Liver Dysfunction In Pregnancy Research Articles

Liver Disorders in PregnancyA Retrospective Study

Introduction: Liver disorders associated with pregnancy are important medical disorders that carries grave prognosis and challenging for both obstetricians and hepatologists. It affects about 3% of pregnancies worldwide and about 3-5% pregnancies in India. It can present with various symptoms like yellowish discolouration of sclera, dark coloured urine, anorexia, nausea, vomiting, abdominal pain etc. The liver disorders unique to pregnancy includes-hyperemesis gravidarum, preeclampsia, eclampsia with liver dysfunction, HELLP syndrome, Intrahepatic Cholestasis of Pregnancy (IHCP) and acute fatty liver of pregnancy. Aim: This study aims to evaluate demographic variables, causes of liver dysfunction during pregnancy and foeto-maternal outcome of pregnancies complicated by jaundice and liver dysfunction. Materials and Methods: This was a retrospective hospital based observational study on the pregnant women admitted with jaundice or any liver disorders in department of Obstetrics and Gynaecology in Rajendra Institute of Medical Sciences, Ranchi, Jharkhand over a period of one year from March 2018 to February 2019. The incidence of liver disorders in pregnancy, its causes, the foetal outcome in terms of preterm birth, stillbirth, Foetal Growth Restriction (FGR) and Intrauterine Foetal Death (IUFD), the maternal outcome in terms of mode of delivery, complications, need for ICU admissions and maternal mortality were evaluated. Descriptive statistics like percentage and mean calculation were used to interpret the data. Results: Out of 8264 obstetrics admissions, 126 had liver disorder in pregnancy, incidence being 1.52%. Total 87 (69%) cases were primigravida, 115 (91.3%) cases presented during 3rd trimester of pregnancy, 101 (80.1%) were unbooked for our institution. A total of 92 (73%) were referred to us. Preeclampsia, eclampsia, HELLP syndrome was the most common cause of liver dysfunction accounting for 46.8% followed by IHCP in 31 (24.6%) cases. Out of 126, 115 women admitted in labour, of which 75 (65.3%) delivered vaginally, 38 (33%) taken for caesarean section and 2 died undelivered. Nine cases were admitted in 1st trimester and two cases in 2nd trimester who did not turn up after discharge. Neonatal mortality was seen in 18 (15.6%). Conclusion: Liver dysfunction in pregnancy carries grave prognosis with high incidence of perinatal and maternal morbidity and mortality. This study emphasises the need for regular Antenatal Care (ANC), need to remain vigilant for preventable causes like haemolytic jaundice, early diagnosis, proper treatment and timely referral of liver disorders with pregnancy to prevent the complications and improve foetal and maternal outcome.

Effectiveness and safety of double-balloon catheter versus intra-amniotic injection of ethacridine lactate for termination of second trimester pregnancy in patients with liver dysfunction.

Severe liver dysfunction in pregnancy (SLDP) is rare but serious complications with high mortality rate. This study compared the effectiveness and safety of double-balloon catheter versus intra-amniotic injection of ethacridine lactate for the termination of second trimester pregnancy in patients with SLD. A total of 55 patients with indications of labor induction were enrolled and analyzed by retrospective control analysis method. Twenty-three cases adopted Cook double balloon dilation as Cook group, and 32 cases received intra-amniotic injection of ethacridine lactate as EL group. The primary outcome was evaluated by successful abortion rate and the difference in the induction-to-abortion interval. Secondary outcomes included liver function recovery and the frequency of adverse events. Both Cook and EL regimens were effective, with successful abortion rate of 87.0% and 93.8%, respectively (P=0.639). The induction-to-delivery interval was similar between Cook group and EL group (38.1 ± 21.5 vs. 41.3 ± 17.4, P=0.543). The liver disease status was more severe in Cook group than in EL group, but it did not show any significant difference after pregnancy termination between the two groups and the improvement rate also did not show any significant difference. Both treatments were safe and there was no significant difference in bleeding and cervical laceration adverse events between the two groups. Our study firstly compared double-balloon catheter and ethacridine lactate for the induction of labor in women with SLD during second trimester pregnancy.

Differentiation of acute fatty liver of pregnancy from syndrome of hemolysis, elevated liver enzymes and low platelet counts

As proposed criteria (Swansea criteria) for the diagnosis of acute fatty liver of pregnancy (AFLP) do not include antithrombin (AT) activity, diagnosis of AFLP may be delayed. The aim of this review is to underscore problems in the differential diagnosis of AFLP and the syndrome of hemolysis, elevated liver enzymes and low platelet counts (HELLP syndrome) and to facilitate prompt diagnosis of AFLP. Published works dealing with liver dysfunction in pregnancy, HELLP syndrome and AFLP were reviewed. AFLP and HELLP syndrome shared common clinical, laboratory, histological and genetic features, and differential diagnosis between them was often difficult. However, HELLP syndrome was likely to occur in patients with hypertension, but AFLP occurred often in the absence of hypertension. In addition, AFLP was exclusively associated with pregnancy-induced antithrombin deficiency (PIATD). Approximately 50% of patients with AFLP did not have thrombocytopenia at presentation. As the Swansea criteria for AFLP did not include PIATD, diagnosis of AFLP was delayed until manifestation of life-threatening complications; 60% of women were admitted to intensive care and 15% to a specialist liver unit. In conclusion, incorporation of AT activity of less than 65% into the diagnostic criteria for AFLP may facilitate suspicion and prompt diagnosis of AFLP, decrease uncertainty regarding the diagnosis of AFLP, and contribute to better investigation and understanding of the process leading to the development of liver dysfunction.

Hyperammonemia: a report of maternal biliary cirrhosis and neonatal outcome.

Although uncommon during pregnancy, cirrhosis results in multiple medical complications impacting both mother and fetus. Previous reports suggest liver dysfunction in pregnancy causes accumulation of neurotoxins within the maternal compartment that increases neonatal morbidity through placental transfer. We present a case of a 36-year-old G2P1 female with history of biliary cirrhosis presenting at 32-weeks' gestation with hepatic congestion progressing to hepatic encephalopathy prompting delivery. Umbilical cord sampling and postnatal infant testing demonstrated elevated ammonia levels which resolved by 12 hours of life without intervention. At discharge, the infant did not demonstrate evidence of neurologic deficit. We conclude that acute maternal hepatic encephalopathy and hyperammonemia due to chronic liver disease do not portend adverse neonatal outcomes, notably encephalopathy.

Pregnancy and the liver

In pregnancy the liver can be affected by diseases specific to pregnancy as well as unrelated conditions. The possible effect of the disease and its management on both the fetus and mother must be considered. Several physiological changes occur during pregnancy as liver metabolism is altered. Serum protein concentrations fall, with a decrease in serum albumin in part the result of the dilutional effect of an increase in plasma volume. Alanine transaminase and aspartate transaminase levels decrease (Table 1), complicating the diagnosis of disorders involving subtle changes in liver function. Alkaline phosphatase is also produced by the placenta, making this an unreliable marker of liver dysfunction in pregnancy.

Acute Fatty Liver of Pregnancy Complicated by Pancreatitis and Multiorgan Failure

Purpose: Introduction: Acute fatty liver is an uncommon but serious complication of pregnancy. It usually occurs in third trimester and was universally fatal until the advent of advanced supportive measures. Case: A 29 year old woman was transferred to our tertiary care center with multiorgan failure. She was found to be have liver failure, renal failure and coagulopathy when she first presented to a city hospital with nausea and vomiting in 32nd week of her first pregnancy. Vaginal ultrasonography revealed an intrauterine dead fetus which was evacuated by cesarean section. Upon arrival to our center, she had developed acute pancreatitis, disseminated intravascular coagulation, intraabdominal bleeding with hemorrhagic shock and hypoglycemia in addition to hepatic and renal failure. She was given aggressive supportive treatment and blood products replacement. Transjugular liver biopsy confirmed the diagnosis of acute fatty liver of pregnancy (AFLP). The patient went on to develop acute respiratory failure and sepsis and ultimately succumbed to multiorgan failure. Discussion: Liver dysfunction in pregnancy can range from benign cholestasis to severe preeclampsia, HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome and AFLP. AFLP usually begins in late third trimester with nausea, vomiting, anorexia and epigastric pain and can progress to jaundice, coagulopathy and hepatic encephalopathy. Key laboratory findings are hyperbilirubinemia with modest elevation in transaminases, leukocytosis, coagulopathy and hypoglycemia. It can be complicated by disseminated intravascular coagulation, sepsis, renal failure and, rarely, pancreatitis. It is challenging to differentiate AFLP from HELLP syndrome due to overlapping features and liver biopsy showing microvesicular steatosis is usually necessary to make the diagnosis of AFLP. Emergent delivery and aggressive supportive care is the key to successful outcomes. Resolution occurs spontaneously after termination of pregnancy. Conclusion: AFLP is a serious condition which usually presents with non specific symptoms. Prompt recognition, termination of pregnancy and advanced supportive care are critical determinants of disease outcome. Prognosis is guarded when it is complicated by multiorgan failure.

Liver dysfunction in pregnancy: an important cause of maternal and perinatal morbidity and mortality in Pakistan.

The objective of this study was to evaluate the maternal and perinatal outcome of women with liver dysfunction during pregnancy. The study involved a prospective observational study design and was carried out at the Dow University of Health Sciences and Civil Hospital Karachi, Pakistan. A total of 800 women, who delivered during the study period from January 2006 to September 2006, constituted the study population. Pregnant women with liver dysfunction underwent evaluation for the aetiology of their liver dysfunction, including screening for hepatitis E. Thirty-five women were identified with liver dysfunction. Fourteen (40%) presented in the second trimester and 21 (60%) presented in the third trimester. Twenty-two of the 35 women (63%) had isolated acute hepatitis E; five (14%) had HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome; two (6%) had intrahepatic cholestasis of pregnancy (IHCP), two had acute fatty liver of pregnancy (AFLP) and two women had hepatitis A. A specific diagnosis was not reached in two women who died prior to delivery. In women with hepatitis E, the mean values of bilirubin and alanine transaminase were 12 mg/dL and 675 U/L, respectively. Abnormal coagulation parameters were present in 20 (57%) of the women and in 18 of 22 (82%) with hepatitis E. Fulminant hepatic failure (FHF) was seen in four patients. Seven women (20%) underwent caesarean section, 26 (74%) delivered vaginally and two women died undelivered. There were six maternal deaths in the study population; two were due to hepatitis E, one each from HELLP and AFLP, and two remained undiagnosed. The overall perinatal mortality within the group was 43%. Hepatitis E was the most common cause of FHF and maternal death in pregnant women with liver dysfunction.

Lebererkrankungen in der Schwangerschaft

Abnormal liver function tests occur in 3 - 5% of pregnancies for different reasons. Apart from pre-existing liver diseases liver diseases occurring during pregnancy, such as gall stones or viral hepatitis, most liver dysfunctions in pregnancy are caused by one of the five pregnancy-related liver diseases. The five known pregnancy-related liver diseases can be classified in two main categories depending on their association with or without preeclampsia. The preeclampsia-associated liver diseases are the preeclampsia itself, the HELLP-syndrome ("Hemolysis" (H), "Elevated Liver Tests" (EL), "Low Platelet Count" (LP)) and the acute fatty liver of pregnancy. Hyperemesis gravidarum and intrahepatic cholestasis of pregnancy are not associated with preeclampsia. Hyperemesis gravidarum is characterised by intractable vomiting in the first trimester of pregnancy. 50% of patients with this condition have liver dysfunction. Intrahepatic cholestasis of pregnancy presents with pruritus and elevated bile acids in the second half of pregnancy. Patients have often mild jaundice and highly elevated liver enzymes. Treatment of choice is ursodeoxycholic acid to relieve the mother's symptoms. With this condition mainly the fetus is at risk. Severe preeclampsia is the most common cause of liver dysfunction in pregnancy, and is in some cases further complicated by HELLP syndrome. The prompt delivery of the baby is the only definitive therapy. However, many life-threatening maternal complications like liver hematoma or rupture and abruptio placentae can occur. Acute fatty liver of pregnancy is also a severe illness occuring mostly in the third trimester; microvesicular fat deposition in the liver can cause liver failure with coagulopathy and encephalopathy. Only the immediate delivery of the fetus can save mother and child.

Liver disease in pregnancy

Abnormal liver tests occur in 3%-5% of pregnancies, with many potential causes, including coincidental liver disease (most commonly viral hepatitis or gallstones) and underlying chronic liver disease. However, most liver dysfunction in pregnancy is pregnancy-related and caused by 1 of the 5 liver diseases unique to the pregnant state: these fall into 2 main categories depending on their association with or without preeclampsia. The preeclampsia-associated liver diseases are preeclampsia itself, the hemolysis (H), elevated liver tests (EL), and low platelet count (LP) (HELLP) syndrome, and acute fatty liver of pregnancy. Hyperemesis gravidarum and intrahepatic cholestasis of pregnancy have no relationship to preeclampsia. Although still enigmatic, there have been recent interesting advances in understanding of these unique pregnancy-related liver diseases. Hyperemesis gravidarum is intractable, dehydrating vomiting in the first trimester of pregnancy; 50% of patients with this condition have liver dysfunction. Intrahepatic cholestasis of pregnancy is pruritus and elevated bile acids in the second half of pregnancy, accompanied by high levels of aminotransferases and mild jaundice. Maternal management is symptomatic with ursodeoxycholic acid; for the fetus, however, this is a high-risk pregnancy requiring close fetal monitoring and early delivery. Severe preeclampsia 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. Acute fatty liver of pregnancy is a sudden catastrophic illness occurring almost exclusively in the third trimester; microvesicular fatty infiltration of hepatocytes causes acute liver failure with coagulopathy and encephalopathy. Early diagnosis and immediate delivery are essential for maternal and fetal survival.

The liver in pregnancy: disease vs benign changes.

Liver dysfunction in a pregnant woman may be caused by the pregnancy, it may be unrelated to the pregnancy, or it may be a chronic condition that existed before the pregnancy. In any case, the clinical clues of liver dysfunction in pregnancy are not specific, and certain "abnormalities" in liver function tests may represent benign changes of pregnancy. On the other hand, prompt recognition of the signs of liver disease in pregnant patients leads to timely management and may save the life of both mother and baby.

Prospective study of liver dysfunction in pregnancy in South Wales, UK

Prospective study of liver dysfunction in pregnancy in South Wales, UK

Liver dysfunction in pregnancy: Prospective study in South Wales

Liver dysfunction in pregnancy: Prospective study in South Wales