Approach to liver disease occurring during pregnancy

Name: Approach to liver disease occurring during pregnancy
Uploaded: 2017-07-16T14:39:03+00:00
Duration: PTM24S39
Channel: Brittney Bryan
Description: Approach to liver disease occurring during pregnancy

Approach to liver disease occurring during pregnancy
Naghshineh E .MD

Liver disease in pregnancy
liver diseases that are specific to pregnancy, or multisystem diseases unique to pregnancy pregnancy-related physiologic changes that may worsen the severity of, or predispose to hepatobiliary diseases diseases that are unassociated with pregnancy but can occur during pregnancy Pregnancy can also occur in women with underlying chronic liver disease Liver disease in pregnancy

THE LIVER DURING NORMAL PREGNANCY
Physical examination — Spider angiomas and palmar erythema Liver disease in pregnancy

Ultrasound examination :Fasting gallbladder volume and residual volume after contraction may be increased Pathology Serum proteins and lipids : albumin , Serum total cholesterol and triglyceride Liver disease in pregnancy

serum fibrinogen increases in late pregnancy. Liver disease in pregnancy

Hyperemesis gravidarum Intrahepatic cholestasis of pregnancy Acute fatty liver of pregnancy HELLP preeclampsia Liver disease in pregnancy

PATTERNS OF HEPATOBILIARY DISEASE IN PREGNANCY
jaundice Pruritus abdominal pain nausea, vomiting liver biochemical test abnormalities Liver disease in pregnancy

American College of Gastroenterology Guidelines: Liver disease in the pregnant patient gestational age of the pregnancy is the best guide Hyperemesis gravidarum ……in the 1st trimester Cholestasis of pregnancy …….in the 2th ,3th trimester HELLP ………………………………….in the second half AFLP……………………………………in the 3th Preeclampsia……………………...in the 3th Liver disease in pregnancy

Evaluation of liver disease in pregnancy

Case 1 A 26-year-old woman gravida 3 para 2 currently in her 10th week with a singleton gestation is hospitalized with intractable nausea, vomiting, and dehydration During her two prior pregnancies, she also had severe nausea and vomiting, which resolved early in the second trimester. Liver disease in pregnancy

Her physical examination is notable for dry mucus membranes, and a gravid uterus She has no abdominal pain, and does not have a palpable liver or spleen Liver disease in pregnancy

What is your first diagnosis?
Liver disease in pregnancy

ALT (175 IU/L), AST (122 IU/L), serum total bilirubin (2.1 mg/dL) Amylase and lipase are normal The albumin is slightly decreased from normal values Liver biochemical tests prior to pregnancy are not available A right upper quadrant ultrasound is normal. Urinalysis shows elevated ketones. Liver disease in pregnancy

Serology for hepatitis A, B, and C is negative, antinuclear antibodies are absent, and serum protein electrophoresis is normal TSH is normal Obstetrical ultrasound examination demonstrates a normal singleton gestation. Liver disease in pregnancy

patient's clinical course and occurrence of symptoms early during pregnancy are consistent with hyperemesis gravidarum Liver disease in pregnancy

Common criteria for diagnosis of hyperemesis are persistent vomiting accompanied by weight loss exceeding 5 percent of prepregnancy body weight and ketonuria unrelated to other causes Liver disease in pregnancy

Abnormal liver enzyme values occur in approximately 50 percent The most striking abnormality is an increase in serum aminotransferases in the low hundreds or two to three times the upper limit of normal, and rarely as high as 1000 U/L Hyperbilirubinemia can occur, but rarely exceeds 4 mg/dL Liver disease in pregnancy

Serum amylase and lipase may increase as much as 5-fold (as opposed to a 5- to 10-fold increase in acute pancreatitis) and are of salivary rather than pancreatic origin Liver disease in pregnancy

Preeclampsia, HELLP syndrome and acute fatty liver of pregnancy are also causes of pregnancy-related nausea and vomiting, but : onset is in the latter half of pregnancy (usually the third trimester) hypertension is usually present thrombocytopenia is common Liver disease in pregnancy

Case 2 A 23-year-old woman gravida 2 para 1 currently at 35 weeks with a singleton gestation is referred from a dermatologist for intractable itching The itching is primarily on the palms of her hands and soles of her feet It is present day and night, and keeps her from sleeping. Liver disease in pregnancy

The patient also had itching during her first pregnancy in which the fetus died in utero in the third trimester Liver disease in pregnancy

What is your first diagnosis?

Intrahepatic cholestasis of pregnancy
Intrahepatic cholestasis of pregnancy (ICP) occurs in the second and third trimester is characterized by pruritus and an elevation in serum bile acid concentrations For unknown reasons the disease is seen more commonly in the colder months Liver disease in pregnancy

PATHOGENESIS The cause of ICP is unknown but genetic, hormonal, and environmental factors are likely involved Liver disease in pregnancy

Estrogens and progesterone
It is recommended that progesterone treatment be avoided in pregnant women with a previous history of ICP and immediately withdrawn when cholestasis occurs during pregnancy Liver disease in pregnancy

CLINICAL MANIFESTATIONS
Pruritus may precede laboratory abnormalities Abdominal pain is uncommon Encephalopathy or other stigmata of liver failure are unusual Physical examination is nonspecific may show excoriations due to scratching Jaundice occurs in less than 10 percent Liver disease in pregnancy

Laboratory findings Serum total bile acid concentrations increase in ICP, and may be the first or only laboratory abnormality Serum cholic acid increases more than chenodeoxycholic acid most women with an elevated bile acid ratio also have elevated total bile acid levels; as a result, obtaining a ratio does not enhance diagnostic performance The ratio of glycine/taurine conjugates is decreased Liver disease in pregnancy

elevations in alkaline phosphatase, 5' nucleotidase, and total and direct bilirubin concentrations Total bilirubin levels rarely exceed 6 mg/dL gamma glutamyl transpeptidase (GGT) are normal or modestly elevated aminotransferases may reach values greater than 1000 U/L The prothrombin time is usually normal prolonged prothrombin times reflect vitamin K deficiency due to cholestasis or to the use of bile acid sequestrants rather than liver dysfunction. Liver disease in pregnancy

ULTRASONOGRAPHY the biliary ducts are not dilated and hepatic parenchyma appears normal Liver disease in pregnancy

DIAGNOSIS Most women are diagnosed during the second or third trimester The diagnosis of ICP is based upon the presence of pruritus associated with elevated total serum bile acids levels and/or aminotransferases Liver disease in pregnancy

PATHOLOGY is rarely necessary for the diagnosis histopathology is characterized by cholestasis without inflammation Bile plugs in hepatocytes and canaliculi predominate in zone 3 The portal tracts are unaffected. Liver disease in pregnancy

TREATMENT UDCA is considered as the first line treatment for ICP(500 BID or 300 TDS) Hydroxyzine (25 to 50 mg/day) Cholestyramine (8 to 16 g/day) Liver disease in pregnancy

Complications of cholestasis
hypoprothrombinemia induced by vitamin K deficiency; should be treated before delivery to prevent hemorrhage. Liver disease in pregnancy

Cholestasis recurs during subsequent pregnancies in 60 to 70 percent increased risk for gallstones some women who develop ICP have underlying liver disease : women in whom ICP is suspected and/or who have elevated serum aminotransferase during pregnancy should be tested for chronic hepatitis (especially hepatitis C) liver function tests should be checked several months after the delivery Liver disease in pregnancy

Hormonal contraception
contraceptives with a low dose of estrogen can be initiated after normalization of liver function tests check liver function tests after three or six months of such contraception. Liver disease in pregnancy

FETAL FOLLOW-UP AND OUTCOME
In contrast to the favorable prognosis for mothers, ICP carries significant risk for the fetus fetal prematurity meconium stained amniotic fluid intrauterine demise neonatal respiratory distress syndrome Liver disease in pregnancy

Timing of delivery 37 wk 35-37 wk : Severe itching Jaundice Prior fetal death Liver disease in pregnancy

Case 3 A 32 year-old woman gravida 1 para 0 with a singleton gestation at 34 weeks of gestation is admitted to the hospital with a three-day history of nausea and vomiting, malaise, and jaundice Her blood pressure is mildly elevated Urinalysis shows trace protein aminotransferases range between 200 to 500 glucose is in the low-normal range White blood cell count and prothrombin time are elevated Liver disease in pregnancy

What is your diagnosis ? Liver disease in pregnancy

Acute fatty liver of pregnancy
characterized by microvesicular fatty infiltration of hepatocytes, is a disorder which is unique to human pregnancy early diagnosis and prompt delivery have dramatically improved the prognosis, and maternal mortality should now be the exception rather than the rule Liver disease in pregnancy

EPIDEMIOLOGY is rare with an approximate incidence of 1 in 7000 to 1 in 20,000 deliveries It is more common with multiple gestations and possibly in women who are underweight. Liver disease in pregnancy

Acute fatty liver occurs typically in the third trimester The disease is always present before delivery, although it is not always diagnosed prior to delivery Symptom? Liver disease in pregnancy

The most frequent initial symptoms are nausea or vomiting 75 percent abdominal pain :50 percent Anorexia Jaundice one-half of patients have signs of preeclampsia at presentation or at some time during the course of illness Liver disease in pregnancy

infection major intraabdominal bleeding Transient polyuria and polydipsia due to central diabetes insipidus pancreatitis, which can be severe. Pancreatitis generally becomes apparent only after development of hepatic and renal dysfunction Liver disease in pregnancy

Laboratory tests aminotransferase ranging from modest values up to 1000 Serum bilirubin levels are also usually elevated The platelet count may be decreased with or without other signs of disseminated intravascular coagulation (DIC) Severely affected patients also have elevations in serum ammonia, prolongation of prothrombin time, and hypoglycemia caused by hepatic insufficiency Acute renal failure and hyperuricemia are often present Liver disease in pregnancy

DIAGNOSIS made clinically based upon the setting, presentation, and compatible laboratory and imaging results Laboratory tests that are helpful include serum aminotransferases, serum bilirubin, coagulation studies, electrolytes, serum glucose, uric acid level and creatinine, and a white blood cell count. Liver disease in pregnancy

TREATMENT AND COURSE the primary treatment is prompt delivery, usually emergently, after maternal stabilization Liver disease in pregnancy

Maternal stabilization requires glucose infusion and reversal of coagulopathy Attention should be paid to the women's overall fluid status because the low plasmatic oncotic pressure can lead to pulmonary edema Hypoglycemia is common and all patients should have glucose monitored until normal liver function returns Liver disease in pregnancy

The liver tests and coagulopathy usually start to normalize shortly after delivery Liver disease in pregnancy

RECURRENCE Acute fatty liver can recur in subsequent pregnancies Liver disease in pregnancy

Case 4 A 23-year-old woman gravida 1 para 0 currently with twin gestations at 32 weeks is hospitalized with hypertension, for which methyldopa had been prescribed earlier in her pregnancy Despite treatment, she continues to be mildly hypertensive and is developing a progressive rise in serum aminotransferases, which are over 85 Hepatitis serology and markers for autoimmune hepatitis are negative. Her platelet count, peripheral blood smear, urinalysis, and right upper quadrant ultrasound are normal Liver disease in pregnancy

The differential diagnosis in this case includes: preeclampsia toxicity due to methyldopa early acute fatty liver of pregnancy Liver disease in pregnancy

HELLP syndrome characterized by hemolysis with a microangiopathic blood smear, elevated liver enzymes, and a low platelet count 15 to 20 percent of affected patients do not have antecedent hypertension or proteinuria Liver disease in pregnancy

INCIDENCE AND ONSET OF DISEASE
HELLP develops in approximately 1 to 2 per 1000 pregnancies overall and in 10 to 20 percent of women with severe preeclampsia/eclampsia The majority of cases are diagnosed between 28 and 36 weeks of gestation Liver disease in pregnancy

Symptoms typically develop in the third trimester, (second trimester or postpartum disease ) The most common clinical presentation is abdominal pain and tenderness in the midepigastrium, right upper quadrant, or below the sternum nausea, vomiting, and malaise Hypertension (blood pressure ≥140/90) and proteinuria Liver disease in pregnancy

Serious maternal morbidity may be present at initial presentation or develop shortly thereafter disseminated intravascular coagulation (DIC) abruptio placentae acute renal failure pulmonary edema subcapsular liver hematoma retinal detachment Liver disease in pregnancy

Microangiopathic hemolytic anemia signs suggestive of hemolysis include an elevated indirect bilirubin and a low serum haptoglobin concentration (≤25 mg/dL). Platelet count ≤100,000 cells/microL Total bilirubin ≥1.2 mg/dL Serum AST ≥70 IU/L. Liver disease in pregnancy

MANAGEMENT The cornerstone of therapy is delivery Pregnancies ≥34 weeks of gestation Nonreassuring tests of fetal status (eg, biophysical profile, fetal heart rate testing) Presence of severe maternal disease: multiorgan dysfunction, DIC, liver infarction or hemorrhage, renal failure, or abruptio placenta. Liver disease in pregnancy

Platelet transfusion significant maternal bleeding (spontaneous or from surgical incisions) less than 20,000 cells/microL preoperative platelet count greater than 40,000 to 50,000 cells/microL Liver disease in pregnancy

NVD OR CS? cesarean delivery is probably preferable in pregnancies less than 30 to 32 weeks of gestation if the cervix is unfavorable for induction Liver disease in pregnancy

Role of dexamethasone PLT< ??? Liver disease in pregnancy

chronic liver disease Pregnancy is unusual in women with severe chronic liver disease. Most such women are not of child-bearing age, or, because of the associated anovulatory state, they are infertile Liver disease in pregnancy

CIRRHOSIS AND PORTAL HYPERTENSION
Some women with cirrhosis can sustain pregnancy without any worsening of hepatic function others may develop jaundice with progressive liver failure, ascites, and hepatic coma Liver disease in pregnancy

The increase in total blood volume associated with pregnancy may worsen pre-existing portal hypertension upper endoscopy to look for varices before pregnancy Liver disease in pregnancy

Hepatitis B virus Pregnancy is generally well tolerated by women who are chronic carriers of hepatitis B virus The overall risk of HBV transmission from the mother to infant is about 40 percent. Transmission at birth is more likely if the mother is hepatitis B e antigen (HBeAg) positive or has high circulating levels of HBV DNA Prenatal screening of all pregnant women for HBsAg is now performed routinely in many countries Liver disease in pregnancy

Hepatitis C virus Women chronically infected with hepatitis C virus (HCV) can have an uneventful pregnancy without worsening of liver disease or other adverse effects on the mother or fetus Transmission of the virus from mother to infant occurs in about 5 to 10 percent of infants born to anti-HCV positive women no evidence that breastfeeding is a risk for infection Liver disease in pregnancy

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Approach to liver disease occurring during pregnancy

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