Liver disorder in pregnancy Hepatic physiology in pregnancy : general total serum bilirubin ( TSB ) transaminases unchanged Prothrombin time   Proteins total protein decrease in 1st trimester Albumin Globulin increase until term . Fibrinogen Lipids Cholesterol Increase Triglyceride Enzymes Alkaline phosphatase increase

Jaundice in pregnancy : Incidence 1/2000 pregnancies It is divided into :   I – Disorders specific to pregnancy : 1. Hyperemsis gravidarum . 2. pre-eclampsia / eclamptic liver . 3. Acute fatty liver of pregnancy

II – Disorders incidental to pregnancy   1. Viral hepatitis . 2. Fulminant hepatic failure . 3. Cirrhosis .

Pre-eclamptic liver Maternal risk : Sub capsular haematoma .   Maternal risk : Sub capsular haematoma . Liver rupture . Coagulopathy .

Fetal risk : 1. Intra-uterine growth restriction ( IUGR )   1. Intra-uterine growth restriction ( IUGR ) 2. Fetal distress during labour . 3. Placental abruption . 4. Intra-uterine fetal death ( IUFD ) .

Management :   Investigations for pre-eclampsia & u/s assessment of fetal well-being . Resuscitation of the mother and termination of pregnancy . ِ

Intrahepatic cholestasis of pregnancy ( IHC ) : This is a liver disease specific to pregnancy , characterized by pruritis affecting the whole body , but particularly the palms and soles , and associated with abnormal liver function tests .

Clinical features : Most commonly presents in the 3rd – trimester around ( 30 – 32 wks gestation ) , as pruritis without rash , or dermatologic lesions . 7 – 14 days later jaundice develops in otherwise healthy mother and fetus . - May be associated with dark urine , pale stool , steatorrhea and malaise . - Jaundice and pruritis disappear after delivery . - It recurs in subsequent pregnancies ( > 90% ) or by using of combined oral contraceptive pills .

Diagnosis : It is a diagnosis of exclusion , and the differential diagnosis includes : 1. Extra hepatic obstruction with gallstones . 2. Acute and chronic viral hepatitis . 3. Primary biliary cirrhosis ( PBC ) 4. Chronic active hepatitis ( CAH ) .

Complications : A ) Fetal : 1. Premature labour ( 30 % ) 2. Meconium – stained liquor . 3. Fetal distress ( Intra partum ) 4. Rarely intra-uterine fetal death : The risk of it increase towards and beyond term .   B ) Maternal : Post partum hemorrhage ( related to vitamine K deficiency 2ndary to malabsorption of fat ) and hypoprothrombinaemia

Investigations : Liver u/s . Serology . Liver auto antibodies .   Liver u/s . Serology . Liver auto antibodies . Serum uric acid Liver function test . Liver biopsy .

Treatment : Pruritis . Monitor fetal – well being .   Pruritis . Monitor fetal – well being . Serial liver function test . Vitamin K . Induction of labour . follow-up .

Acute Fatty liver of pregnancy   Clinical features : In the 3rd – trimester . Abnormal pain , nausea & vomiting , anorexia, jaundice . Renal impairment . Hypoglycaemia . Excessive bleeding . Hepatic coma encephalopathy . Management : - Intensive care unit . - Termination of pregnancy .

Hepatitis A , non A – non B ( Delta , C , E )   Effect of Hepatitis on pregnancy : 1. Perinatal mortality and morbidity . 2. risk of preterm labour . 3. Acute fulminant hepatic failure . 4. Feto-maternal transmission ( in Hepatitis B )