1. 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

2. 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

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

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

5. 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 ) .

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

7. 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 .

8. 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 .

9. 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 ) .

10. 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

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

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

13. 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 .

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