Hepatic disorders and jaundice

Some liver disorders are specific to pregnant women, and some pre-existing or co- existing disorders may complicate the pregnancy, as Box 12.5 Hepatic disorders o f pregnancy Specific to pregnancy Intrahepatic cholestasis of pregnancy Acute fatty liver in pregnancy Pre-eclampsia and eclampsia Severe hyperemesis gravidarum. Pre- or co-existing in pregnancy Gall bladder disease Hepatitis

C a use s o f ja undice in pr e g na ncy Not specific to pregnancy Viral hepatitis – A, B, C are the most prevalent Hepatitis secondary to infection, usually cytomegalovirus, Epstein–Barr virus, toxoplasmosis or herpes simplex Gall stones Drug reactions Alcohol/drug misuse Budd–Chiari syndrome Pregnancy-specific causes Acute fatty liver HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome Intrahepatic cholestasis of pregnancy Hyperemesis gravidarum Note: Jaundice is not an inevitable symptom of liver disease in pregnancy.

Obstetric cholestasis (OC) This is an idiopathic condition that usually begins in the third trimester of pregnancy, but can occasionally present as early as the first trimester. It affects 0.7% of pregnancies and resolves spontaneously following birth, but it has up to a 90% recurrence rate in subsequent pregnancies (Williamson and Girling 2011). Its cause is unknown, although genetic, geographical and environmental factors are considered to be contributory factors. It is not a life-threatening condition for the woman, but there is an increased risk of pre-term labour, fetal compromise and meconium staining, and the stillbirth risk is increased unless there is active management of the pregnancy.

Clinical presentation The presentation may include: pruritus without a rash insomnia and fatigue as a result of the pruritus fever, abdominal discomfort, nausea and vomiting urine may be darker and stools paler than usual a few women develop mild jaundice.

Investigations The following investigations should be done: Tests to eliminate differential diagnoses such as other liver disease or pemphigoid gestationalis (a rare autoimmune disease of late pregnancy that mimics OC) include hepatic viral studies, an ultrasound scan of the hepatobiliary tract and an autoantibody screen. Blood tests to assess the levels of bile acids, serum alkaline phosphatase, bilirubin and liver transaminases, which would be raised. Management Management consists of: Application of local antipruritic agents, such as antihistamines. Vitamin K supplements are administered to the woman, 10 mg orally daily, as her absorption will be poor, leading to prothombinaemia which predisposes her to obstetric haemorrhage if left untreated. Monitor fetal wellbeing possibly by Doppler of the umbilical artery blood flow. Consider elective birth when the fetus is mature, or earlier if the fetal condition appears to be compromised by the intrauterine environment, or the bile acids are significantly

raised, as this is associated with impending intrauterine death. Provide sensitive psychological care to the woman. Advise the woman that her pruritus should disappear within 3–14 days of the birth. If the woman chooses to use oral contraception in the future, she should be advised that her liver function should be regularly monitored.

Gall bladder disease Pregnancy appears to increase the likelihood of gallstone formation but not the risk of developing acute cholecystitis. Diagnosis is made by exploring the woman's previous history, with an ultrasound scan of the hepatobiliary tract. The treatment for gall bladder disease is based on providing symptomatic relief of biliary colic by analgesia, hydration, nasogastric suction and antibiotics. If at all possible, surgery in pregnancy should be avoided.

Viral hepatitis Viral hepatitis is the most commonly diagnosed viral infection of pregnancy (Andrews 2011). See Table 12.3 for information about hepatitis A, B and C in pregnancy. Hepatitis D, E and G have more recently been described in medical literature but their relevance to pregnancy is not yet known.

Skin disorders Many women suffer from physiological pruritus in pregnancy, particularly over the abdomen as it grows and stretches. The application of calamine lotion is ohen helpful. However pruritus can be a symptom of a disease process, such as OC and pemphigoid gestationalis, an auto-immune disease of pregnancy where blisters develop over the body as the pregnancy progresses. Women with pre-existing skin conditions such as eczema and psoriasis should be advised about the use of steroid creams and applications containing nut oil derivatives, which may adversely affect the fetus.