The document discusses liver disease in pregnancy. It notes physiological changes in pregnancy that can affect the liver such as increased alkaline phosphatase levels. It describes different types of liver diseases that can occur including those induced by pregnancy like hyperemesis gravidarum or coinciding with pregnancy like viral hepatitis. It provides details on obstetric cholestasis including its causes, clinical features, investigations, management, and maternal and perinatal prognosis. Management of obstetric cholestasis includes monitoring liver function tests, inducing labor at 38 weeks, fetal surveillance during labor, administering vitamin K, and using ursodeoxycholic acid or cholestyramine to relieve symptoms and normalize liver tests.

1. Liver Disease In
Pregnancy
Gopisankar.M.G
2008MBBS

2. Physiologicalchangesin pregnancy
• Palmar Erythema, vascular spiders
• Placenta  Alkaline Phosphatase in last trimester
• Bilirubin and Transaminase levels are normal

3. Liver diseases
1. Pregnancy Induced Liver disease
• Hyperemesis Gravidarum
• Obstetric Cholestasis
• AFLP
• Pre- eclampsia and HEELP syndrome
2. Coincidental Liver Disease
• Viral Hepatitis
• Drug Induced Jaundice
3. Pregnancy superimposed on Chronic Liver Disease
• Congenital hyperbilirubinaemia
• Cirrhosis
• Chronic Hepatitis

4. Obstetric Cholestasis
• Intra hepatic cholestasis of pregnancy / icterus gravidarum
Aetiology
• Normal pregnancy –mildly cholestatic/retarded biliary flow
• Due to estrogen
• Also genetic basis
• 50% family history
• Inc bile acids in circulation
• h/o pruritis on OCP anticipate tendency for cholestasis in
pregnancy

5. Clinical features
• Generalised severe Pruritis in third trimester
• More in palms , soles, trunk
• Rarely jaundice may follow the pruritis after 2-4weeks
• Significant hepatosplenomegaly is unlikely
• Investigations
• Abnormal LFT
• Elevated s.bile acids ,Alkaline Phosphatase ,SGOT ,SGPT-mild
• If very high SGOT/PT(>250) think of hepatitis
• Elev. S.bilirubin –but not > 5g/dL
• USG –exclude Gall stones

6. Management
• LFT frequently
• Antepartum Fetal surveillance and Induction at 38 weeks is
ideal
• Continuous CTG at time of labour
• Vitamin K administration –reduce chance of PPH and Fetal
intracranial haemorrhage
• Pruritus  Ursodeoxycholic acid -300mg BD hydrophilic bile
acid
• Releives symptoms ,normalise LFT – reduce the proportion of
hydrophobic and hepatotoxic bile acids
• Another option is Cholestyramine  but won’t corrects LFT

7. Maternal and Perinatal Prognosis
• Inc perinatal mortality and morbidity
• Fetal distress
• Unexplained IUD – due to acute anoxia
• No IUGR /Oligamnios so USG and Doppler are not helpful
• Fetal coagulopathy
• IC bleed - Vit K deff.
• Maternal morbidity  Malbsorption and Vitamin K deff. 
prolongation of clotting time and PPH
• Jaundice usually disappears after 1-2 weeks of delivery
• Recurrence – may happens , and with use of OCP with
estrogen