Friday, 1 June 2018

Liver diseases in pregnancy



For healthcare providers liver diseases during pregnancy have a challenge. The liver diseases unique to pregnancy include hyperemesis gravidarum(HG), acute fatty liver of pregnancy (AFLP), intrahepatic cholestasis of pregnancy (ICP), and hemolysis and elevated liver enzymes and low platelets (HELLP) syndrome.

The diseases unique to pregnancy, pregnant women are also ingenuous to viral infections such as acute hepatitis A, hepatitis B, hepatitis C, hepatitis E. Out of these four viruses, only hepatitis B and C can lead to chronic disease, and therefore could be pre-existing. Hepatitis A and hepatitis E does not lead to chronic hepatitis. There are safe and effective vaccines against hepatitis A and B only but are not usually administered during pregnancy. Pregnant women have to be aware not to become infected during pregnancy. Both hepatitis A and E are transmitted through contaminated food and water (via the fecal-oral route).

Despite several hypotheses, the pathogenesis of liver disease in HG is not well understood. Over expression of cytokine-producing cells was implicated as a potential cause for pregnancy-related liver diseases such as preeclampsia and HG. Other hypotheses predicted damage to the liver resulting from impaired maternal or fetal mitochondrial fatty acid oxidation, implicating deficiency in long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) as a reason for accumulation of fatty acids in the placenta and eventually causing liver damage. Other report linked fetal deficiency of hepatic carnitine palmitoyltransferase I, the enzyme responsible for transporting long chain fatty acids from the cytoplasm of cells across the outer mitochondrial membrane, to HG.
Patients with HG usually require hospitalization for intravenous fluid replacement, anti-emetics, bowel rest, and possible parenteral nutrition.
Hyperemesis gravidarum is usually a reversible condition with no permanent damage to the liver and almost never fatal.

Intrahepatic cholestasis of pregnancy (ICP) is a reversible condition of cholestasis that happens usually in the third trimester. Findings such as pruritus, high serum bile acids levels, and abnormal liver function tests usually resolve after delivery.
Although ICP is a gentle condition for the mother, poor fetal outcomes can occur. In some studies ICP resulted in premature births up to 60%. Other complications such as fetal distress and intrauterine fetal death were reported at 61% and 1.6% respectively.



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