This document discusses various liver diseases that can occur during pregnancy, including:
- Hyperemesis gravidarum, a condition of severe nausea and vomiting in early pregnancy that can cause abnormal liver tests.
- Intrahepatic cholestasis of pregnancy (ICP), a reversible cholestatic condition characterized by pruritus and elevated bile acids in late pregnancy. Ursodeoxycholic acid and early delivery are used to treat ICP.
- Acute fatty liver of pregnancy (AFLP), a rare but life-threatening condition associated with preeclampsia where fatty acids accumulate in hepatocytes. Early recognition and management of AFLP is important due to the risk of mortality for both
Intrahepatic Cholestasis of Pregnancy : Dr Sharda Jain & Dr Jyoti Agarwal Lifecare Centre
Intrahepatic Cholestasis of Pregnancy : Dr Sharda Jain & Dr Jyoti Agarwal
Intrahepatic cholestasis of pregnancy (ICP) is characterized by Pruritus and an elevation in serum bile acid concentrations, typically developing in the late second and/or third trimester and rapidly resolving after delivery.
Intrahepatic Cholestasis of Pregnancy : Dr Sharda Jain & Dr Jyoti Agarwal Lifecare Centre
Intrahepatic Cholestasis of Pregnancy : Dr Sharda Jain & Dr Jyoti Agarwal
Intrahepatic cholestasis of pregnancy (ICP) is characterized by Pruritus and an elevation in serum bile acid concentrations, typically developing in the late second and/or third trimester and rapidly resolving after delivery.
Explore the intricate interplay between hepatic disorders and pregnancy with this insightful PowerPoint presentation. Delve into the complexities of liver conditions during gestation, including their impact on maternal and fetal health. This presentation covers key topics such as the epidemiology of hepatic disorders in pregnancy, clinical manifestations, diagnostic challenges, and optimal management strategies. Gain valuable insights into the nuances of liver function tests, obstetric considerations, and therapeutic interventions tailored to ensure the well-being of both mother and baby. Whether you’re a healthcare professional, researcher, or student, this presentation provides a comprehensive understanding of the unique challenges posed by hepatic disorders in the context of pregnancy. Elevate your knowledge and awareness by downloading and exploring this essential resource on SlideShare.
Explore the intricate interplay between hepatic disorders and pregnancy with this insightful PowerPoint presentation. Delve into the complexities of liver conditions during gestation, including their impact on maternal and fetal health. This presentation covers key topics such as the epidemiology of hepatic disorders in pregnancy, clinical manifestations, diagnostic challenges, and optimal management strategies. Gain valuable insights into the nuances of liver function tests, obstetric considerations, and therapeutic interventions tailored to ensure the well-being of both mother and baby. Whether you’re a healthcare professional, researcher, or student, this presentation provides a comprehensive understanding of the unique challenges posed by hepatic disorders in the context of pregnancy. Elevate your knowledge and awareness by downloading and exploring this essential resource on SlideShare.
Dr Anil Arora address the liver diseases that are specific during pregnancy. The presentation contains case discussions on diagnosis, treatments & take home messages
nausea and vomiting in pregnancy is very common. it may be a manifestation of some medical - surgical - gynecological complications. hyperemesis gravidarum is a severe type of vomiting in pregnancy which has got deleterious effects on the health of the mother. it is a very important topic and it is also a topic in obstetrics. we should encourage and help young mothers to identify the symptoms. please read it and get knowledge about nausea and vomiting in pregnancy. stay tuned.
Please find the power point on Hyperemesis gravidarum and its managemen. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Dr Abdullah Ansari
MBBS, MD Medicine
Aligarh Muslim University
The physiological changes in the liver during pregnancy
The possibilities of liver diseases
LFT in pregnancy
Intercurrent and pre-existing liver disease: viral hepatitis, autoimmune hepatitis, gall stones
Pregnancy associated liver disease: Hyperemesis Gravidarum, Acute cholestasis of pregnancy, Acute fatty liver of pregnancy, HELLP syndrome
laparoscopy and minimal invasive surgery is modern gyn surgical tool tool it is wise to know some basics about electro- cauterization … and how to avoid its dangers.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
2. physiology
• Spider angioma and palmar erythema, which are typical clinical
markers of liver disease, are commonly seen during pregnancy as a
consequence of the hyperestrogenic state.
• Gall bladder motility is decreased, increasing the incidence of
cholelithiasis in pregnant women
• decreased albumin in all trimesters due to hemodilution, and the
decline in albumin levels becomes more pronounced as pregnancy
advances.
• Alkaline phosphatase (ALP) is increased in the third trimester, but it
is of placental origin due to fetal bone development.
• Alpha fetoprotein (AFP) levels also increase because it is produced
by the fetal liver.
• In contrast, other liver biochemical tests, remain within the normal
range during normal pregnancy. such as total bile acids
concentration, serum alanine transaminase (ALT or SGPT) aspartate
transaminase, (AST or SGOT) gamma-glutamyl transpeptidase
(GGT), and bilirubin,
3. • Pregnancy is a pro-coagulant state in which clotting
factors (I, II, V, VII, X, and XII) and fibrinogen are
increased .
• whereas the ranges for prothrombin time (PT) and
activated partial thromboplastin (APT) time are
within normal values .
physiology
4.
5. LIVER FUNCTION TESTS
• Alanine aminotransferase (ALT) – an enzyme found mainly in the liver; best test to
detect hepatitis
• Alkaline phosphatase (ALP) – an enzyme related to the bile ducts; often increased if ducts are
blocked
• Aspartate aminotransferase (AST) – an enzyme found in the liver and a few other places,
particularly the heart and other muscles
• Gamma-glutamyl transferase (GGT) – an enzyme found mainly in the liver; very sensitive to
changes in liver status, especially when bile ducts are blocked
• Total bilirubin – measures all of the bilirubin in the blood; levels are increased with many liver
diseases and other conditions, such as hemolysis, that lead to increased production of bilirubin
• Direct bilirubin – measures a form of bilirubin that is conjugated (combined with another
compound) in the liver; only increased in liver disease
• Albumin – measures albumin, the main protein made by the liver, and tells how well the liver is
making it
• Total protein – measures albumin and all other proteins in blood, including antibodies present
to help fight off infections (antibodies are not made in the liver)
• Lactate dehydrogenase (LD or LDH) – an enzyme released with tissue damage; may be elevated
with acute liver disease
6. physiology
• aspartate aminotransferase (AST)
• and alanine aminotransferase (ALT)
evaluate Liver cell injury or necrosis
• albumin level
• prothrombin time
evaluate liver synthetic function (are depressed in cirrhosis or
severe acute liver disease)
• alkaline phosphatase,
• bilirubin,
• gamma glutamyl transpeptidase
evaluate Cholestasis and biliary obstruction
7. Liver diseases with pregnancy
coincidental liver disease
• hepatitis
• Gallstones
• Drug toxicity .
underlying chronic liver
disease.
pregnancy-related
1. The preeclampsia-
associated liver diseases
• (HELLP) syndrome
• (AFLP) acute fatty liver of
pregnancy
2. Not preeclampsia-
associated liver diseases
• Hyperemesis gravdarum
• (ICP) intrahepatic
cholestasis of pregnancy
8.
9. Hyperemesis gravidarum
• is intractable, dehydrating vomiting in the first trimester
of pregnancy; 50% of patients with this condition have
abnormal liver test
have been shown to be risk factors for HG development
• Multiple gestations
• increased body mass index (BMI)
• pre-existing diabetes
• psychiatric illness
• and HG in a previous pregnancy
.
10. • Elevations in serum aminotransferases usually go up to 200
U/L and this is the most common abnormal liver test result.
• In pregnant women presenting with abnormal liver enzymes
with or without HG in the first trimester, other causes of
abnormal liver enzymes must be ruled out .
Hyperemesis gravidarum
11. • Initial management is conservative
• The only FDA-approved drug for treating nausea and
vomiting in pregnancy is doxylamine/pyridoxine ( VIT B6) .
• Ginger may be used as a nonpharmacologic option, as it
has had some beneficial effects in the treatment of
nausea and vomiting of pregnancy.
• However, antihistamines, antiemetics of the
phenothiazine class, and promotility agents (eg,
metoclopramide) are used
• In refractory cases, ondansetron ( zofran) and steroids
may be considered
Hyperemesis gravidarum
12.
13. • Obstetric cholestasis is diagnosed when otherwise
unexplained pruritus occurs in pregnancy and abnormal liver
function tests (LFTs) and/or raised bile acids occur in the
pregnant woman and both resolve after delivery.
• Pruritus that involves the palms and soles of the feet is
particularly suggestive
• Other evidence of cholestasis should be sought, including pale
stool, dark urine and jaundice, and other risk factors identified
such as a personal or family history of obstetric cholestasis,
multiple pregnancy, carriage of hepatitis C and presence of
gallstones.
Intrahepatic cholestasis of pregnancy
14. • ICP is the most common cause of jaundice during pregnancy
characterized by a reversible cholestatic condition that usually
occurs during the late second and third trimester, when
serum concentrations of estrogen reach their peak; it has a
higher incidence in twin pregnancies, which have higher
estrogen levels, and resolves after delivery, when sex
hormone levels fall
• ICP has rapid postnatal resolution, with signs and symptoms
usually disappearing spontaneously within 6 weeks of
delivery.
Intrahepatic cholestasis of pregnancy
15. • The main symptom of ICP is pruritus, which typically predominates
on the palms and soles of the feet and worsens at night.
• Pruritus often develops after 25 weeks of gestation, with 80% of cases
occurring after the 30th week.
• Other symptoms of ICP can include steatorrhea, malabsorption of fat-
soluble vitamins, and weight loss due to cholestasis .
• Jaundice has an incidence of 14–25% and may develop 1 to 4 weeks
after the onset of pruritus, with dark urine and pale feces in some women.
• The most important biochemical test in the context of ICP is total bile
acids concentration, greater than 10 μmol /L which can be the first, and
sometimes only, laboratory abnormality
• Serum bile acid values may fluctuate and increase with advancing
pregnancy; therefore, it is advisable to check it weekly in women with ICP
• >40 μmol serum bile acids in severe ICP is currently considered to be
associated with adverse pregnancy outcomes
Intrahepatic cholestasis of pregnancy
16. • Ursodeoxycholic acid improves clinical symptoms and liver
parameters in a number of cholestatic liver disorders.
• UDCA at a daily dose ranging from 600-2000 mg or 15 mg/kg per day was
effective at reducing pruritus, decreasing the total serum bile acid levels,
ALT values, and bilirubin levels and allowing delivery closer to term
• Antihistamines are commonly administered in conjunction with UDCA to
alleviate pruritus symptoms.
• Dexamethasone should not be first-line therapy for treatment of obstetric
cholestasis,
• Other medications, such as cholestyramine and S-adenosyl-methionine,
have not had satisfactory results
Intrahepatic cholestasis of pregnancy
17. • where the prothrombin time is prolonged, the use of water-
soluble vitamin K (menadiol sodium phosphate) in doses of
5–10 mg daily is indicated.
• when prothrombin time is normal, water-soluble vitamin K
(menadiol sodium phosphate) in low doses should be used .
Intrahepatic cholestasis of pregnancy
18. Mortality/Morbidity
• From a maternal viewpoint, the main consideration is
intense pruritus, It is characterized by profound itching
often beginning with the palms of the hands and soles of
the feet without evidence of a rash which may become so
intolerable that delivery is considered as early as 35-37
weeks
• The fetal viewpoint is more concerning, as even with
modern treatment the risk for fetal demise can range from
2-11 %. One of the more worrisome aspects of ICP is the
possibility of sudden fetal death, sometimes within hours of
normal fetal heart rate tracings
Intrahepatic cholestasis of pregnancy
19. • Poor outcome cannot currently be predicted by biochemical
results and delivery decisions should not be based on results
alone.
• No specific method of antenatal fetal monitoring for the
prediction of fetal death can be recommended.
• Ultrasound and cardiotocography are not reliable methods for
preventing fetal death in obstetric cholestasis
Intrahepatic cholestasis of pregnancy
20. Delivery is commonly recommended at 37 weeks’ without an amniocentesis
for fetal lung maturity due to increased risk of fetal mortality and morbidity .
• A discussion should take place with women regarding induction of labour
after 37+0 weeks of gestation.
• Women should be informed of the increased risk of perinatal morbidity
from early intervention (after 37+0 weeks of gestation).
• Women should be informed that the case for intervention (after 37+0
weeks of gestation) may be stronger in those with more severe
biochemical abnormality (transaminases and bile acids).
• Women should be informed of the increased risk of maternal morbidity
from intervention at 37+0 weeks of gestation.
• Women should be informed of the inability to predict stillbirth if the
pregnancy continues.
Intrahepatic cholestasis of pregnancy
21.
22. • AFLP is a microvesicular fatty infiltration of hepatocytes due to Defect in beta-
oxidation of fatty acids in mitochondria, leads to fat droplets formation in
hepatocyte that is also known as acute yellow atrophy or acute fatty
metamorphosis .
• AFLP is a medical and obstetric emergency because it can be fatal for both the
mother and fetus in the absence of early recognition and appropriate
management .
• AFLP is a rare condition, usually occurring in the third trimester, with an
approximate incidence of 1: 7000 to 1: 16000 and is commonly associated
(or complicated ) with preeclampsia (50 to 100 percent).
Acute fatty liver of pregnancy
23. • AFLP usually occurs in the third trimester, rarely before the
30th gestational week, but up to 20% of cases present
postnatally .
• Clinical presentation is variable and includes non-specific
symptoms such as nausea, vomiting, abdominal pain,
headache, and malaise.
• The clinical course can rapidly progress to acute liver failure
and its complications, such as encephalopathy, jaundice, and
coagulopathy
Acute fatty liver of pregnancy
24. • Laboratory tests can show abnormal liver values, including:
elevated aminotransferase levels (from mild elevation to 1000 IU/L, but
usually 300–500 IU/mL) .
hyperbilirubinemia (frequently >5 mg/dL).
leukocytosis, normochromic anemia, and thrombocytopenia are present,
as well as hypoalbuminemia, elevated uric acid, renal dysfunction,
metabolic acidosis, hyperammonemia, and biochemical pancreatitis.
Ketonuria and proteinuria can be present.
Hypoglycemia is characteristic and predicts a poor prognosis.
In severe cases, prolonged PT and reduced fibrinogen levels may be found,
whereas disseminated intravascular coagulation (DIK) is seen in
approximately 10% of patients with AFLP.
Acute fatty liver of pregnancy
25. Fifteen years ago, Ch’ng et al.published a study in which they
proposed diagnostic criteria, known as the Swansea
criteria, for the diagnosis of AFLP.
Acute fatty liver of pregnancy
26. Swansea criteria
he presence of ≥6 abnormal variables had positive predictive value of 85 percent and
negative predictive value of 100 percent for finding microvesicular steatosis
●Vomiting
●Abdominal pain
●Polydipsia/polyuria
●Encephalopathy
●Elevated bilirubin (>0.8 mg/dL or >14 micromol/L)
●Hypoglycemia (<72 mg/dL or <4 mmol/L)
●Leukocytosis (>11,000 cells/microL)
●Elevated transaminases (AST or ALT) (>42 international unit/L)
●Elevated ammonia (>47 micromol/L)
●Elevated uric acid (5.7 mg/dL or >340 micromol/L)
●Acute kidney injury, or creatinine 1.7 mg/dL or >150 micromol/L
●Coagulopathy or prothrombin time >14 seconds
●Ascites or bright liver on ultrasound scan
●Microvesicular steatosis on liver biopsy
The criteria are intended for use in women without hemolysis, elevated liver enzymes, and a
low platelet count syndrome or preeclampsia, which limits their clinical utility
27. • The main differential diagnosis is HELLP syndrome due to the great overlap
between AFLP and HELLP syndrome. Thus, distinguishing between these 2
disorders is often very difficult, potentially delaying diagnosis.
• Early recognition of the disease and delivery of the fetus regardless of
gestational age are the keys to successful management,
Acute fatty liver of pregnancy
28.
29. • itself is the commonest cause of hepatic tenderness
and liver dysfunction in pregnancy, and 2%-12% of
cases are further complicated by hemolysis (H),
elevated liver tests (EL), and low platelet count (LP)-
• the HELLP syndrome. Immediate delivery is the only
definitive therapy, but many maternal complications
can occur, including abruptio placentae, renal failure,
subcapsular hematomas, and hepatic rupture.
SEVER PREECLAMPSIA
“ HELLP ”
30. • preeclampsia is a multisystem disorder defined by de
novo hypertension after the 20th week of pregnancy with
blood pressure (BP) ≥140/90 mmHg and proteinuria of >300
mg/day in association with other organ dysfunction of the
mother, such as renal impairment, liver involvement,
neurological or hematological complications, and
uteroplacental dysfunction, as well as fetal growth restriction .
• The main feature that distinguishes eclampsia from
preeclampsia is the presence of seizures
SEVER PREECLAMPSIA
“ HELLP ”
31. • The diagnosis of HELLP syndrome is based mainly on clinical features.
Women often present with fluctuating colic-like pain in the upper
abdomen, usually epigastric or in the right upper quadrant. In addition,
non-specific symptoms such as nausea, vomiting, and malaise are often
present.
• Arterial hypertension and proteinuria are noted in most women. Due to
microangiopathic hemolytic anemia,
• unconjugated bilirubin and LDH are increased,
• whereas liver enzymes are moderately elevated (ALT 2–30 fold). Low
haptoglobin may be used as another parameter for the diagnosis of
hemolysis.
SEVER PREECLAMPSIA
“ HELLP ”
32. there are 2 classifications of HELLP
syndrome: the Tennessee , and
Mississippi classifications,
SEVER PREECLAMPSIA
“ HELLP ”
33. The Tennessee classification of HELLP
The Tennessee classification describes HELLP as either complete or
partial.
Complete HELLP syndrome is characterized by the following:
• Platelet count of 100,000/μL or less
• AST or ALT levels of 70 IU/L or more
• LDH (or bilirubin) (with hemolysis as evidenced on abnormal
peripheral smear) levels of 600 IU/L (≥0.2 mg/dL) or more
Partial HELLP syndrome is characterized by severe preeclampsia plus
one of the following:
• ELLP: Elevated liver enzyme levels, thrombocytopenia, no hemolysis
• EL: Mildly elevated liver enzyme levels, no thrombocytopenia, no
hemolysis
• LP: Thrombocytopenia, no hemolysis, normal liver enzyme levels
• HEL: Hemolysis, liver dysfunction, no thrombocytopenia
34. The Mississippi classification OF HELLP
The Mississippi classification divides HELLP syndrome into 3 classes
based on platelet count, AST or ALT levels, and LDH levels.
Class 1, which has an approximately 13% incidence of bleeding, is
associated with the highest maternal morbidity and mortality rates
and longest recovery time. Patients in this class have a platelet
count less than 50,000/µL, liver dysfunction with AST or ALT levels
greater than 70 IU/L, and hemolysis as evidenced by an LDH level
greater than 600 IU/L.
Class 2 includes platelet counts from 50,000-100,000/µL with AST,
ALT, and LDH levels similar to those in class 1. Class 2 has an 8%
incidence of bleeding.
class 3 The mild form of HELLP has a platelet count from 100,000-
150,000/µL, AST and ALT greater than 40 IU/L, and LDH greater
than 600 IU/L, with no increased risk of bleeding.
36. Abdominal imaging methods, such as ultrasonography, CT, and
MRI, should be performed in all women with HELLP syndrome in
order to investigate liver complications, such as liver infarction,
intraparenchymal hemorrhage, subcapsular hematoma, and
hepatic rupture
SEVER PREECLAMPSIA
“ HELLP ”
37. As mentioned, HELLP syndrome and AFLP share similar presentations. The
differential diagnosis among AFLP and HELLP syndrome is shown in Table
38. • A pregnant patient presenting with abnormal liver tests should undergo
standard workup as with any non-pregnant individual .
• Imaging in pregnancy Ultrasound is safe and the preferred imaging
modality used in assessment of abnormal liver tests suggestive of biliary
tract disease
• Magnetic resonance imaging without gadolinium can be used in the
second and third trimester .
• Computed tomography scans carry a risk of teratogenesis and childhood
hematologic malignancies but may be used judiciously with minimized
radiation protocols (2–5 rads).
• Endoscopy in pregnancy Endoscopy is safe in pregnancy but should be
deferred until the second trimester if possible .
• Meperidine and propofol can be used for endoscopic.
Take home
39. • Active–passive immunoprophylaxis with hepatitis B immunoglobulin and
the HBV vaccination series should be administered to all infants born to
HBV-infected mothers to prevent perinatal transmission .
• Women chronically infected with HBV and high viral load (>10 6 log
copies/ml (200,000 IU/ml) and higher) should be offered antiviral
medication with tenofovir or telbivudine in the third trimester to reduce
perinatal transmission of HBV
• C-section should not be performed electively in HBV-positive mothers to
prevent fetal infection .
• Women chronically infected with HBV should be allowed to breastfeed as
recommended for infant health
Take home
40. Take home
All pregnancy related liver diseases that occur in late
second trimester or third trimester either preeclampsia
associated ( HELLP or AFLP ) OR not preeclampsia
associated ( ICP) necessitate termination of pregnancy ,
irrespective of fetal maturity in HELLP , AFLP and in ICP
if bile acids level is > 40 micromole/ L