Liver Disease In Pregnancy

Dr Amita Suneja
Professor, OB & GYN
UCMS & GTBH
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
 Physiological changes in hepatic
parameters
NO CHANGE WITH CHANGE
Hepatic blood flow Albumin - 20%-50%
Hepatic & splenic size Globulin -
Liver histopathology Fibrinogen - 50%
Bilirubin- direct or Ceruloplasmin & transerrin -
indirect, AST, ALT, ALP - 2-4 fold
GGTP, TBA LDH - slight
PT/INR Cholesterol & TGL - 2fold

AST, ALT,S Bb, TBA during

pregnancy indicate liver disease
 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
 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/A36wks, Vx, mild contractions, FHS-128/m
P/V-early labor, unclotted blood in vagina
 Investigations
Hb-10g%, TLC-11000/mm, BUN-6mg/dl
platelet-110,000/ul Creatinine-1.5mg%

Bb-11.8mg%: D-8mg% Co2-13mEq/L

AST-144U/L
ALT-197U/L Blood glucose- Normal
ALP-578U/L
Viral markers-negative
PT,PTTK,TT
INR 3.25 Urine-normal

USG-normal
 AFLP or HELLP
AFLP HELLP
Normal BP Can occur in normal BP
No haemolysis Had EL & LP
Less thrombocytopenia No hypoglycemia
Marked coagulopathy
 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
 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,
 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
 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
 Differential diagnosis
IHCP

Anicteric viral hepatitis

Obstructive jaundice
 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
 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
 Etiology:
genetic mutation of MDR3 gene
- hypersensitivity to oestrogens
Environmental
Future pregnancy
Recurrence
No OCP
No progesterone in next pregnancy
IgM HAV +ve Anti HEV +ve
Similar course, PTL, Severe course in preg
PPH, No perinatal 20% fatal
transmission 50% of fulminant hepatitis
IG to baby 0.02ml/kg IM if No vaccine for it
infection within 2 weeks
of delivery or immediate Supportive T/t
postpartum Maternal outcome fatal if
Vaccination to mother fetus dies of hepatitis
when she moves to No carrier stage
endemic area
IG to mother 0.02ml/kg
deep IM within 2 weeks of
exposure to index case
 Positive HBsAg, IgM anti HBc, HBeAg

Course = non preg PNT-20%

10% carrier rate: 25% +ve HBeAg-90%
have ch active hepatitis anti HBe ab-no
& CA transmission
With HBeAg highrisk Transplacental - 5%
for ca vertical at TOD 95%
& Breast Feeding

Infants born with HB are generally asymptomatic but

become carrier in 85%
 Immunoprophylaxis for HBV

Neonate of HBsAg +ve Unimmunised Mother

mother PEP within 48hrs
HBIG-0.5ml(250IU) HBIG-500IU, IM
IM HBV vaccine 0,1,6
TOD and 6 weeks months at different
HBV vaccine-different site
site, IM
0,6,10,14, weeks vs.
0,1,6 months
 Hepatitis C & D & G
Hepatitis C Hepatitis D
IgM anti HCV +ve Co infects with HBV
Course = non preg Course = HB
85% develop ch HC+HB is more severe
hepatitis than HB alone
Vertical transmission 75% develop cirrhosis
only IgM +ve 10% HB vaccine prevents
PCR +ve - 30% delta hepatitis
or HIV +ve Hepatitis G
No immunoprophylaxis HC coinfection
Does not cause hepatitis
 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
 Chronic hepatitis
Liver cirrhosis & portal hypertension
Cholelithiasis in pregnancy
Budd-Chiari syndrome
Post liver transplantation pregnancy