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Liver disease in pregnancy
Gastroenterology and Hepatology Unit
National Hospital of Sri Lanka

• A 24-year-old woman, history of high risk behavior
• P1C0
• POA: 34-weeks
• Admitted to the hospital with a history of absence of
foetal movements for the past one day.
• She also complained of malaise, nausea, vomiting since
last ten days.
• She was detected to be hypertensive in the third
trimester and was on tablet Alpha-methyl dopa 250 mg
three times a day.

• Well-nourished
• Temperature was 36.7°C,
• Vitals: PR was 104/min, RR 20/ min, and BP 120/80
mmHg.
• CNS: She was somnolent but easily arousable.
Oriented to person, place, and time. No focal signs
• Abdomen :Icteric, with mild edema of the legs.
Abdomen was nontender.

• Ultrasonography revealed demise of the 34- week
fetus and a ultrasonically normal liver.
• FBC:
• Hemoglobin: 11g/ dl
• White blood cell count: 10,400/cumm
• Platelet count: 57,000/cumm.
• Peripheral smear was negative for hemolysis and
serum lactate dehydrogenase (S.LDH) levels
were 238 mg%.

• Liver function tests
• AST: 208 U/l
• ALT: 304 U/l
• Total bilirubin: 8.3 mg/dl (direct: 6.7 mg/dl)
• ALP: 532 U/l
• Total protein: 6g/dl (albumin: 2.6 g/dl)
• INR : 3.2

• Blood urea: 40 mg/dl
• serum creatinine: 1.5 mg/dl
• serum glucose: 60 mg/dl
• serum ammonia: 106 μmol/L
• ﬁbrinogen: 62 mg/dl, and ﬁbrin degradation
products (FDP): 360 μg/ml.
• Urine analysis showed mild proteinuria.

Primi mother in POA of 34/52
PIH - on methyldopa
Presented with an IUD
Dark urine, Icteric
high bilirubin, high ALP
ALT ~300
AST ~200
Low albumin
Low platelets
High INR
No signiﬁcant encephalopathy
mild proteinuria
creatinine 1.5 mg/dl
High risk for viral hepatitis

Is this fatty liver of
pregnancy?
What else can it be?
Is this HELLP?
What is the next step?

Are they common?
Intrahepatic
Cholestasis of
Pregnancy
HELLP
Acute Fatty
Liver of
Pregnancy
Hepatitis A
Dengue
Inﬂuenza
Hepatitis B
Hepaitis C
HH
Wilsons
Drug induced
Leptospirosis
0.1% 0.2-0.6% 0.005% …….

Tran, Tram T., Joseph Ahn, and Nancy S. Reau. "ACG clinical guideline: liver disease and pregnancy."
The American journal of gastroenterology (2016).
Reference

Additional tests
• Serology tests like HBsAg, HCV, and HIV were all
negative.
• Blood picture : no haemolysis, LDH normal
• Ammonia levels elevated

• Common scenario - (3-5% of all pregnancies)
• Pregnancy related /unrelated conditions
• Focus on wellbeing of the foetus and the mother
Abnormal liver function tests
in pregnancy

• Transaminases (AST/ALT)
• Bilirubin
• PT/INR
• Gamma GT
• Bile acids
• Albumin
• Haemoglobin
• ALP
• Alfa feto protein
Jamjute, Pradumna, et al. "Liver function test and pregnancy." The Journal of Maternal-Fetal & Neonatal Medicine 22.3 (2009): 274-283.Reference :

• Transaminases (AST/ALT)
• Bilirubin
• PT/INR
• Gamma GT
• 5’ nucleotidase
• Albumin
• Haemoglobin
• ALP
• Alfa feto protein
Jamjute, Pradumna, et al. "Liver function test and pregnancy." The Journal of Maternal-Fetal & Neonatal Medicine 22.3 (2009): 274-283.Reference :
Any abnormality in
transaminases or bilirubin
needs further evaluation

Tran, Tram T., Joseph Ahn, and Nancy S. Reau. "ACG clinical guideline: liver disease and pregnancy."
The American journal of gastroenterology (2016).
Reference
• Ultrasound scan
• MRI without Gadolinium
• CT - not recommended
Liver imaging in pregnancy

Hyperemesis Gravidarum
• Incidence : 0.3-2% of all pregnancies
• Typical presentation ….
• Impact on liver functions :
• Mild/moderate transaminitis
• Bilirubinaemia and dysfunction of synthetic
liver functions are uncommon
• Liver functions recover when vomiting stops

• Incidence 1.2 - 1.5% of South Asians
• Pathophysiology : defect of excretion of bile salts
• Etiology / risk factors :
• Estrogen : high hormone states, past history of
cholestasis with estrogen
• Genetic predisposition - recurs in subsequent
pregnancies
• Advanced maternal age
Intrahepatic cholestasis of pregnancy
Abedin P, Weaver JB, Egginton E. Intrahepatic cholestasis of pregnancy: prevalence and ethnic distribution. Ethn Health1999;4:35–7.
Lee NM, Brady CW. Liver disease in pregnancy. World J Gastroenterol. 2009 Feb 28. 15(8):897-906

• Estrogen : high
hormone states, past
history of cholestasis
with estrogen
• Genetic predisposition -
recurs in subsequent
pregnancies
• Multiparity
Risk factors/etiology
Intrahepatic cholestasis of pregnancy: Relationships between bile acid levels and fetal complication rates. lantz A, Marschall HU, Mattsson LA Hepatology. 2004 Aug; 40(2):467-74.

• Estrogen : high
with estrogen
pregnancies
• Multiparity
• Impaired sulfation and
transportation of bile
acids
• Decreased hepatocytes
membrane permeability
and bile acid uptake by
the liver
Pathophysiology

• Estrogen : high
with estrogen
pregnancies
• Multiparity
Pathophysiology
• High bile acids affect myometrial
contractility and causes vasoconstriction of
chorionic veins in placenta
• leading to preterm deliveries, meconium
staining of liquor, fetal bradycardia,
distress and fetal loss associated with
fasting serum bile acid levels >40 μmol/L.
• The fetal complications correlate with
serum bile acid concentrations. The fetal
risk is very low if levels remain below 40
μmol/L.

• Usually T2 or T3 - but rarely T1
• Pruritus… - sites, timing, usually no rash
• Jaundice
• Fatigue, anorexia, epigastric pain
• Fat malabsorption, steatorrhoea and vitamin deﬁciencies
- via k pph
• Physical signs
Presentation
1 Abedin P, Weaver JB, Egginton E. Intrahepatic cholestasis of pregnancy: prevalence and ethnic distribution. Ethn Health1999;4:35–7.
2 Lee NM, Brady CW. Liver disease in pregnancy. World J Gastroenterol. 2009 Feb 28. 15(8):897-906
in <25%. Always 1-4/52 after pruritus. Increased risk of
cholecystitis and cholelithiasis

• Serum bile acids (fasting) > 10 micromol/l
• Increased Cholic acid : chenodeoxycholic acid ratio
• Aminotransferase : mild to 10-25 times
• Total bilirubin : may be elevated but <6mg/dl
• ALP : up to 4 times - cannot be used in pregnancy
• Gamma GT : mildy elevated
• Liver biopsy (not indicated) : centrilobular cholestasis without
inﬂammation and bile plugs in hepatocytes and canaliculi.
Investigations
Palma J, Reyes H, Ribalta J, Hernández I, Sandoval L, Almuna R, et al. Ursodeoxycholic acid in the treatment of cholestasis of pregnancy: a randomized,
double-blind study controlled with placebo. J Hepatol. 1997 Dec. 27(6):1022-8

Approach to a patient with pruritus in pregnancy
NICE based hospital guidelines - 2017

Differential Diagnoses of
extensive pruritus in pregnancy
Oyarzun, Enrique. "Intrahepatic Cholestasis of Pregnancy-The Riddle Revisited Once Again." reason 1 (2016): 10.

• Ursodeoxycholic acid (500mg - 1.5g daily - divided doses)
• With meals
• Relieves pruritus and improve liver test abnormalities
• Others :cholestyramine, S-adenosyl-L-methionine and
dexamethasone
• Pruritus :Antihistamines, aqueous menthol cream 1%
• Vitamin K and other fat-soluble vitamin supplementation
(vitamin K 10mg daily from 34/52 till delivery if PT prolonged)
Management
Tran, Tram T., Joseph Ahn, and Nancy S. Reau. "ACG clinical guideline: liver disease and pregnancy." The American journal of
gastroenterology 111.2 (2016): 176.

• Lifestyle advices
• Low fat intake
• Frequent tepid water baths
• Soft cotton cloths
• ## Avoid sweating/hot conditions !
• ## Scratch with a babies soft hairbrush
Management
Tran, Tram T., Joseph Ahn, and Nancy S. Reau. "ACG clinical guideline: liver disease and pregnancy." The American journal of
gastroenterology 111.2 (2016): 176.

• Ultimate treatment is delivery - after 36-37 weeks only
• Outcome is usually favourable unless bile acids are markedly
elevated
• If pre-partum is uncomplicated no adversities to the baby
• Rare case reports of progression of ﬁbrosis in familial forms
• Recurrent in future pregnancies (40-90%)
• Cholestasis with estrogen containing contraception (10%)
Intrahepatic cholestasis of pregnancy: Relationships between bile acid levels and fetal complication rates. lantz A, Marschall HU, Mattsson
LA Hepatology. 2004 Aug; 40(2):467-74.

Acute fatty liver of pregnancy
• Rare (1:10,000 or 1:15,000
Deﬁciency of long-chain 3-hydroxyacyl-CoA
dehydrogenase (LCHAD) enzyme - impaired uptake
and oxidation of fatty acids
Normal change in pregnancy to ensure the fetus has
adequate sources of energy
20% of the neonates of mothers who had AFP have
shown known genetic mutations with impaired fatty
acid uptake
Increased free fatty acids
Genetic defects++
T3 : increased fatty acids
from fetus accumulate
Impaired fatty acid uptake
by the fetus/mother
Microvesicular
steatosis

• Rare (1:10,000 or 1:15,000
Increased free fatty acids
Genetic defects++
T3 : increased fatty acids
from fetus accumulate
Impaired fatty acid uptake
by the fetus/mother
• Risk factors
• Male infant
• Twin pregnancy
• Nulliparity
• Low maternal BMIMicrovesicular
steatosis

• 30th - 38th weeks (mean 36)
• 20% present postnatally
• Non speciﬁc systemic upset to overt liver failure

• 1-2 week history of nausea vomiting abdominal pain
and fatigue
• Hypoglycemia, coagulopaty
• Reduced antithrombin III activity
• May progress rapidly to liver failure with
encephalopathy
• 50% will have signs of pre-eclampsia
• DIC in 80-100% (c.f. 20% in HELLP)
AFP : typical presentation

• Aminotransferases (mild - 1000 IU/L)
• Bilirubinaemia
• Deranged coagulation
• Raised ammonia, lactic acids
• Low albumin
• Thrombocytopenia
• Neutrophil leukocytosis
• Renal failure and elevated uric acids
AFP : labs

• Aminotransferases mildly to moderate (up to 1000 IU/L)
• Bilirubinaemia
• Deranged coagulation
• Raised ammonia
• Low albumin
• Thrombocytopenia
• Neutrophil leukocytosis
AFP : labs
• Ultrasound ﬁndings inconsistent
• Liver biopsy is usually not performed
• Exclude other hepatitides : viral, autoimmune,
metabolic
• Diagnosis is based on clinical and laboratory criteria

• Renal failure
• DIC
• Excessive bleeding
• Ascites, affections
• Pancreatitis
• Fulminant liver failure requiring LT
• Death
Potential complications
High lactate
Encephalopathy

• Delivery of the baby
• Supportive care to the mother
• Plasmapharesis
• If haptic functions fail to recover/fulminant refer for a
transplant program
• Mortality reduced with modern care
• maternal 80-85% to 7-18%
• fetal 50% to 9-23%
AFP : Management and outcome

• Child needs to be screened for genetic defects in
fatty acid oxidation
• If homozygous : failure to thrive, hepatic failure,
cardiomyopathy, neuropathy, myopathy, non-ketotic
hypoglycaemia, and death
• Recurrence in subsequent pregnancies : 25%
AFP : Management and outcome

• Hepatic : ﬁbrin deposition within the hepatic sinusoids resulting in
sinusoidal obstruction and subsequent hepatic ischaemia.
• Diffuse areas of hemorrhage and necrosis leading to large
hematomas, capsular tears, and intraperitoneal bleeding.
• Pre-eclampsia 3% of pregnancies / HELLPS 0.5% - 1%
• Pathophysiology
• Abnormal placentation leading to release of cytokines etc. that leads
to generalized endothelial dysfunction, platelet aggregation and
arterial hypertension
• MAHA.
HELLP syndrome

• Multiparity
• Nulliparity
• May develop in late pregnancy/post partum in
patients who did not have hypertension/proteinuria in
T2/T3
Pre-eclampsia/HELLP : Risk factors
HELLP syndrome - a multisystemic disorder. Mihu D, Costin N, Mihu CM, Seicean A, Ciortea R J Gastrointestin Liver Dis. 2007 Dec; 16(4):419-24.

• Usually develops from 27-36 weeks of POA but 25%
post partum
• Initially asymptomatic elevation of blood pressure
• Non speciﬁc: RHQ pain, headache, visual changes,
nausea vomiting
• Hyper-reﬂexia, edema
• Elevated transaminases (30%) indicate advanced
pre-eclampsia
Pre-eclampsia/HELLP : clinical course

• Usually develops from 27-36 weeks of POA but 25%
post partum
• Initially asymptomatic elevation of blood pressure
• Non specific: RHQ pain, headache, visual changes,
nausea vomiting
• Hyper-reflexia, edema
• Elevated transaminases (30%) indicate advanced
pre-eclampsia
• Although majority in T3, 25% present post partum
• Asymptomatic/non specific symptoms
• Jaundice rare in early disease (5%)
• Liver dysfunction less prominent
• Hypertension/proteinuria is not essential for
diagnosis

• renal failure
• cerebral hemorrhage
• hepatic infacrtions/haematomas/rupture
• death

• Conﬁrmed by angiogenic markers including
decreased placental growth factor, increased serum
soluble endoglin, and increased soluble fms-like
tyrosine kinase-1 (VEGF) receptor
Pre-eclampsia/HELLP : Diagnosis

• Features of HELLPS : Low platelets, high LDH
• AST/ALT from mild to 10-20 times
• Bilirubin usually <5mg/dL
• Liver imaging (USS/CT) : sub capsular hematomas,
intraparenchymal hemorrhage, infarction or hepatic rupture
• PT/INR normal unless DIC/advanced liver injury
• Uric acid >7.8mg/dL increased morbidity and mortality for both
mother and foetus
Pre-eclampsia/HELLP : Diagnosis

• If in doubt exclude other Das
• Delivery
• Supportive care - pre-op preparation etc.
• BP control
• Foetal optimisation/lung maturation
• Control of seizures
Pre-eclampsia/HELLP : Management

Case report…
• ? HELLPS ? AFLP
• Uncomplicated LSCS on the day of admission
• Blood products, vitamin K, ﬂuids given
• Subsequently developed AKI, ARDS, DIC
• Ventilated, HD received, ICU care
• Recovery from post op day 10 - discharged on day 40

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