Liver disorders during pregnancy and their management

Arun Kumar Mitra, MBBS, DGO, MO, FICOG, FRCOG PhD (London)
Former Professor and Head, Department of Obstetrics and Gynecology, Medical College. Calcutta.
Pralhad S. Patki* , M.D., Head -Medical Services and Clinical Trials
S.K. Mitra, M.D., Executive Director R&D Center, The Himalaya Drug Company, Bangalore, India.

INTRODUCTION During pregnancy, the human body undergoes several changes in the process of its adaptation to the growing fetus. Although these changes are physiological, there is potential for morbidity and mortality to both mother and fetus. Liver is the site of many important metabolic and synthetic functions of the body. In normal pregnancy, the liver is not palpable. Due to hemodilution, biochemical tests may reveal mild increase in liver function tests. Abnormal liver tests occur in 3%-5% of pregnancies, with many potential causes, including coincidental liver disease (most commonly viral hepatitis or gallstones) and underlying chronic liver disease (Table 1). Wide multitudes of liver diseases are encountered in pregnancy. For instance, the liver could be the target of diseases specific to the pregnancy such as intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy, and there are

Table 1: Physiological Changes during Pregnancy Increase 1. Blood volume, heart rate and cardiac output rise by 35%-50% and peak at 32 weeks. Further increase by 20% occur in twin pregnancies 2. Alkaline phosphatase levels rise 3 to 4 fold 3. Clotting factors: 4. Ceruloplasmin 5. Transferrin 6. ESR, CRP, C3 and C4 Decrease 1. Gallbladder contractility 2. Hemoglobin 3. Uric Acid 4. Albumin and total protein 5. Antithrombin III and protein S 6. Systemic vascular resistance 7. Modest decline in blood pressure 8. Modest or no decline in platelet levels No Change 1. Liver transaminase levels (AST, ALT) 2. GGT 3. Bilirubin level 4. Prothrombin time 5. Blood flow to the liver .

no available means by which to predict with certainty how and when such illnesses may occur.In tropical countries like India, morbidity and mortality due to liver diseases in pregnancy is very high.1 In addition, morbidity is more likely in the presence of a preexisting liver disease as in autoimmune hepatitis or when a new onset liver disease occurs during pregnancy as in herpes simplex hepatitis. Several physiologic changes occur during pregnancy and could pose difficulty in evaluating hepatobiliary function because they may be misinterpreted as pathological. For example, the blood volume expands during pregnancy due to retention of salt and water. This induces a state of hemodilution, an increase in cardiac output, and a reduction in

systemic vascular resistance and systemic blood pressure. These changes peak during the second trimester then plateau until delivery. Consequently serum levels of uric acid, albumin, total protein and hematocrit are decreased. On the other hand, serum alkaline phosphatase levels may be elevated three to four folds due to placental production while serum values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), and bilirubin and prothrombin time remain in the normal range. Estrogens promote biliary cholesterol saturation and inhibit the hepatic synthesis of chenodeoxycholic acid, while progesterone decreases the contractility of the gallbladder and contributes to lithogenicity resulting in sludge and gallstone formation. However, when appropriately diagnosed and managed, the outcome may be favorable and the liver disease in pregnancy could resolve without any chronic consequences.

Liver Disorders in Pregnancy

Liver dysfunction can appear at any point of pregnancy and causes great anxiety to the patient, her family and sometimes her medical attendants1. A number of these diseases have been identified which are responsible for morbidity and mortality (Figure 1).

Viral Hepatitis:²

Acute viral hepatitis is the most common cause of jaundice in pregnancy. The outcome is usually but not always benign except in viral hepatitis E and Herpes Simplex hepatitis. While infections with viral hepatitis in pregnancy may not always affect the outcome of the pregnancy, transmission to the newborn is always a concern. Diagnosis of viral hepatitis in pregnancy is not different from the diagnosis in the non pregnant state. Viral hepatitis in pregnancy has been a subject of continuing interest and controversy.3 Reports from Europe and US have shown the course of viral hepatitis during pregnancy to be in no way different from non pregnant women.4,5 However studies carried out in India , Iran Africa have found the incidence of fulminated hepatitis to be higher in pregnancy. Malnutrition superimposed on the normal demands of pregnancy and inversion of T and B lymphocytes in early pregnancy have been postulated to be the contributing factors.6,7 In one study of 97 consecutive pregnant patients with acute viral hepatitis, the mortality was seen in 18 patients. Mortality is in the range of 30-45 % and it may be as high as 70%. Majority of cases die undelivered.7,8 Besides, greater mortality and morbidity has been noted during epidemics of viral hepatitis, particularly in developing countries.9,10 This may indicate that the nutrition may be involved. About 6 % of women with hepatitis can develop gallstones during their pregnancy.11,12 The problem of liver diseases in pregnancy is more in women from low socio economic group living in unhygienic surroundings and drinking unfiltered water. If it is considered necessary to confirm the diagnosis, needle biopsy can be performed with all the precautions.⁹

Refference: http://www.himalayahealthcare.com/pdf_files/liv251.pdf