By Prof. Dr. Madhulatha Alexander
Pregnancy may cause an upward displacement of the liver. The signs of liver disorder in pregnant ladies include palmar erythema and spider angiomas––which usually subside after delivery after the estrogen levels normalize.
The diagnostic evaluation of pregnant patients is the same as that for nonpregnant patients with liver disease. However, the liver may not be palpable.
Laboratory parameter changes:
- AST/ALT – no change
- Bilirubin – no change
- Prothrombin Time – no change
- Serum Albumin – decreases
- Alkaline Phosphatase – increases
- Hemoglobin (Hb) – decreases
- Alpha-Fetoprotein – increases
- 5’ Nucleotidase – no change
- Gamma Glutamyl Transpeptidase (GGT) – no change
- Bile Acids – no change
Liver Diseases Unique to Pregnancy:
- Primary Liver Diseases – Intrahepatic Cholestasis of Pregnancy (IHCP), Acute Fatty Liver of Pregnancy (AFLP)
- Systemic Diseases with Hepatic Manifestations – Preeclampsia with severe features; Hyperemesis gravidarum
Indications for Liver Function Test (LFT):
- Pre-gestational liver disease
- Chronic hypertension
- Gestational hypertension
- Risk factors for liver disease
- Viral Hepatitis on prenatal screening
The first trimester is characterized by hyperemesis gravidarum – severe nausea and vomiting, can occur in up to 3.6% of the cases––due to starvation injury, release of inflammatory cytokines, or impaired fatty acid oxidation.
The management includes confirming the viability of the pregnancy as the first step and excluding multiple pregnancies and other causes of gestational hyperemesis. The evaluation must involve urine analysis (ketone bodies, pus cells), checking the electrolyte balance, LFT, and creatinine. The treatment strategy includes medication change, dietary changes, counseling, and oral hydration.
In cases with ketonuria, hospitalization may be warranted. In-patient management entails:
- Nil PO
- IV Lifeline
- Vitals monitoring
- Pulse rate should be <120/min; urinary output >60ml/2 hrs
- Multivitamin Supplementation (Thiamine) – 100 mg IV, 2-3 days daily for those with vomiting.
- Inj KCL based on the electrolyte levels
- Ondansetron
- Metoclopramide
- Promethazine
- Fluid correction – rehydration therapy
Management of Refractory cases:
- Complete evaluation
- ABG to rule out metabolic disturbance
- Endoscopy
- Specialist Opinion
- IV Hydrocortisone
- Control vomiting
- Switch to oral Hydrocortisone
- H2 RA and PPIs
Intrahepatic Cholestasis of Pregnancy:
The condition is common in Asian women, and more prevalent in older age, and is characterized by increased total bile acids. The assessment involves serum bile acids and LFT. Treatment choice depends on the AST/ALT levels and may warrant Ursodeoxycholic acid (UDCA) 500 mg twice daily administration.
In cases with increased bile acids – UDCA and rifampicin can be prescribed. Other adjuncts include – antihistamines, chlorpheniramine maleate, and topical creams for relieving the pruritus.
Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) syndrome:
It is characterized by increased total bilirubin levels; it usually resolves post-delivery. The risk factors include a prior history of preeclampsia. The confirmatory laboratory parameters show at least two of the following signs; vis, hemolysis, elevated liver enzymes, and low platelet count. CT scan or MRI may show hepatic hematoma or rupture. The preeclampsia profiles usually present with pain.
Delivery after maternal stabilization is advisable, irrespective of the gestational age. The management involves patient stabilization and assessing fetal status; vaginal birth is desirable.
Dexamethasone has no role.
Acute Fatty Liver of Pregnancy (AFLP):
AFLP is rare and the most fulminant and usually presents in the thirst trimester. The condition is characterized by acute kidney injury, multisystem failure, encephalopathy, coagulopathy, pancreatitis, pulmonary edema, and adult respiratory distress syndrome.
The diagnosis is based on signs, symptoms, laboratory findings, and imaging. Laboratory features include:
- Elevated bilirubin
- Hypoglycemia
- Leukocytosis
- Elevated Transaminases
- Elevated Ammonia
- Elevated Uric Acid
- AKI and Coagulopathy
Ultrasound shows ascites or bright liver. Biopsy exhibits microvesicular steatosis. Obstetric management includes – prompt labor induction after maternal stabilization.
Other Diseases Exacerbated During Pregnancy:
- Gall stones
- Vascular disease – Budd-Chiari Syndrome
Prof. Dr. Madhulatha Alexander is Obstetrician and Gynaecologist. Professor, Government Medical College, Nizamabad, Telengana