Liver disease in Pregnancy

1. Liver Disease In
Pregnancy
Gopisankar.M.G
2008MBBS

2. Physiologicalchangesin pregnancy
• Palmar Erythema, vascular spiders
• Placenta  Alkaline Phosphatase in last trimester
• Bilirubin and Transaminase levels are normal

3. Liver diseases
1. Pregnancy Induced Liver disease
• Hyperemesis Gravidarum
• Obstetric Cholestasis
• AFLP
• Pre- eclampsia and HEELP syndrome
2. Coincidental Liver Disease
• Viral Hepatitis
• Drug Induced Jaundice
3. Pregnancy superimposed on Chronic Liver Disease
• Congenital hyperbilirubinaemia
• Cirrhosis
• Chronic Hepatitis

4. Obstetric Cholestasis
• Intra hepatic cholestasis of pregnancy / icterus gravidarum
Aetiology
• Normal pregnancy –mildly cholestatic/retarded biliary flow
• Due to estrogen
• Also genetic basis
• 50% family history
• Inc bile acids in circulation
• h/o pruritis on OCP anticipate tendency for cholestasis in
pregnancy

5. Clinical features
• Generalised severe Pruritis in third trimester
• More in palms , soles, trunk
• Rarely jaundice may follow the pruritis after 2-4weeks
• Significant hepatosplenomegaly is unlikely
• Investigations
• Abnormal LFT
• Elevated s.bile acids ,Alkaline Phosphatase ,SGOT ,SGPT-mild
• If very high SGOT/PT(>250) think of hepatitis
• Elev. S.bilirubin –but not > 5g/dL
• USG –exclude Gall stones

6. Management
• LFT frequently
• Antepartum Fetal surveillance and Induction at 38 weeks is
ideal
• Continuous CTG at time of labour
• Vitamin K administration –reduce chance of PPH and Fetal
intracranial haemorrhage
• Pruritus  Ursodeoxycholic acid -300mg BD hydrophilic bile
acid
• Releives symptoms ,normalise LFT – reduce the proportion of
hydrophobic and hepatotoxic bile acids
• Another option is Cholestyramine  but won’t corrects LFT

7. Maternal and Perinatal Prognosis
• Inc perinatal mortality and morbidity
• Fetal distress
• Unexplained IUD – due to acute anoxia
• No IUGR /Oligamnios so USG and Doppler are not helpful
• Fetal coagulopathy
• IC bleed - Vit K deff.
• Maternal morbidity  Malbsorption and Vitamin K deff. 
prolongation of clotting time and PPH
• Jaundice usually disappears after 1-2 weeks of delivery
• Recurrence – may happens , and with use of OCP with
estrogen