Liver disease in pregnancy

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Chapter 23 LIVER DISEASE IN PREGNANCY

The most common liver diseases during pregnancy are preeclampsia and viral hepatitis. Less common causes that are specific to pregnancy include intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, Budd-Chiari syndrome, liver hematoma and rupture, and liver infarction.

In evaluating a patient with possible hepatic disease, liver cell damage is assessed by measurement of aspartate aminotransferase (AST) and alanine aminotransferase (ALT), whereas hepatic synthetic function is assessed by measurement of albumin level and prothrombin time (PT). Cholestatic disease is assessed by measurement of levels of alkaline phosphatase and bilirubin.

Acute fatty liver of pregnancy usually occurs late in pregnancy and is a medical emergency. It often manifests with nausea and vomiting, abdominal pain, headache, jaundice, and altered mental status. Acute fatty liver of pregnancy is associated with ALT levels lower than 500 IU/L; in acute viral hepatitis, in comparison, levels are often higher than 1000 IU/L. In addition, acute fatty liver of pregnancy is associated with disseminated intravascular coagulation, renal failure, pancreatitis, and hypoglycemia.

Intrahepatic cholestasis of pregnancy usually manifests initially with pruritus, followed by the development of jaundice. It is associated with elevations in serum bile acids (at least three times the normal level), bilirubin (<5 mg/dL), cholesterol and triglyceride levels, and normal or mildly elevated transaminase levels.

Budd-Chiari syndrome is the occlusion of the hepatic venous system and usually occurs in women with an underlying thrombophilia. This syndrome can occur at any time in pregnancy, and patients usually present with abdominal pain and distension, which progresses to ascites.

Key Historical Features

✓ Vision changes

✓ Facial and hand swelling (preeclampsia)

✓ Fever (cholangitis, acute viral hepatitis)

✓ Pruritus (intrahepatic cholestasis of pregnancy, primary biliary cirrhosis)

✓ Decreased appetite and fatigue (chronic liver disease)

✓ Gastrointestinal symptoms

• Nausea and vomiting

• Abdominal pain

• Abdominal distension

• Rectal bleeding

• Color of urine and stool

✓ Medical history, especially history of the following:

• Liver disease

• Previous episodes of jaundice

✓ Surgical history, especially previous biliary surgery

✓ Obstetric history

• Most recent menstrual period

• Previous ultrasonography during the pregnancy

• Previous obstetric complications

✓ Medications

✓ Travel history

✓ Social history, including alcohol use, drug use, and sexual history

Key Physical Findings

✓ Vital signs

✓ Examination for evidence of chronic liver disease: jaundice, scleral icterus, muscle mass loss, ascites, palmar erythema, spider angiomas, caput medusa, Dupuytren contracture, clubbing of digits

✓ Abdominal examination for hepatomegaly, splenomegaly, abdominal tenderness, or ascites

✓ Skin examination for excoriations that indicate pruritus

✓ Neurologic examination for evidence of hepatic encephalopathy

Suggested Work-Up

ALT, AST, bilirubin, and alkaline phosphatase measurements	To determine whether the liver disease is caused by hepatocyte damage or cholestasis
Serum bile acid measurements	To evaluate for intrahepatic cholestasis of pregnancy
Urinalysis	To evaluate for proteinuria
Complete blood cell count	To evaluate for anemia and thrombocytopenia, which are associated with liver disease
Blood urea nitrogen (BUN) and creatinine measurement	To evaluate for renal disease
Partial thromboplastin time (PTT), PT, and international normalized ratio (INR)	To evaluate for coagulopathy
Albumin measurement	To evaluate liver synthetic function
Serum electrolyte measurements	To evaluate for electrolyte abnormalities
Serum blood glucose measurement	To evaluate for hypo- or hyperglycemia

Additional Work-Up

Right upper quadrant ultrasonography	To evaluate the liver and gallbladder
Test for hepatitis A immunoglobulin M antibodies	To evaluate for acute hepatitis A infection
Test for hepatitis B surface antigen	To evaluate for hepatitis B infection (usually performed as a routine part of prenatal screening)
Test for hepatitis B core antibody	To evaluate for hepatitis B infection
Test for hepatitis C antibody	To evaluate for hepatitis C infection
Twenty-four-hour urine test for total protein	To evaluate for proteinuria (if preeclampsia is suspected)
Uric acid measurement	Elevated level is associated with preeclampsia
Lactate dehydrogenase measurement	Elevated level may be a sign of hemolysis associated with preeclampsia
Test for antimitochondrial antibody	To evaluate for primary biliary cirrhosis
Test for antinuclear antibody (ANA) and smooth muscle antibody	To evaluate for autoimmune hepatitis

FURTHER READING

Benjaminov FS, Heathcote J. Liver disease in pregnancy. Am J Gastroenterol. 2004;99:2478-2479.

Cappell MS. Hepatic and gastrointestinal diseases. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: Normal and Problem Pregnancies. 5th. New York: Churchill Livingstone; 2007:1105-1115.

Hunt CM, Sharara AI. Liver disease in pregnancy. Am Fam Physician. 1999;59:829-836.

Schutt VA, Minuk GY. Liver diseases unique to pregnancy. Best Pract Res Clin Gastroenterol. 2007;21:771-792.

Teoh NC, Farrell GC. Liver disease caused by drugs. In: Feldman M, Friedman LS, Brandt LJ, editors. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 8th. Philadelphia: Elsevier; 2006:1807-1843.

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