Liver Disease with Pregnancy

Posted by e-Medical PPT
Liver disease is a rare complication of pregnancy, but when it occurs it may do so in a dramatic and tragic fashion for both mother and infant. Diseases such as acute fatty liver of pregnancy (AFLP) may begin innocuously with mild symptoms and liver enzyme abnormalities but, if left untreated, can progress to jaundice, liver failure, and death.
Some of the normal physiologic changes of pregnancy can mimic abnormalities associated with liver disease.
Telangiectasia, particularly on the chest, back, and face, and palmer erythema occur in up to 60 percent of normal pregnant women but disappear after delivery.

Summary of physiological changes in the liver during pregnancy   
Increased:
Blood volume and cardiac ouput rise by 35%–50%
Alkaline phosphatase levels rise threefold or fourfold due to
placental production
Clotting factor changes create a hypercoagulable state
Decreased:
Gallbladder contractility
Hemoglobin
Uric acid levels
Albumin, total protein, and antithrombin III concentrations
No change:
Liver aminotransferase levels (aspartate aminotransferase,
alanine aminotransferase, gamma-glutamyl transferase)
Bilirubin level
Prothrombin time

Spectrum of liver diseases in pregnancy
Preexistent liver diseases
Portal hypertension, cirrhosis, primary biliary cirrhosis
Autoimmune hepatitis
Wilson disease
Chronic infection with hepatitis B or hepatitis C virus
Alcoholic liver disease

Liver diseases coincidental with but not induced by pregnancy
Acute viral hepatitis and other viral infections
Alcohol-related diseases
Gallstone disease
Budd-Chiari syndrome

Liver diseases induced by pregnancy
First trimester
Hyperemesis gravidarum
Second and third trimesters
Intrahepatic cholestasis of pregnancy
Preeclampsia, eclampsia, and the HELLP syndrome
(hemolysis, elevated liver enzymes, low platelet counts)
Acute fatty liver of pregnancy

Intrahepatic Cholestasis of Pregnancy
The syndrome has been variously called recurrent jaundice of pregnancy, cholestatic jaundice of pregnancy, jaundice of late pregnancy, and hepatosis of pregnancy. ICP, however, is the preferred term, because jaundice is inconstant in any type of cholestatic disorder.
Clinical Description
Pruritus is the dominant and  initial symptom and appears in the third trimester in more than 70% of cases. Most of the remaining patients date their onset of symptoms to the second trimester.
The symptom may become very severe and usually involves the trunk and the extremities, including the palms and the soles of the feet. As a result of the pru­ritus, insomnia, fatigue, and even mental disturbances have been reported
Many patients report the appearance of dark urine without frank jaundice shortly after the onset of pruritus. Only a minority of patients develop obvious jaundice, and this is usually mild.
It is notable that abdominal pain, biliary colic, fever, anorexia, nausea, vomiting, and arthralgias are absent.
The improvement in both pruritus and jaundice begins to occur quite promptly after delivery, most often within 24 hours. However, jaundice may continue for several days after delivery, and some of the abnormal chemistry profiles persist for as long as several months.
Subsequent pregnancies are frequently accompanied by recurrences of the syndrome.

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