The document discusses the physiological changes in the liver during pregnancy, highlighting increased alkaline phosphatase levels and the potential for various liver diseases. It outlines specific conditions such as acute cholestasis, fatty liver, and HELLP syndrome, emphasizing the risks and management strategies associated with each. Key points include the importance of early delivery in cases of pregnancy-associated liver disease to reduce maternal and fetal mortality and the evaluation of liver function tests during pregnancy.

1. PREGNANCY
&
LIVER DISEASES
Dr Abdullah Ansari
MBBS, MD Medicine
Aligarh Muslim University

2. PHYSIOLOGICAL CHANGES IN THE LIVER
DURING PREGNANCY
Increased
 ALP rise 3-4 fold due to placental production
 Fibrinogen rise by 50 %, with other clotting factors
Decreased
 Gallbladder contractility
 Albumin and total protein

3. No change
 Liver size
 Liver blood flow despite increased blood volume
and cardiac output
 Liver aminotransferase levels, may decrease
 Bilirubin level
 Prothrombin time

4. THE POSSIBILITIES OF LIVER DISEASES
1. A worsening of pre-existing chronic liver or biliary
disease (may not have previously been
diagnosed)
2. A genuine first presentation of liver disease that is
not intrinsically related to pregnancy
3. A genuine pregnancy-associated liver injury
process

5. THE GENERAL RULE
 The earlier in pregnancy the liver abnormality
presents, the more likely it is to represent either
preexisting liver disease or non-pregnancy-related
acute liver disease

6. LFT IN PREGNANCY
 ALT levels and albumin normally fall in pregnancy
 ALP levels can rise due to contribution of placental
ALP

7. INTERCURRENT AND PRE-EXISTING
LIVER DISEASE
Viral hepatitis
 Acute hepatitis A: no effect on fetus
 Chronic hepatitis B: requires identification to
reduce perinatal transmission
 Chronic hepatitis C: perinatal transmission 1%
 Acute hepatitis E: progresses to fulminant hepatic
failure, with 20% maternal mortality

8. Autoimmune hepatitis
 Improves during pregnancy and flare-up
postpartum
 Azathioprine to be continued during pregnancy
Gallstones
 More common during pregnancy,
 May present with cholecystitis or biliary obstruction
 ERCP safely performed with lead protection

9. Cirrhosis
 Pregnancy uncommon as cirrhosis causes relative
infertility
 Ascites or polyhydramnios treated with amiloride
rather than spironolactone
Wilson’s disease
 Penicillamine to be continued during pregnancy

10. PREGNANCY-ASSOCIATED LIVER DISEASE
 Predominant in the third trimester and resolve post-
partum
 Maternal and fetal mortality and morbidity
prevented by early delivery
 Hyperemesis Gravidarum is a disease of 1st
trimester

11. HYPEREMESIS GRAVIDARUM
 0.3-2% of all pregnancies
 Presents with persistent vomiting, leading to
dehydration with associated ketosis and weight
loss of >5%
 Risk factors include previous pregnancies with
hyperemesis gravidarum, multiple gestations,
trophoblastic disease, nulliparity
 Hormonal peaking of HCG and estradiol probably
plays role

12.  Mild elevation of transaminase in 50% cases,
Bilirubin may rise to 4 mg/dl
 Amylase elevated in 10%
 A transient hyperthyroidism associated in 50-60%
cases
 Complications include electrolyte imbalance,
esophageal rupture, retinal hemorrhage, renal
failure

13.  Initial management is conservative
 The only FDA-approved drug for treating nausea
and vomiting in pregnancy is doxylamine/pyridoxine
 However, antihistamines, antiemetics of the
phenothiazine class, and promotility agents (eg,
metoclopramide) are used
 In refractory cases, ondansetron and steroids may
be considered

14. ACUTE CHOLESTASIS OF PREGNANCY
 20% of jaundice in pregnancy
 Presents with itching
 Associated with IUGR, premature birth and IU fetal
death (if pregnancy >36 weeks)
 Cholestatic LFT and elevated serum bile salts

15.  Delivery leads to resolution and pregnancy should
not be continued beyond term
 UDCA (15 mg/kg daily) effective in itching and
probably prevents premature birth
 UDCA requires long time for effective levels in bile
pool, hence of little use in late pregnancy
 Recurs in 60% subsequent pregnancies

16. ACUTE FATTY LIVER OF PREGNANCY
 More common in twins, first pregnancies and male
fetus
 Presents with vomiting and abdominal pain followed
by jaundice
 Fulminant hepatic failure in severe cases
 Defect in beta-oxidation of fatty acids in
mitochondria, leads to fat droplets formation in
hepatocyte (microvesicular fatty liver)

17.  Differentiates from toxaemia of pregnancy by high
levels of serum uric acid and absence of hemolysis
 Maternal and perinatal mortality 1% and 7%
respectively
 Delivery regardless of gestational age is the only
treatment

18. HELLP SYNDROME
 Hemolysis, elevated liver enzymes and low
platelets, a variant of pre-eclampsia
 Presents with hypertension, proteinuria and fluid
retention
 Jaundice only in 5% cases
 Blood tests shows low haemoglobin, with
fragmented red cells, markedly elevated serum
transaminases and raised D-dimers

19.  Complications include hepatic infarction and
rupture, DIC and placental abruption
 Maternal and perinatal mortality 1% and 30%
respectively
 Delivery leads to prompt resolution
 Recurs < 5% subsequent pregnancies

20. Thank You