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Liver Diseases of Pregnancy

by Carlo Raj, MD

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    00:01 Liver Diseases of Pregnancy. A big topic for us.

    00:05 Liver diseases in pregnancy, give it two tables that are coming up and which we will go through with explanations on the top and the comments and give you a quick little treatment measure.

    00:19 This one here is Hyperemesis gravidarum.

    00:24 The patient may present with clinical features of nausea and vomiting and dehydration in the first trimester.

    00:30 But remember this vomiting happening quite a bit, obviously in a early pregnancy or over here, the bilirubin up to five times the upper limit of normal and you might find ALT two to three times the upper limit of normal ULN.

    00:45 Management would be hydration and resolves spontaneously.

    00:49 If you're suspecting intra-hepatic cholestasis of pregnancy, look for in your pregnant lady to have pruritis and jaundice in the second or third trimester more commonly and you will then find often times your serum total bile acid concentration that maybe the only and really the first thing to be elevated in laboratory.

    01:12 Now, with bile acid the serum cholic acid increases more so than the chenodeoxycholic acid.

    01:18 So therefore the cholic/chenodeoxycholic acid ratio would be elevated often times.

    01:24 You would find ALT, your aminotransferase close to and up to levels of 1000 units per liter.

    01:34 This then makes it quite distinct from viral hepatitis, that's important.

    01:40 And management might be cholestyramine, maybe ursodeoxycholic acid, those are the things that you are looking for and ultimately delivery.

    01:51 Hepatic rupture, severe abdominal pain is what you're looking for.

    01:56 Third trimester with shock management here. Well, it has to be immediate surgery.

    02:01 Continue discussion of liver disease in pregnancy.

    02:07 We come in through a phenomena known as pre-eclampsia.

    02:12 You wanna group together pre-eclampsia and HELLP and the reason for that is because HELLP is worst case scenario of pre-eclampsia.

    02:23 So what is Pre-eclampsia? Eclampsia is defined as seizures in a pregnant woman. This is pre-eclampsia.

    02:37 The patient is not -- the pregnant woman is not experiencing seizure, thank goodness.

    02:42 I walk you through seizures in a second here.

    02:44 But he's suffering from the following: she's a pregnant woman, she's going to be suffering of hypertension.

    02:51 Along with hypertension, she's also losing protein in the urine.

    02:58 Do not worry about how much protein, that a little controversial but she's definitely losing protein in her urine.

    03:06 With that said, let's take a look at the symptoms.

    03:08 Nausea and vomiting, hypertension, usually it's above 160 over 90, okay? And edema, explain us to how that occurring? What do you finding in the urine? Protein.

    03:22 When you lose protein, the pregnant woman who is already pregnant is also gaining weight due to edema.

    03:29 So her expected weight of gestation is actually an excess because of the further accumulation of fluid.

    03:37 If seizure kicks in by definition you've moved from pre to eclampsia.

    03:45 I wanna quickly at this point jump down to treatment cuz that's the most important here.

    03:50 With pre-eclampsia, maybe perhaps symptomatically can control a few things but my goodness for sure prophylactically you think pregnancy, third trimester, she has hypertension, immediately high new differential, you're suspecting, oh my goodness it's a pre-eclampsia.

    04:09 I'm worried about your pregnant woman going to seizures, what are you gonna give this patient, prophylactically immediately your next step of management? Magnesium, magnesium, magnesium sulfate.

    04:20 What's absolute cure? Delivery, delivery, delivery.

    04:24 Delivery often times will cure pregnant woman of certain pathologic issues.

    04:30 Pre-eclampsia here, in the previous discussion we had hyperemesis gravidarum.

    04:35 Technically speaking, you would find your bilirubin to be quite high.

    04:39 As I told you earlier, HELLP syndrome is not eclampsia.

    04:44 It is worst case scenario of pre-eclampsia.

    04:47 Now, what are you looking for? First H, stands for hemolytic anemia.

    04:53 So there is an increase destruction of your RBCs.

    04:56 Next, EL stands for -- excuse me, elevated liver transaminases.

    05:04 So transaminase will be elevated, the reason that we've been have this discussion here with pregnancy is because there's liver damage.

    05:11 You expect the liver transaminase to be elevated and finally there'll be -- the last LP stands for low platelet.

    05:20 Let's put all these together and take a look at the symptoms.

    05:23 Now, we have right upper quadrant pain, the liver is being damage excessively because it's still part of pre-eclampsia, notice please that we still have hypertension, that will remain in both.

    05:35 Now, since we have other sequelae taking place, bilirubin will be quite high, rumor that hemolysis its taking place.

    05:43 Then, hemolysis its taking place within your blood vessels.

    05:46 This goes back to hematology close your eyes, if I tell you that the RBC is being destroyed intravascularly.

    05:55 I'm releasing hemoglobin, does hemoglobin balance too? Haptoglobin, which your haptoglobin level in intravascular hemolysis, low Finally, the patient, take a look at the pregnant woman, she has petechiae, what would you expect your platelet count to be? Normal platelet count, please tell me, normal platelet count, 150,000 to 400,000.

    06:21 You try to memorize as many lab values as possible, prior to taking to your boards, you go to your USMLE, you go to -- they give you the labs that you need, don’t go to any book or whatever, just go to the source.

    06:34 You go to the website, you take out the page, that's what you wanna memorize.

    06:39 150,000 to 400,000 is normal platelet count, you might find your platelet count to be down to 50,000.

    06:46 Petechiae is what I just said. Treatment here, delivery.

    06:51 Put these together, make sure you know pre-eclampsia, HELLP syndrome, if seizure kicks in, eclampsia.

    06:59 If seizures kicks in, our topic in pregnancy, pathology or gestational pathologies would be the fact that, wow, that seizure here, there's every possibility that there might be mixing between the fetus and the mother resulting amniotic fluid emboli perhaps and going into DIC like issues, no joke.

    07:20 That discussion, pregnancy, female reproductive pathology.

    07:25 Acute fatty liver, disease of pregnancy.

    07:28 Once again, a cause of fulminant liver disease.

    07:31 Jaundice, right upper quadrant pain.

    07:33 Here you will find bilirubin to be elevated and DIC is a possible, possible trigger and elevated ammonia.

    07:41 Treatment here would be delivery, keep in mind that acute fatty liver disease of pregnancy is every possibility in a woman who is pregnant, quite dangerous.


    About the Lecture

    The lecture Liver Diseases of Pregnancy by Carlo Raj, MD is from the course Cirrhosis – Liver Diseases.


    Included Quiz Questions

    1. Hyperemesis gravidarum
    2. Acute fatty liver disease of pregnancy
    3. Intrahepatic cholestasis of pregnancy
    4. HELLP syndrome
    5. Pre-eclampsia
    1. Hepatic rupture
    2. Intrahepatic cholestasis of pregnancy
    3. HELLP syndrome
    4. Pre-eclampsia
    5. Acute fatty liver of pregnancy
    1. Magnesium sulfate treatment dose
    2. Magnesium sulfate prophylactic dose
    3. Delivery
    4. Cholestyramine
    5. Spontaneously resolves
    1. Delivery of the fetus
    2. Use cholestyramine
    3. Prophylactic doses of magnesium sulfate
    4. Treatment doses of magnesium sulfate
    5. Monitor the blood pressure every 6 hours
    1. Pre-eclampsia
    2. Eclampsia
    3. HELLP syndrome
    4. Intrahepatic cholestasis
    5. Acute fatty liver of pregnancy
    1. Seizures
    2. Increased unconjugated bilirubin
    3. ALT levels >1000
    4. Platelets < 100000 cells/dl
    5. High blood pressure
    1. Hepatic rupture
    2. Intrahepatic cholestasis of pregnancy
    3. Pre-eclampsia
    4. HELLP syndrome
    5. Acute fatty liver of pregnancy

    Author of lecture Liver Diseases of Pregnancy

     Carlo Raj, MD

    Carlo Raj, MD


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