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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...
Physiological changes in hepatic
parameters
NO CHANGE
• Hepatic blood flow
• Hepatic & splenic size
• Liver histopathology...
Classification
Unique to pregnancy
• Hyperemesis Gravidarum
• Intrahepatic cholestasis of pregnancy
• Preeclampsia & liver...
Case report
• 36yrs, G2P1+0+0+1, 36wks, prev LSCS,↓FM
• c/o nausea, malaise & jaundice
• Treated as viral hepatitis x 3day...
Investigations
Hb-10g%, TLC-11000/mm,
platelet-110,000/ul
Bb-11.8mg%: D-8mg%
AST-144U/L
ALT-197U/L
ALP-578U/L
PT,PTTK,TT ↑...
AFLP or HELLP
• AFLP
Normal BP
No haemolysis
Less thrombocytopenia
Marked coagulopathy
• HELLP
Can occur in normal BP
Had ...
Treatment
• 19U FFP & 10U cryoprecipitate
• LSCS 5hrs later for AFD, Male baby A&H
• Hysterectomy for PPH
• D2- moderate a...
Acute Fatty Liver Of Pregnancy
• Rare & fatal disorder
• 50% mortality, with early diagnosis & T/t
mortality is 20%
• More...
• If starts improving- full recovery
• LCHAD (long chain 3-hydroxyacyl-coenzyme A
dehydrogenase) deficiency in fetus →no
o...
Case History II
• 24yrs,G2P1+0+0+1, 34 wks, intense pruritis
H/O pruritis & jaundice in previous pregnacy
ANC in this preg...
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 diag...
IHCP
• IIIrd trimester, Recurrent, Mild icterus (Bb is
not > 5 mg%)
• No prodrome, itching, ↑ALP, ↑TBA, n USG
• Counsellin...
• Etiology:
genetic – mutation of MDR3 gene
- hypersensitivity to oestrogens
Environmental
• Future pregnancy
Recurrence
N...
IgM HAV +ve
• Similar course, ↑PTL, ↑
PPH, No perinatal
transmission
• IG to baby 0.02ml/kg IM if
infection within 2 weeks...
Positive HBsAg, IgM anti HBc, HBeAg
• Course = non preg
• 10% carrier rate: 25%
have ch active hepatitis
& CA
• With HBeAg...
Immunoprophylaxis for HBV
Neonate of HBsAg +ve
mother
• HBIG-0.5ml(250IU)
IM
TOD and 6 weeks
• HBV vaccine-different
site,...
Hepatitis C & D & G
Hepatitis C
• IgM anti HCV +ve
• Course = non preg
• 85% develop ch
hepatitis
• Vertical transmission
...
Fulminant hepatitis
• HE is commonest cause
• Jaundice, encephalopathy, coagulopathy, ARF
• Multiple organ failure
• DD: A...
• Chronic hepatitis
• Liver cirrhosis & portal hypertension
• Cholelithiasis in pregnancy
• Budd-Chiari syndrome
• Post li...
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overview of liver disease in pregnancies with few examples of case summaries

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Liver Disease In Pregnancy2

  1. 1. Liver Disease In Pregnancy Dr Amita Suneja Professor, OB & GYN UCMS & GTBH
  2. 2. 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
  3. 3. Physiological changes in hepatic parameters NO CHANGE • Hepatic blood flow • Hepatic & splenic size • Liver histopathology • Bilirubin- direct or indirect, AST, ALT, GGTP, TBA • PT/INR WITH CHANGE • Albumin - ↓ 20%-50% • Globulin -↑ • Fibrinogen - ↑50% • Ceruloplasmin & transerrin - ↑ • ALP - ↑2-4 fold • LDH - ↑slight • Cholesterol & TGL - ↑2fold ↑ AST, ALT,S Bb, TBA during pregnancy indicate liver disease
  4. 4. 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
  5. 5. 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/A–36wks, Vx, mild contractions, FHS-128/m • P/V-early labor, unclotted blood in vagina
  6. 6. Investigations Hb-10g%, TLC-11000/mm, platelet-110,000/ul Bb-11.8mg%: D-8mg% AST-144U/L ALT-197U/L ALP-578U/L PT,PTTK,TT ↑↑ INR 3.25 BUN-6mg/dl Creatinine-1.5mg% Co2-13mEq/L Blood glucose- Normal Viral markers-negative Urine-normal USG-normal
  7. 7. AFLP or HELLP • AFLP Normal BP No haemolysis Less thrombocytopenia Marked coagulopathy • HELLP Can occur in normal BP Had EL & LP No hypoglycemia
  8. 8. 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
  9. 9. 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,
  10. 10. • 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
  11. 11. 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
  12. 12. Differential diagnosis • IHCP • Anicteric viral hepatitis • Obstructive jaundice
  13. 13. 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
  14. 14. 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
  15. 15. • Etiology: genetic – mutation of MDR3 gene - hypersensitivity to oestrogens Environmental • Future pregnancy Recurrence No OCP No progesterone in next pregnancy
  16. 16. IgM HAV +ve • Similar course, ↑PTL, ↑ PPH, No perinatal transmission • IG to baby 0.02ml/kg IM if infection within 2 weeks of delivery or immediate postpartum • Vaccination to mother when she moves to endemic area • IG to mother 0.02ml/kg deep IM within 2 weeks of exposure to index case Anti HEV +ve • Severe course in preg • 20% fatal • 50% of fulminant hepatitis • No vaccine for it • Supportive T/t • Maternal outcome fatal if fetus dies of hepatitis • No carrier stage
  17. 17. Positive HBsAg, IgM anti HBc, HBeAg • Course = non preg • 10% carrier rate: 25% have ch active hepatitis & CA • With HBeAg – highrisk for ca • PNT-20% +ve HBeAg-90% anti HBe ab-no transmission • Transplacental - 5% vertical at TOD – 95% & Breast Feeding Infants born with HB are generally asymptomatic but become carrier in 85%
  18. 18. Immunoprophylaxis for HBV Neonate of HBsAg +ve mother • HBIG-0.5ml(250IU) IM TOD and 6 weeks • HBV vaccine-different site, IM 0,6,10,14, weeks vs. 0,1,6 months Unimmunised Mother • PEP within 48hrs HBIG-500IU, IM HBV vaccine 0,1,6 months at different site
  19. 19. Hepatitis C & D & G Hepatitis C • IgM anti HCV +ve • Course = non preg • 85% develop ch hepatitis • Vertical transmission only IgM +ve – 10% PCR +ve - 30% or HIV +ve • No immunoprophylaxis Hepatitis D • Co infects with HBV • Course = HB • HC+HB is more severe than HB alone • 75% develop cirrhosis • HB vaccine prevents delta hepatitis Hepatitis G • HC coinfection • Does not cause hepatitis
  20. 20. 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
  21. 21. • Chronic hepatitis • Liver cirrhosis & portal hypertension • Cholelithiasis in pregnancy • Budd-Chiari syndrome • Post liver transplantation pregnancy
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overview of liver disease in pregnancies with few examples of case summaries

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