Liver disease is rare during pregnancy. Few pregnant patients (10%) have been diagnosed of liver disease during pregnancy. Most of these cases indicate liver disease may have been present prior to pregnancy. Routine blood examination during pregnancy may indicate abnormal liver function test if patient has associated liver disease. Pregnancy does not cause liver disease. In this article, we will discuss about various types of liver diseases that can occur during pregnancy. We will also discuss about the various causes of liver diseases, their treatment and some of the factors that one has to consider during pregnancy.
How Is Liver Disease In Pregnancy Defined?
- Cause of liver disease during pregnancy covers a wide variety of diseases.
- Liver disease and abnormal liver function test is observed during gestational period and during the postpartum period.
- Liver diseases when present during pregnancy causes abnormal liver function studies with hepatobiliary dysfunction.
- The abnormal liver function test is observed in 10% of pregnancies.
Causes Of Liver Disease In Pregnancy
- There are several liver dysfunctions, which causes abnormal liver function test during Pregnancy.
- Diseases which may cause abnormal liver function test are as follows-
- Acute Fatty Liver of Pregnancy
- Intrahepatic Cholestasis of Pregnancy
- Autoimmune Hepatitis
- Wilson's Disease1
- Viral Hepatitis2
Types Of Liver Diseases That Are Unique And Occur Only During Pregnancy
Following are the liver diseases discussed in literature when associated with pregnancy.
Acute Fatty Liver of Pregnancy: 3
- Serious liver disease usually occurs in the third trimester of pregnancy.
- Although this condition is rare, it can eventually lead to liver failure as well as encephalopathy.
- Undiagnosed fatty liver during pregnancy may cause life-threatening complication.
- Complications can be harmful to mother and child.
- Recent studies show a maternal mortality rate of 20% with this disease suggesting need for better awareness of the disease in order to make early inroads into the disease and treat it.
Intrahepatic Cholestasis of Pregnancy: 4
- Some females experience extremely severe itching in the advanced stages of their pregnancy.
- Itching is observed mostly in the palms of hands and soles of feet, which then becomes generalized.
- Cholestasis is the name given to a medical term in which the liver is unable to excrete bile.
- The bile breaks down to bilirubin, which is circulated in blood in large quantity compared to normal traces.
- Bilirubin and bile salt gets deposited in the skin resulting in the severe itching.
- During pregnancy, normal flow of bile in gallbladder is affected as a result of elevated amount of hormones as a result of the pregnancy.
- This condition is seen mostly in the last trimester and fades away after a few days after delivery.
- Fetal heart rate may not show abnormal variations.4
- Preeclampsia is pathological condition that results in:
- Retention of fluid causing edema feet
- Weight gain
- In preeclampsia, the liver also gets affected and elevated liver enzymes are observed
- HELLP Syndrome is a medical condition that results in-
- Elevated liver enzymes
- Depressed levels of platelets.
Diagnosis of Liver Disease In Pregnancy
It is quite a challenge to diagnose a liver dysfunction during pregnancy. It usually is dependent on laboratory investigations.
Nonspecific Symptoms Of Liver Disease During Pregnancy-
- Feeling tired and fatigued
- Loss of appetite
Specific Symptoms And Signs Of Liver Disease During Pregnancy
- Abdominal pain
- Urine yellow in color
- Pale and white stool
- Jaundice- yellow conjunctiva
- Palmer erythema
- Spider angioma
- Dry skin
- Enlarged liver
Diagnostic Procedure To Investigate Liver Disease During Pregnancy
- Urine Examination-
- Urine bilirubin
- Blood Examination-
- Increased serum bilirubin
- Increased level of liver enzymes
- Blood examination to diagnose autoimmune disease
- Imaging Studies like CT/MRI-
- Hepatomegaly- Enlarged liver
- Signs of inflammation and scarring.
- Liver Biopsy-
- Evaluate the cause of liver disease.
Morbidity and Mortality
- Depends on severity of disease
- Depends on investigation and early diagnosis
- The underlying dysfunction can significantly impact the morbidity and mortality in the mother as well as the fetus.
- Diagnostic workup needs to be done appropriately and in a timely fashion.
- Fulminant hepatic failure in pregnancy has very high fetal and maternal mortality which is mostly due to viral hepatitis E.2
Treatment for Liver Disease In Pregnancy
There are three main lines of treatment of liver disease during pregnancy-
- Conservative Treatment
- Supportive Care
- Medication Therapy.
Conservative Therapy For Liver Disease In Pregnancy -
- Organic nutrition and vitamin supply
Supportive Care for Liver Disease in Pregnancy -
- Check fetus and mother frequently
- Keep a close watch on fetal growth and mother's weight
- Actively look for pre-eclampsia or eclampsia.
Medical Treatment for Liver Disease in Pregnancy -
The outcome of medical treatment are classified as follows-
- Category A: Studies have shown no risk to the mother or fetus
- Category B: No risk as far as humans are concerned
- Category C: Potential for some risk
- Category D: There has been evidence of risk
- Category X: Absolutely contraindicated in pregnancy
What Are Some Of The Factors That One Has To Consider For Liver Disease During Pregnancy?
- During pregnancy, safety to the mother and the fetus is absolutely vital and hence the medication that the female uses needs to pose no risk to the fetus or in fact the mother herself.
- The FDA has classified medication that can be used in pregnancy and has divided them into the categories as mentioned above.
Pregnancy After Liver Transplant:
- Females who have undergone a liver transplant and are of a reproductive age can attempt pregnancy approximately two years after the transplant.
- The risk of maternal and fetal illness and morbidity is lot less if female patient gets pregnant 2 years after liver transplant.5
1. Wilson's disease in pregnancy.
Zegarac Z, Duić Z, Stasenko S, Partl JZ, Valetić J, Cvrlje VC.
Acta Clin Croat. 2013 Dec;52(4):529-32.
2. Etiology, clinical features and outcome of fulminant hepatic failure in pregnancy.
Brohi ZP1, Sadaf A2, Perveen U3.
J Pak Med Assoc. 2013 Sep;63(9):1168-71.
3. Acute fatty liver of pregnancy.
Papafragkakis H1, Singhal S, Anand S.
South Med J. 2013 Oct;106(10):588-93.
4. Intrahepatic cholestasis of pregnancy: the effect of bile acids on fetal heart rate tracings.
Sheibani L1, Uhrinak A, Lee RH, Fong A, Pathak B.
Obstet Gynecol. 2014 May;123 Suppl 1:78S-9S
5. Liver diseases in pregnancy: liver transplantation in pregnancy.
Hammoud GM1, Almashhrawi AA, Ahmed KT, Rahman R, Ibdah JA.
World J Gastroenterol. 2013 Nov 21;19(43):7647-51.