- Liver disease occurs in 3% of pregnancies and can be coincidental, preexisting conditions exacerbated by pregnancy, or specific to pregnancy. - It is important to determine the etiology to guide management. Common causes include viral hepatitis, cholelithiasis, portal hypertension, hyperemesis gravidarum, Budd-Chiari syndrome, Wilson's disease, autoimmune hepatitis. - Many conditions pose risks to both mother and baby such as complications, mortality, fetal loss, prematurity or transmission. Careful monitoring and treatment optimized for pregnancy is needed.

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