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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.

    00:06 Liver diseases in pregnancy.

    00:08 I'll give you two tables that are coming up.

    00:10 In which we will go through the explanations on the top, and the comments, and give you a quick little treatment measure.

    00:20 First one, Hyperemesis gravidarum. Nausea and vomiting is what you're looking for, dehydration in the first trimester.

    00:29 Pay attention to the trimester of your pregnant woman.

    00:33 Here you find your Bilirubin levels to be extremely high, upper limit of normal or your ALT to be incredibly high.

    00:42 Hyperemesis gravidarum, with all these vomiting, you can expect there to be decreased blood pressure.

    00:47 Thus, hydration becomes important and resolves spontaneously, which is always a good thing.

    00:54 Intra-hepatic cholestasis of pregnancy.

    00:56 What's that mean to you? That means that, the liver is having a hard time getting the bowel out of the pregnant woman's liver.

    01:07 How's your patient going to present? Pruritis and jaundice in second or third trimester.

    01:12 Here the bilirubin will be elevated by ten times greater than upper limit of normal.

    01:20 Treatment here, Cholestyramine, which is the resin, UDCA or ultimately deliveries, which you're thinking of. Keep Cholestyramine in play.

    01:32 Hepatic rupture, liver disease in pregnancy.

    01:35 This is where the patient in the third trimester, severe abdominal pain and the patient goes into shock Hepatic rupture. Treatment, no doubt, surgery.

    01:48 You want to keep Hyperemesis gravidarum, Intra-hepatic cholestasis pregnancy for sure in mind, Hepatic rupture is a state of emergency.

    01:58 To continue our discussion of liver diseases of pregnancy, we're coming into a phenomenon known as Pre-eclampsia.

    02:06 You want to group together Pre-eclampisa and HELLP.

    02:09 And the reason for that is because HELLP is worst case scenario of Pre-eclampsia. So what is Pre-eclampsia? From henceforth, Eclampsia is defined as seizures in a pregnant woman.

    02:28 This is Pre-eclampsia.

    02:31 The patient is not the pregnant woman, is not experiencing seizures, thank goodness.

    02:35 I'll walk you through seizures in a second here but it's suffering from the following.

    02:41 She's a pregnant woman.

    02:43 She's going to be suffering of hypertension.

    02:46 Along with hypertension, she's also losing protein in the urine.

    02:51 Do not worry about how much protein.

    02:54 That's a little controversial but she's definitely losing protein in her urine.

    02:59 With that said, let's take a look at the symptoms.

    03:02 Nausea and vomiting, hypertension, usually it's above 160/90, okay, and Edema.

    03:11 Explain to us how that occuring, what do you find in your urine? Protein. When you lose protein, the pregnant woman, who's already pregnant, is also gaining weight due to Edema.

    03:22 So her expected weight of gestation is actually an excess because of the further accumulation of fluid.

    03:32 If seizures kicks in, by definition, you'll move from "Pre" to "Eclampsia".

    03:39 I want to quickly, at this point, jump down to treatment.

    03:42 That's the most important here.

    03:45 With Pre-eclampsia, maybe perhaps symptomatically can control a few things, but my goodness for sure, prophylacticly, you think pregnancy third trimester, she has hyper-tension, immediately highly differential you're suspecting, oh my goodness, this is Pre-eclampsia.

    04:03 I'm worried about your pregnant woman going to seizures.

    04:05 What are you going to give this patient? Prophylactic immediately, your next step of management.

    04:11 Magnesium, magnesium, magnesium sulfate.

    04:14 This is prophylactic and that would then prevent the female from going into pregnancy.

    04:19 It does not cure though.

    04:21 There's no guarantee that it's not going to occur.

    04:23 So what's absolute cure? Delivery, delivery, delivery.

    04:27 Delivery often times will cure pregnant woman of certain pathologic issues.

    04:33 Pre-eclampsia here.

    04:34 In the previous discussion we had, Hyperemesis gravidarum.

    04:39 Technically speaking, you'd find your bilirubin to be quite high.

    04:43 As I told you earlier, HELLP syndrome is not Eclampsia. It is worst case scenario of Pre-eclampsia.

    04:50 Now, what are you looking for? First "H" stands for hemolytic anemia.

    04:56 So there's increase destruction of your RBCs.

    05:00 Next, "EL" stands for Elevated Liver transaminases.

    05:07 So, transaminases will be elevated.

    05:09 The reason that we even have this discussion here with pregnancies, because there's liver damage.

    05:14 You can expect the liver transaminases to be elevated.

    05:17 And finally, that will be, the last "LP" stands for, Low Platelet.

    05:23 Let's put all these together and take a look at the symptoms.

    05:26 Now, we have Right Upper Quadrant (RUQ) pain.

    05:28 The liver is being damaged excessively.

    05:31 Because it's still part of Pre-eclampsia, notice please, that we still have hyper-tension, So it will remain on both.

    05:39 Now since we have other sequelea taking place, bilirubin will be quite high.

    05:43 Remember that, hemolysis has taken place.

    05:47 That hemolysis has taken place within your blood vessels.

    05:50 So it goes back to Hematology. Close your eyes if I tell you, that the RBCs is being destroyed inter-vascularly.

    05:59 I'm releasing hemoglobin.

    06:00 This hemoglobin binds too? Haptoglobin. Which haptoglobin level in intra-vascular hemolysis? Low.

    06:08 Finally, the patient.

    06:11 Take a look at the pregnant woman.

    06:12 She has petechia.

    06:16 What do you expect her platelet count to be? Normal platelet count, please tell me.

    06:19 Normal platelet count, 150,000 to 400,000.

    06:24 You try to memorize as many lab values as possible.

    06:27 prior to taking to your boards. You go to your USMLE, you go to the book that give you the labs that you need.

    06:34 Don't go to any book or whatever. Just go to the source.

    06:37 You go to the website. You take out the page, that's what you want to memorize.

    06:42 150,000 to 400,000 is normal platelet count.

    06:46 You might find your platelet count to be down to 50,000.

    06:50 Pretechia is what I just said.

    06:52 Treatment here, delivery.

    06:55 Put these together, makes you know Pre-eclampsia, HeLLP Syndrome, if seizure kicks in, Eclampsia.

    07:02 If seizures kicks in, our topic in pregnancy pathology or gestational pathologies, would be the fact that, wow, that's seizure here, there's every possibility that there might be mixing between the fetus and the mother, resulting to amniotic fluid emboli, perhaps, and going into DIC-like issues. No joke.

    07:23 That discussion, pregnancy, female reproductive pathology.

    07:28 Acute fatty liver disease of pregnancy.

    07:32 Once again, a cause of fulminant liver disease.

    07:34 Jaundice, Right Upper Quadrant (RUQ) pain, here we find bilirubin to be elevated, and DIC is at possible, possible trigger.

    07:42 And elevated ammonia. Treatment here will be delivery.

    07:46 Keep in mind, that acute fatty liver disease of pregnancy is every possibility in a woman who's pregnant or 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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