzymes and thrombocytopenia and fluid retention.
b. Serum transaminases are high.
c. The condition can be complicated by hepatic infarction and rupture.