Liver disease pregnancy

Question 1

Risk of chronic carriage of Hep B if infected at delivery?

Answer 1

90%

subsequent cirrhosis and hepatocellular carcinoma

Question 2

Risk of Hep B vertical transmission related to antigen status.

Answer 2

HBsAg +, HbeAg+ = 95%
HBsAg +, HBeAg- = 2-15%

Measurement of HBV DNA has replaced HBeAG as most sensitive test of viral activity.

Question 3

Risk of HBV transplacental transmission?

Answer 3

5%

Question 4

List significance of following ab/ag presence:

1. HBsAb
2. HBsAg
3. HBcAb
4. HBeAg

Answer 4

1. vaccination or previous infection
2. infected
3. natural infection previously
4. active viral replication

Question 5

Risk of chronic infection after HBV exposure in adults?

Answer 5

10%. 25% of those develop chronic liver disease.

Question 6

When is tenofovir indicated antenatally?

Answer 6

third trimester

HBV DNA >200,000IU/mL or 10^6 log copies/mL

Question 7

What is the effect of antenatal tenofovir on infant infection?

Answer 7

RR 0.15 SS

Question 8

Neonatal HBV immunisation consists of:

Answer 8

1. HBIG <12 hrs after delivery
2. DTAP <12 hours after delivery
3. DTAP 6w, 3m, 5m

Reduces risk of infection RR0.08
Less effective if LBW or preterm.

Question 9

Risk factors for hepatitis C?

Answer 9

80% of IVDU or blood product dependent patients

<5% sexually transmitted.

Question 10

Course of hepatitis C infection in adults?

Answer 10

15-30% of untreated patients develop cirrhosis within 20 years
27% of those will develop hepatocellular carcinoma in 10 years.

Question 11

Determinate of Hepatitis C vertical transmission ?

Answer 11

HCV viral load
1% RNA negative mothers
5% RNA positive mothers

Question 12

Management of HCV in pregnancy

Answer 12

direct acting antivirals pre conceptually + treatment
DAA contraindicated antenatally
NIPT/MSS1 (no invasive tests if possible)
Avoid FSE/FBS
Bfing. Start DAA after finished + contraception.
No vaccines for HCV prevention.

No increase risk of congenital abnormalities, miscarriage or prematurity. Detection of infant infection reliable 3mo PP.

Question 13

Prevalence of obstetric cholestasis?

Answer 13

0.7%

Question 14

Risk factors for obstetric cholestasis?

Answer 14

family (autosomal dominant inheritance)
hep C carriage
gallstones
multiple pregnancy

Question 15

Genetic pathology of obstetric cholestasis

Answer 15

MDR3 gene- hepatocellular transport system
lower oestriol circulates
bile salts accumulate—> vasoconstriction
dyslipidaemia
hyperbilirubinaemia

Question 16

liver autoantibody screen?

Answer 16

anti-mitochondrial, anti-smooth muscle antibodies

Question 17

Perinatal mortality/morbidity associated with obstetric cholestasis?

Answer 17

mortality = 1.1-3.5% (used to be 11%)
stillbirth= 1.5%
intrapartum fetal distress = 2-22%
fetal arrhythmia
preterm birth 25%
meconium 44%
vitamin K deficiency (intracranial haemorrhage)

Question 18

Maternal intrapartum risks of obstetric cholestasis

Answer 18

LSCS fetal distress
PTB
PPH 2-22%

Question 19

When would UCDA be prescribed for cholestasis?

Answer 19

non significant improvement in maternal itch scores. does not seem to effect any other perinatal/maternal outcomes.

Question 20

Evidence for timing of delivery with peak BS <100

Answer 20

no difference in stillbirth rate compared with background population risk before 39 weeks gestation.

BS >100 individualise timing. HR 30.50 stillbirth. May be reasonable to consider timing ~36 weeks.

Question 21

Delivery considerations of cholestasis?

Answer 21

What was the peak BS level
LFTs
BP monitoring 
CTG in induction/labour
active management 3rd stage
coagulation profile at start (vitamin K if PTT prolonged)
IVL
Neonatal vitamin K
Avoid oestrogen OC's
Repeat LFT >10/7.

Question 22

Risk of AFLP in pregnancy?

Answer 22

1/7000-20,000

Question 23

Risk factors AFLP

Answer 23

male fetus (3:1)
primigravida
multiple preganncy
homozygous genetic defect in child (LCHAD deficiency)

Question 24

LCHAD function

Answer 24

catalyses step in beta oxidation of mitochondrial fatty acid
instead unmetabolised long-chain fatty acids spill into maternal circulation
leads to hepatotoxicity

LCHAD def also impairs placental vasopressinase enzyme degradation. Increases ADH= polydipsia, polyuria.

Question 25

maternal mortality and perinatal mortality of AFLP?

Answer 25

``` maternal = 7% fetal = 15% ```

Question 26

serum findings AFLP?

Answer 26

``` Abnormal coags lft deranged wcc elevated, plt low BSL low hypocholesterolaemia ```

Question 27

Define HELLP syndrome

Answer 27

haemolysis elevated liver ensyme low platelets unclear if on spectrum with PET or seperate

Question 28

Prevalence of HELLP?

Answer 28

1% | 5-20% of pregnancies with PET.

Question 29

Difference of HELLP and HUS

Answer 29

``` HUS no jaundice, no neurological symptoms. AST/ALT normal. LDH elevated. Hypertension is not common. Severe AKI ``` HELLP LDH may be elevated, but not profoundly AST/ALT elevated

Question 30

Liver complications of HELLP?

Answer 30

liver rupture sub capsular haematoma massive hepatic necrosis

Question 31

Live birth rate after liver transplant?

Answer 31

92% | Increased PTB, FGR, NICU

Question 32

Prevalence of asymptomatic gallstones and cholecystitis in pregnancy?

Answer 32

2.5-10% | 1/1000 have cholecystitis.

Question 33

What may prompt cholecystitis in pregnancy?

Answer 33

stones due to more bile cholesterol/less bile acid | gallbladder stasis

Question 34

Swansea criteria? (8)

Answer 34

raised - bilirubin - urate - WCC - ALT/AST - ammonia - creatinine low - glucose - coagulopathy (cc wat bug)