Liver Problems in Pregnancy

Function of liver is not impaired in pregnancy. Any liver ailment from whatever reason can occur incidentally and concur with pregnancy. For instance, viral hepatitis is responsible for 40% of all cases of jaundice in pregnancy. Pregnancy does not inevitably worsen established liver disease, but it is unusual for women with advanced liver ailment to conceive.

Changes in the liver during pregnancy:

#Plasma and blood volumes are raised during pregnancy but the hepatic blood flow remains stable.

#The quantity of cardiac output supplied to the liver therefore reduce from 35% to 29% in late pregnancy; drug metabolism can thus be affected.

#The size of the liver remains the same.

#Liver biochemistry remains unaffected apart from a increase up to three to four times in serum alkaline phosphatase from the placental source and a diminish in total protein due to raised plasma volume.

#Triglycerides and cholesterol levels increase, and caeruloplasmin, transferrin, antitrypsin and fibrinogen levels are elevated due to augmented hepatic synthesis.

#Postpartum there is a propensity to hypercoagulability, and acute Budd-Chiari syndrome may occur.


These are some liver diseases specific to pregnant women:

Hyperemesis gravidarum

Pathological nausea and vomiting during pregnancy can sometimes be associated with dysfunction of liver and jaundice. Liver dysfunction resolves automatically in this case when vomiting ceases.

Intrahepatic cholestasis of pregnancy

This is a common ailment of unknown cause presents typically with itching all over the body alone in the third trimester. It has a familial propensity and there is a higher prevalence in Scandinavia, Chile and Bolivia.

Investigation of Cholestasis of pregnancy:

Liver biochemistry shows a cholestatic picture with raised serum ALP (up to four times normal) and increased amino transferases which occasionally can be toohigh. The serum bilirubin is to some extent elvated with jaundice in 60% of women. Liver biopsy is not warranted as an investigative procedure.

Treatment of cholestasis of pregnancy is mostly symptomatic with ursodeoxycholic acid 15 mg/kg orally. This bile salt may cause diarrhea in some women.

Prognosis of Cholestasis of pregnancy is usually very good for the mother but there is somewhat increased incidence of fetal loss and the condition cures after delivery of the baby. Repeated cholestasis may occur during succeeding pregnancy or with the intake of estrogen-containing oral contraceptive pills.


Liver problem in pregnancy associated with Pre-eclampsia and eclampsia

Pre eclampsia is a condition where there is hypertension, proteinuria and oedema occurring in the second or third trimester. Eclampsia is evidenced by seizures or coma in addition to these featues. Liver involvement include subcapsular haematoma and infarction, and occasionally fulminant liver failure. The HELLP syndrome - a combination of haemolysis, elevated liver enzymes and a low platelet count can sometimes occur in association with severe and uncontrolled pre-eclampsia. HELLP syndrome present with epigastric pain, nausea and vomiting, with jaundice in 5% of patients. Early delivery is only the definitive treatment for eclampsia.

Acute fatty liver of pregnancy (AFLP)

This is though rare but very serious condition of cause unknown. There is an relationship between acute fatty liver and longchain 3-hydroxylacyl-CoA-dihydroxyl (LCHAD) deficiency. It usually affects in the last trimester of pregnancy with symptoms of fulminate hepatitis with jaundice, vomiting, abdominal pain, occasionally haematemesis (vomitting of blood) and coma.
Immediate delivery of the baby may save both baby and mother. Quick diagnosis and proper management can reduce the mortality to less than 20%. Treatment is done in the line of acute liver failure.