0813 GMT October 22, 2018
“The first thing is recognition. Recognition is most important because early recognition allows us to take better care of our patients,” Nancy Reau, MD, FACG, from the Rush University Medical Center in Chicago, said during her presentation, healio.com reported.
“Liver diseases can be unique to pregnancy, but there are a lot of things that can happen to a woman with [pre-existing] liver disease who becomes pregnant, so you need to manage both directions.”
According to Reau, it is common in pregnant patients for albumin and hemoglobin levels to decrease and for alkaline phosphatase and alpha-fetoprotein to increase. In contrast, liver transaminase and bilirubin levels typically remain steady and changes in these levels should be investigated.
“We approach the liver through pattern recognition — is this a hepatocellular or a cholestatic process?” she said. “In a pregnant woman, you should go through the same sort of decisional tree as any other individual who presents with abnormal liver enzymes.”
Ultrasound should be the first line in liver imaging when investigating abnormal liver enzymes in a pregnant patient, Reau said. Magnetic resonance imaging should be performed without gadolinium if possible. If computed tomography is required, it should be performed with minimal radiation.
A ‘trimester-based approach’ can help prognosis, Reau explained. Liver complications such as acute viral hepatitis, drug-induced liver injury and liver masses can present during any of the three trimesters, whereas intrahepatic cholestasis of pregnancy and pre-eclampsia present in the second or third trimester. Acute fatty liver of pregnancy is seen in the third trimester.
Cholelithiasis is the ‘most common cause for liver tests in pregnant women,’ Reau said, and added that surgical prevention prior to delivery is preferred. Budd-Chiari Syndrome is also common, according to one study, and the recommended treatment is heparin.
The recommended therapy for hyperemesis, gravidarum, includes monitoring for metabolic alkalosis or acidosis, thiamine replacement, and gut rest followed by low fat-high carb diet.
Intrahepatic cholestasis can be misleading because bilirubin and gamma-glutamyl transferase levels can appear normal. Primary presentation is pruritis and management should include weekly bile acid testing and treatment with ursodeoxycholic acid.
“Acute fatty liver in pregnancy is the most frightening and important to recognize liver-related pregnancy outcome,” Reau said.
“It is rare, but the symptoms can be nondescript. Although our outcomes now are excellent, before we did rapid recognition in supportive care almost all of these mothers and children died.”
Acute fatty liver in pregnancy symptoms include nausea, vomiting, abdominal discomfort, and up to 50 percent of pregnant patients may develop pre-eclampsia, which can rapidly lead to liver failure. According to Reau, management includes prompt delivery, maternal support which could include plasma exchange after delivery, and monitoring the child for long-chain L-3 hydroxyacyl-CoA dehydrogenase deficiency.