1. Jaundice with Pregnancy

2. Peculiar to pregnancy Acute Fatty Liver of pregnancy
Intra-hepatic cholestasis of pregnancy
Jaundice complicating pre- eclampsia
HELLP syndrome
Hepatic rupture and infarction ( 2nd and 3rd trimester)
Hyperemesis gravidarum ( Ist trimester)

3. Intercurrent jaundice affecting pregnant female:
Viral hepatitis
Gall stones
Hepatotoxic drugs
Budd Chiari syndrome

4. Effect of pregnancy on pre existing liver disease:
Liver Cirrhosis
post viral,
Wilson’s disease
Autoimmune
PBC
Liver masses
Alcoholic liver disease

5. Acute Fatty Liver of pregnancy:
Rare ( 5/ pregnancies)
Risk factors:
Ist pregnancy
Twins
Male fetus
Preeclampsia
Pathogenesis:
Mutant gene causing a defect in mitochondrial fatty oxidation and caused by deficiency in long chain hydroxy acetyl Co-A dehydrogenase leading to increased deposition of triglycerides in hepatocytes leading to micro and macrovesicular steatosis

6. Pathogenesis cont. Clinical picture: suggestive host factors :
Increased urinary organic acids
Increased plasma carnitine and ethyl carnitine ( detected by overnight fasting) .
Clinical picture:
3rd trimester
May be earlier or immediately after delivery
Acute onset of Headache, abdominal pain, nausea , vomiting ,pruritis, fever, ascites in 50%
Jaundice appears soon after the onset
Fulminant liver failure may follow

7. Investigations: Increased serum bilirubin ++ AST, ALT
+++ serum Ammonia
+++ TLC with neutrophilia
--- platelets
Coagulopathy
--- fibrinogen ( DIC in 10%)
Hypoglycemia
Proteinuria, ++ serum uric acid

8. Invest. Cont. Abdominal ultrasound ( bright liver)
Liver biopsy ( contraindicated).

9. Treatment: Mild cases: Advanced disease: Early delivery is considered
ICU admission
Dexamethasone 8mg/kg/12hours
High doses of FFP
Termination of pregnancy if the condition is life threatening

10. Complications: DIC GIT bleeding Hepatic coma renal failure
Pancreatitis
Hypoglycemia
Fetal mortality ( 85%) if associated with eclampsia

11. Intrahepatic cholestasis of pregnancy:
Pathogenesis
Inherited senitivity to estrogens
Lower plasma level of selenium
Decreased hepatocyte membrane fluidity
Alteration of Na- K adenosine triphosphatase activity in hepatocyte membrane
Production of cholestatic metabolites

12. Intra-hepatic cholestasis of pregnancy:
Clinical picture
second and third trimester
The onset of ICP is typically heralded by the development of pruritus, which may be intolerable.
Pruritus predominates on the palms and the soles of the feet, and is worse at night
The diagnosis of ICP is based upon the presence of pruritus associated with elevated levels of serum bile acids and/or aminotransferases, and the absence of diseases that may produce similar symptoms.

13. Treatment for ICP focuses on reducing symptoms and preventing maternal and fetal complications.
ursodeoxycholic acid at a dose of 500 mg twice a day (or 15 mg/kg per day) until delivery
Cholestyramine 8 g/day for 15 days ( binds bile acids and improves pruritis)
Vitamin K may help and avoids the risk of hemorrhage at delivery
Early delivery because of the risks to the fetus

14. The timing of delivery
the patients' symptoms (jaundice if present), potential risks associated with prematurity
whether the cervix is favorable.
In most patients not treated with UDCA, delivery should be accomplished by 38 weeks.
However, when cholestasis is severe , delivery should be considered at 36 weeks gestation if lung maturity is achieved or as soon thereafter as fetal lung maturity is established

15. The maternal prognosis in ICP is good.
Severe cholestasis leading to deficiencies of fat soluble vitamins is uncommon.
The maternal prognosis in ICP is good.
Recurrent ICP 60-70%
Gall stones
ICP carries significant risk for the fetus
prematurity
Neonatal respiratory distress syndrome
IUFD

16. HEV in pregnancy:
Acute viral hepatitis can complicate pregnancy. The course of hepatitis A, B and C is similar to that of non-pregnant patients. By contrast, Hepatitis E is more severe during pregnancy. Several other viral infections have been reported in pregnancy.
Rare condition in developed countries
Higher incidence in developing countries
Fulminant hepatic failure and mortality in pregnant females
16% maternal mortality in the 3rd trimester and 50% fetal mortality
DD : acute fatty liver pregnancy, other viral hepatitis in pregnancy
Diagnosed by serum IgM anti HEV antibody

17. Effect of pregnancy on pre existing liver disease:
Pregnancy is unusual in women with severe chronic liver disease
Old age
Anovulatory state
Those with milder form of disease may get pregnant
Cirrhosis and portal hypertension
Worsening of jaundice
Progression of LCF
Increased incidence of still birth and prematurity
All medications should be reviewed for potential teratogenicity
Early Termination of pregnancy in case of hepatic decompensation
Successful liver transplantation has been described during pregnancy

18. Autoimmune hepatitis:
affects women in the child bearing period
The course of the disease is unpredictable
Although spontaneous remission may occur, exacerbation of the disease and maternal mortality has been reported during pregnancy.
Pregnancy induces a state of immune tolerance accomodating the fetus and causing a shift of T- helper 1 to T- helper 2 immune response causing an ammeloration of disease activity( TH1 dependent)

19. Exacerbation of the disease post partum occurs due to T hepler 1 predomination
The high hormone level in pregnancy also plays a part in immune tolerance
Treatment :
Low dose prednisolone seems to be the preferred treatment
Treatment of pruritis ( cholestyramine)
Use of azthioprine must be individualized

20. Primary biliary cirrhosis:
May be exacerbated during pregnancy
Spontaneous improvement during pregnancy may occur
UDCA ( 15 mg/kg) is the treatment of choice
Cholestyramine and vit. K may be needed
Treatment may be continued during pregnancy and breast feeding
Increased incidence of abortion, still births

21. Wilson’s disease:
Ceruloplasmin and copper concentrations in sera may double in the third trimester of pregnancy
May develop neuropsychiatric stigmata of the disease
Interruption of treatment ( d- penicillamine, trientine, zinc ) during pregnancy has resulted in fulminant hepatic failure
However the dose of treatment should be reduced to the minimum necesssary dose ( 25-50% original dose) especially in the last trimester.

22. D penicillamine:
teratogenic in 5 % of cases ( doses > 500mg/day)
Oral supplementation with pyridoxine is recommended
Zinc is the treatment of choice during pregnancy ( safe to fetus), 50 mg/8 hours

23. Enlarge and rupture during pregnancy due to high level of estrogen
Liver masses:
Adenomas
FNH
Haemangiomas
Enlarge and rupture during pregnancy due to high level of estrogen
Tumors greater than 5 cm---- surgical resection before becoming pregnant

24. Liver Abscess: Amebic liver abscess: Pyogenic abscess: Rare
Preterm labor
Jaundice and peritonitis are rare
Ultasound and serology
Aspiration for imminent rupture
Pyogenic abscess:
Life threatening condition
Fever , jaundice, tender hepatomegaly
Polymicrobial
Ttt combination of antibiotics and percutaneous aspiration

25. Evaluation of liver disease in pregnancy
History and review of systems:
History of pruritus during previous pregnancies or while using oral contraceptives.
abdominal pain, nausea or vomiting.
polyuria and polydipsia.
Drugs.
Travel.
exposure to viral hepatitis.
history of gallstones.
Note trimester of pregnancy.

26. Physical examination Blood tests Temperature, blood pressure.
Proteinuria.
liver examination (difficult during late pregnancy)
Blood tests
Complete blood count including platelets
Routine liver function tests including prothrombin time
Serum creatinine, electrolytes, glucose and uric acid levels
Serology for viral hepatitis (A, B, C) and cytomegalovirus
Test for hepatitis E if suspected (especially in endemic countries less commonly in non-endemic countries)

27. Measure serum total bile acids if cholestasis is suspected and not otherwise apparent (not a routine test)
Urinalysis and culture
Ultrasonography of the liver and bile ducts
Monitor evolution of symptoms and liver function tests before and after delivery

28. Thank you