LIVER DISEASE IN PREGNANCY

1. Approach to liver disease
in pregnancy
Dr. charles panackel

2. Introduction
 3% of pregnancy
 Mild to severe
 Coincidental A/c hepatobiliary disease
 Preexisting Hepatobiliary disease
exacerbated by pregnancy
 Hepatobiliary disease specific to pregnancy
 Vital to make etiologic diagnosis

3. Physiologic changes
 Decrease is serum albumin
 Increase in S.alkaline Phosphatase
 S. bil, AST/ALT, LDH, GGT, PT, remain normal
 Palmar erythema, spider naevi
 Liver span
 Increased blood volume, decreased peripheral
resistance, increased cardiac output, increased
splanchenic circulation, increased IVC pressure

6. Viral Hepatitis
 Most common cause of jaundice in
pregnancy
 HEV, HSV – Mortality is increased
 HAV –
 Same course
 Maternal fetal transmission
 No fetal loss or developmental anomalies
 No CI for breast feeding

7. Viral Hepatitis
 Hepatitis B
 A/c HBV Course not altered
 C/c HBV
 Risk of transmission
 HBeAg positive- 90%
 HBeAg Negative – 10-40%
 Risk more if infection occurs in 3rd trimester
 HBV Ig + Vaccination
 Lamivudine

8. Viral Hepatitis
 HCV
 Does not interfere with normal pregnancy
 Vertical transmission of HCV - 0-36%
 HIV co infection, HCV RNA levels more than 1
million copies/ml, IV drug abuse
 No contraindication for breast feeding
 A/c infection less chance for transmission
 Interferon and Ribavarin - CI

9. Viral Hepatitis
 HEV
 Females in child bearing age group
 58% can develop fulminant hepatitis
 Mortality 1st -1.5%, 2nd -8.5%, 3rd -21%
 Increased risk of abortions
 No CI for breast feeding
 HDV
 No vertical transmission reported

10. Viral hepatitis
 HSV, VZ
 2nd and 3rd trimester
 50% mucocutaneous lesions
 Liver biopsy, cultures and serology
 MMR – 40%
 Acyclovir
 CMV
 Rare
 Hepatitis
 Gancyclovir- teratogenic

11. Cholelithiasis
 6% of pregnancy
 Decreased bile acid pool
 Increased bile cholesterol
 Impaired contraction of GB
 Cholecystitis, Cholangitis and gall stone
pancreatitis
 Gall stone pancreatitis has 15%MMR and 60%
fetal mortality
 Laparoscopic cholecystectomy can safely be
done in 1st and2nd
 ERCP

12. Portal Hypertension
 Cirrhosis V/s NCPHT
 Cirrhosis – pregnancy is rare
 NCPHT – Liver function and fertility
 Increased portal pressure - Maximum in
2nd trimester
 Increased risk of variceal bleed in 2nd
trimester and 2nd stage of labor

13. Portal hypertension
 Fetal wastage –
 cirrhotics – 9.6% - 66%,
 NCPHT- 7.9% - 20%
 Spontaneous abortions –
 cirrhotics – 15-20%,
 EHPVO- 3-6%
 Most spontaneous abortions occur in first
trimester
 Portal decompression surgery/endoscopic
obliteration of varices prior to conception
decreases risk
 Perinatal mortality increased 11-18%

14. Portal hypertension
 30-50% pregnant women develop complication
 Variceal hemorrhage occurs in 19-45%
 Maternal mortality from variceal hemorrhage
 - cirrhotics- 18-89%,
 Non cirrhotics- 2-6%
 PPH occurs in 2-6%
 A/c on C/c hepatic failure 24% - 1/3rd die in 48
hours
 Overall maternal mortality –
 EHPVO- 4-7% and
 cirrhosis- 10-18%

15. Portal hypertension
 Preconception counseling
 Planned pregnancy
 Liver transplantation
 Medications optimized
 Screened with endoscopy
 Primary prophylaxis
 Antenatal monitoring
 Management of bleed

17. Portal hypertension
 Delivery closely monitored
 Sedation
 Second stage kept short
 Avoid overzealous IVF
 Caesarian section

18. Hyperemesis gravidarum
 2% of pregnancies
 Severe dehydration, electrolyte imbalance
 Young age, obese, non smokers,
hyperthyroidism
 50% have elevated transaminases
 Mild hyperbilirubinemia
 IVF, antiemetics
 Good outcome
 Low birth weight

19. Budd chiari syndrome
 20%
 2nd trimester to 3 months after pregnancy
 Hypercoagulable state
 Ascites
 A/C v/s C/C
 Anticoagulation
 TIPS
 Transplant

20. Wilsons disease
 Decreased fertility
 Treatment same as non pregnant
 D Pencillamine- micrognathia, low set
ears, inguinal hernia and cutis laxa
 Trientene and oral Zinc also safe

21. Autoimmune hepatitis
 Course is augmented
 Maternal mortality and morbidity increased
 Fetal loss is 13-44%
 Steroids / azathioprin

22. Liver Transplant and Pregnancy
 High risk pregnancy
 Conception delayed up to 6 months
 Increased risk of preecclampsia
 Well tolerated provided graft function and
renal function are normal

24. Dengue and pregnancy
 Can mimic HELLP/AFLP
 Vertical transmission
 Fever, thrombocytopenia, hepatomegaly,
circulatory failure
 Severe thrombocytopenia can lead to PPH

25. Leptospirosis and pregnancy
 Fetal wastage, premature delivery
 Vertical transmission
 No congenital infection
 Mimic HELLP syndrome

28. Dengue and Pregnancy