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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