midwifery & obstetrical nursing

1. LIVER
DISEASES IN
PREGNANCY

2. LIVER FUNCTION TESTS
PARAMETER NORMAL RANGE
Alanine aminotransferase 0-45 IU/L
Alkaline phosphatase 90-300 IU/L
Aspartate aminotransferase 0-50 IU/L
Gamma glutamyl transferase 0-40 IU/L
Total bilirubin 3-20 µmol/L
Direct bilirubin <0.3 mg/dl
Albumin 35-55 g/L
Total protein 60-80 g/l
Lactate dehydrogenase 140-280 U/L

3. LFT AND PREGNANCY

4. CLASSIFICATION OF LIVER DISEASES
IN PREGNANCY
Liver diseases
Coincidental
Pregnancy
associated
Chronic
Eclampsia
associated
Not
preelampsia
associated
IHCP
Hyperemesis
gravidarum
Viral hepatits
Gallstones
Drug toxicity
Sepsis
Budd-chiari
syndrome
AFLP
HELLP
Chronic hepatitis
Cirrhosis
Esophageal varices

5. 01
INTRAHEPATIC
CHOLESTASIS OF
PREGNANCY

6. 31/461
0.1-1% of all pregnancies

7. CHOLESTASIS
● Histological demonstration of bile in liver tissue
● Measurable reduction in hepatic secretion of solutes
and water
● Demonstrable accumulation in blood of substances
normally excreted in bile(bilirubin, cholesterol, bile acids)

8. ETIOLOGY
Estrogen
Advanced
maternal
age
Genetic
predispositi
on
Multiparity
01 02 03 04

9. CLINICAL PRESENTATION
● Pruritus
● Jaundice
● Fatigue
● Anorexia
● Epigastric pain
● Fat malabsorption
● Steatorrhea
● Vitamin deficiencies
● Physical signs

10. Total bilirubin
GGT
Serum bile
acids
↑Cholic
acid:chenodeox
ycholic acid
ratio
Aminotransfer
ase
ALP
LAB INVESTIGATIONS
May be elevated but
<6mg/dl
Upto 4 times
>10 µmol/L 10-25 times
Mildly elevated

11. PROGNOSIS
● No maternal mortality
● Fetal mortality 1-2%
● Recurs in 60-70% of subsequent pregnancies

12. MANAGEMENT
● UDCA : 500 mg -1.5 g daily(10 mg/kg/day)
● Pruritus: antihistamines
● Vitamin K supplementation
● Lifestyle advices
● Ultimate treatment: delivery
● Consider early delivery in severe cases:
○ Unbearable maternal pruritus or risk of fetal
distress/death
○ Deliver at 38 weeks if mild, at 36 weeks for severe
cases-if jaundice

13. 02
ACUTE FATTY
LIVER OF
PREGNANCY

14. PATHOPHYSIOLOGY
● Deficiency of the enzyme long chain 3 hydroxyacyl
coenzyme A dehydrogenase
● Defect in β-oxidation of fatty acids in mitochondria
● Accumulation of long chain 3 hydroxyacyl metabolites
● Micro vesicular fatty infiltration of hepatocytes
● Fat droplet formation in hepatocytes

15. Twin pregnancy Nulliparity Low maternal BMI
RISK FACTORS

16. CLINICAL PRESENTATION
● 1-2 week history of nausea, vomiting, abdominal pain and
fatigue
● Hypoglycaemia
● Coagulopathy
● Reduced antithrombin III activity
● May progress rapidly to liver failure with
encephalopathy
● 50% will have signs of preeclampsia
● DIC in 80-100%

17. LAB FINDINGS
● Aminotransferases (1000 U/L)
● Bilirubinemia
● Deranged coagulation
● Raised ammonia, lactic acid
● Low albumin
● Thrombocytopenia
● Neutrophil leukocytes
● Renal failure, elevated uric acid

18. SWANSEA CRITERIA
≥6 of the following, in absence of another explanation
● Abdominal pain
● Ascites
● Coagulopathy
● Elevated serum ammonia levels
● Elevated serum AST or ALT levels
● Elevated serum bilirubin levels
● Elevated serum urate levels
● Encephalopathy
● Hypoglycaemia
● Leucocytosis

19. ● Micro vesicular steatosis
● Polydipsia/polyuria
● Renal impairment
● Vomiting

20. COMPLICATIONS
● Renal failure
● DIC
● Excessive bleeding
● Pancreatitis
● Fulminant liver failure
● Death

21. PROGNOSIS
● Maternal or fetal mortality is low
● Can recur in future pregnancies

22. MANAGEMENT
● Delivery of the baby
● Supportive care to the mother
● Plasmaphoresis
● If hepatic functions fail to recover/ fulminant, liver
transplant
● Screen child for genetic defects in fatty acid oxidation

23. PREECLAMPSIA/
HELLP
SYNDROME
03
Severe preeclampsia complicated by
hemolysis, elevated liver enzymes, and low
platelets

24. PATHOPHYSIOLOGY

26. RISK FACTORS
● Advanced maternal age
● Multiparity
● Nulliparity
● Late pregnancy/ post partum patients who did not have
hypertension/ proteinuria in t2/ t3

27. CLASSIFICATION
i. Tennessee classification
ii. Mississippi classification

30. CLINICAL COURSE
● Initially asymptomatic elevation of BP
● RHQ pain, headache, visual changes, nausea, vomiting
● Hyperreflexia, weight gain/edema
● Elevated transaminase
● Renal failure
● Cerebral haemorrhage
● Hepatic infarctions/ hematomas/ rupture
● Death

31. LAB FINDINGS
● Low platelets<100,000
● High LDH>600 IU/L
● AST/ ALT from mild to 10-20 times
● Bilirubin <5 mg/dL
● Liver imaging: sub capsular hematomas,
intraparenchymal haemorrhage, infarction or hepatic
failure
● Uric acid>7.8 mg/dL
● Proteinuria
● ↑ creatinine

32. PROGNOSIS
● Low maternal mortality but can have high morbidity
● Fetal mortality-35%
● Recurs in 3-27% of future pregnancies

33. MANAGEMENT
● Delivery
● Supportive care
● BP control
● Fetal optimization/ lung maturation
● Control of seizures

34. QUESTIONS?

35. THANK YOU