Liver Disease in Pregnency( Jaundice in Pregnancy)
Obstetric Cholestasis:• Cholestasis is an impairment of bile flow which
may clinically present with fatigue, pruritus
and, in its most overt form, jaundice.
• Obstetric cholestasis is uncommon condition,
specific to pregnancy
• Aetiology relate to genetic predisposition to the
cholestatic effect of estrogen ( Increased
estrogen levels lead to increased cholesterol
secretion and supersaturation of bile) .
• The importance of this condition is its
association with sudden IUFD, mostly at term.
Presentation• It is most commonly present in the third
trimester at around 32 weeks
• Itching can vary from mild to intense and
persistent, affecting the whole body
particularly the palms & soles.
• There is no rash .
• There may be associated dark urine, pale stool,
steatorrhea & malaise.
• Hepatic transaminases are only mildly
elevated. Bile acids may be elevated.
• differential diagnosis include:• extrahepatic obstruction with gall stones
• acute & chronic viral hepatitis
• primary biliary cirrhosis
• chronic active hepatitis.
• Pre - eclampsia
• HELLP syndrome
• Acute fatty liver of pregnancy
• Drug - induced hepatitis
• Investigations should include:• LFT
• Serum Bile acids
• Full blood count
• Clotting profile
• Renal function
• serology for hepatitis A, B, C, Ebstien - Bar
virus & cytomegalovirus
• liver autoantibodies (anti - mitochondrial
antibodies, & anti - smooth muscle antibody ).
• liver ultrasound & ultrasound for fetal growth
& amniotic fluid
Complications:• postpartum haemorrhage
• premature labour
• meconium - stained liquor
• fetal distress in labour
• intra - uterine death.
Management:• Pruritus may be troublesome and is thought
to result from elevated serum bile salts.
• Control of pruritis : a combination of
antihistamines & emollients , if no response
ursodeoxycholic acid used.
• Vitamin K (water soluble form) should be
given to the mother from the time of
diagnosis to reduce the risk of postpartum
• LFT & clotting time should be monitoredregularly.
• Fetal surveillance with CTG &ultrasound.
• delivery should be induced at 37 - 38weeks.
• Following delivery, LFT returns tonormal. Should be monitored at 6 weeks
• Symptoms may recur with estrogen
containing oral contraceptives which
should be avoided.
• Recurrence in subsequent pregnancy is
Acute Fatty Liver of pregnancy:• AFLP is closely related to pre - eclampsia
(genetic defect in fatty acid oxidation).
• presents in the third trimester with
abdominal pain, nausea, vomiting,
anorexia & jaundice.
• aetiology is unknown but histologicallyperilobular fatty infiltration of liver cells
• Following the onset, there is a rapidlyworsening cascade of problems.
• markedly deranged LFT, renal
impairment, raised uric acid, raised white
blood cells, hypoglycaemia &
• Perinatal & maternal mortality &
morbidity are increased. Maternal death
result from hepatic encephalopathy or
Management:• Relies on early diagnosis.
• intensive care unit & multidisciplinary team.
• Delivery should be expedited, this will be by
CS under GA, following correction of
hypoglycaemia or coagulopathy with 50 %
dextrose, vitamin K , fresh frozen plasma &
• Management after delivery is conservative.
Referral to liver unit is indicated if liver
function still abnormal or there are features of
Viral Hepatitis & Pregnancy:• most common cause of jaundice in
• None of the hepatitis viruses are known
to be teratogenic .
• The course of most viral hepatitis
infections is unaltered by pregnancy
except with hepatitis E which exhibit
markedly increased fatality rates .
Treatment:• may benefit from pharmacologic therapy for
chronic HBV and chronic HCV infections.
• Interferon does not have an adverse effect on
the embryo or fetus while the use of ribavirin
during pregnancy is contraindicated.
• Post - exposure Prophylaxis for Susceptible
Pregnant Women: HBV immunoglobulin,
HAV vaccine, and HBV vaccine are approved
for use during pregnancy.
Vertical Transmition :• HAV is not transmitted to the fetus in utero
but may be transmitted to the neonate during
delivery or during the postpartum period
( fecal - oral route .
• The risk of HBV vertical transmission is 10 %
in mothers with negative HBeAg and positive
HB s Ab while it is 90 % in those with positive
HBeAg. Neonatal HBV infection increase with
• Universal screening of pregnant women for
HBsAg is performed to reduce perinatal
transmission of hepatitis B virus .
• Neonatal prophylaxis: Infants of HBsAg -positive mothers should receive hepatitis
B immune globulin immunoprophylaxis
at birth and hepatitis B vaccine at one
week , one month and six months after
• This regimen reduces the incidence of
hepatitis B virus vertical transmission to
zero to 3 %.
• Delivery by cesarean section is not recommended.• Intrapartum fetal scalp electrode & fetal blood
sampling should be avoided.
• If instrumental delivery is needed,forceps rather than ventouse is
• With appropriate hepatitis Bimmunoprophylaxis, breast - feeding poses
no additional risk for maternal to child
Asthma in PregnancyPhysiological changes in pregnancy
• Dyspnea is experienced by approximately half of all
pregnant women by 20 weeks gestation because of
high progesterone levels which acts via the
Hypothalamus to increase respiratory drive.
• Anatomically, the lower chest wall circumferenceincreases by 5 -7 cm, the diaphragm is elevated 4 -5
cm by term & the costal angle widens. These
changes occur due to the pressure from the expanding
uterus & the relaxation of thoracic ligaments.
Asthma in Pregnancy• The prevalence of asthma in pregnancy is about 3 – 12 per
Effect of pregnancy on asthma severity:
• asthma remains stable in one -third of women, worsens in
another third and improves in the remaining third.
• most episodes occur between 24 and 36 weeks of pregnancy
• The potential benefit of pregnancy -induced immune systemmodulation & progesterone -mediated bronchodilatation
may be opposed by the reluctance of patient & physician to
treat asthma for the fear of harming the fetus through drug
The effect of asthma on pregnancy:• Severe & poorly controlled asthma have a
detrimental effect on pregnancy including:
• intrauterine growth restriction
• hypertensive disorders
• preterm labour
• intrauterine fetal death.
• Labour a nd delivery : are not usually affected byasthma and attacks are uncommon in labour .
• Postpartum, there is no increased risk of exacerbationsand those whose asthma deteriorated during pregnancy
have usually returned to pre -pregnancy levels by three
months after birth.
Management of asthma in pregnancy:• Same as in non - pregnant patient. Prevention is the
key & known triggers of exacerbations should be
• Short - acting & long - acting beta 2 - agonists, inhaledsteroids & theophylline can be used in pregnancy.
These drugs will suffice for mild to moderate
• Epinephrine should be avoided in the pregnantpatient. it can lead to possible congenital
malformations, fetal tachycardia, and
vasoconstriction of the uteroplacental circulation
• Women with more severe asthma who havestabilized on leukotriene receptor antagonist
may continue them through out pregnancy.
• Prednisolone is the oral steroid of choice inpregnancy, as 88 % of it is metabolized by the
placenta, limiting fetal exposure.
The teratogenic risk & possible harmful fetal
effects of maternal steroid treatment remain an
area of controversy.
Managing pregnancy in asthmatic patients:• Well -controlled mild to moderate asthmatics will
have a normal out come with standard antenatal
care. For those with poorly controlled or severe
asthma , care should be multidisciplinary.
• Baseline investigations, such as peak flow
measurements should be obtained at booking.
• Medical treatment should be optimized, with
repeated reassurance about the use of necessary
drugs in pregnancy .
• Women taking Prednisolone should be screened
for glucose intolerance
Labour & delivery:• Parenteral steroid cover may be needed for those who are on
• regular medications should be continued throughout labour .• bronchoconstrictors , such as ergometrine or prostaglandin
F 2 α, should be avoided.
• Adequate hydration is important.• regional anaesthesia favoured over general, to decrease the
risk of bronchospasm, provide adequate pain relief and to
reduce oxygen consumption and minute ventilation.
• Breast feeding is not contraindicated with anyof the medications used although high -dose
oral steroid use ( ≥ 40 mg per day )carries a
risk of neonatal adrenal suppression