Liver Disease in Pregnancy - Franco

Question 1

Name two skin findings associated with liver disease during pregnancy.

Answer 1

1. Spider angiomas
2. Palmar erythema

Question 2

Why are pregnant women at a higher risk of gallstones?

Answer 2

Reduced gallbladder activity

Question 3

What hematologic / liver panel findings are seen in pregnant women?

Answer 3

• Increased:
  
  • Alk Phos (From placenta & bone)
• Decreased:
  
  • HCt
  • Serum Urea
  • Uric Acid
  • Albumin
  • Total protein

Question 4

1. What is Hyperemesis Gravidarum?
2. When does it occur?
3. How common is it?

Answer 4

1. Intractable vomiting during pregnancy
   
   • Dehydration
   • Electrolyte abnormalities
   • Cause unknown
2. First trimester
3. ~0.4/1000 deliveries

Question 5

1. What liver abnormalities can result from Hyperemesis Gravidarum?
2. How is HG treated?

Answer 5

1. 2x to 20x increase in ALT
2. Treat with rehydration and antiemetics

Question 6

1. What is Intrahepatic Cholestasis of Pregnancy (IHCP)?
2. When during pregnancy does it typically occur?
3. How does it present?

Answer 6

1. Cholestasis (bile cannot flow into duodenum) during pregnancy, as the name suggests. Etiology is unclear.
2. Third trimester, but can occur anytime during pregnancy
3. Pruritis

Question 7

How common is Intrahepatic Cholestasis of Pregnancy?

What risks to the fetus are associated with IHCP?

Answer 7

0.1% of all pregnancies

Increased risk of:

• Prematurity
• Perinatal death
• Fetal distress

Question 8

1. What lab findings are noted in Intrahepatic Cholestasis of Pregnancy?
2. How is IHCP treated? Name two drugs.

Answer 8

1. Labs:
   
   • Up to 4x increase in AST/ALT
   • Serum bile acids increased 30x-100x
     
     • Jaundice in 25% of women with IHCP
2. Treatment:
   
   • Cholestyramine
     
     • Binds bile acids
   • Ursodeoxycholic Acid
     
     • Modifies bile acid pool
     • Inhibits absorption of more hydrophobic bile acids

Question 9

1. What is Preeclampsia/Eclampsia?
2. What does it present with?

Answer 9

1. A disorder of pregnancy with unknown etiology.
2. Preeclampsia presents with:
   
   • Hypertension
   • Proteinuria
   • Edema

• ​​Eclampsia = Preeclampsia + Seizures

Question 10

1. How common is preeclampsia?
2. Eclampsia?
3. When during pregnancy does preeclampsia typically occur?

Answer 10

1. Preeclampsia is common: 5-7% of all pregnancies
2. Eclampsia: 0.1-0.2% of pregnancies
3. Usually occurs after 20 weeks (most commonly after 32 weeks - Wiki)

Question 11

How is preeclampsia/eclampsia treated?

Answer 11

Delivery of the baby and placenta is the only definitive treatment / cure.

As you might expect, preeclampsia that begins earlier in pregnancy is associated with increased morbidity.

Question 12

What is Acute Fatty Liver of Pregnancy?

Explain the pathophysiology.

Answer 12

(Etiology is actually known for this one!)

Caused by LCHAD **Deficiency **in the fetus (Long-Chain 3-HydroxyAcyl coenzyme Dehydrogenase Deficiency)

• tl;dr: Fatty acid oxidation defect in fetus; leads to fatty liver in mother

Question 13

How common is Acute Fatty Liver of Pregnancy?

When in pregnancy does it occur?

What other disorder of pregnancy is AFLP associated with?

Answer 13

1 in 7,000-15,000 pregnancies

Third trimester

Preeclampsia occurs in 20-40% of AFLP pts

Question 14

How does AFLP present?

How is it treated?

Answer 14

Presentation varies:

• Mild: liver test abnormalities
• Severe: Jaundice, coagulopathy, encephalopathy

Urgent Delivery Indicated

Question 15

What life-threatening condition is associated with preeclampsia/eclampsia, AFLP, or both?

How does it present?

Answer 15

HELLP Syndrome

• Hemolytic anemia
• _E_levated _L_iver tests
• _L_ow _P_latelets

Question 16

When in pregnancy is HELLP syndrome seen?

What is the treatment?

Answer 16

Similar to preeclampsia/eclampsia and AFLP alone:

Third trimester

Urgent delivery indicated

Question 17

How common is HELLP syndrome?

Answer 17

0.2-0.6% of pregnancies

4-12% in women with (pre)eclampsia