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Unformatted text preview: LIVER DISEASES WITH LIVER DISEASES WITH PREGNANCY Professor Mahmoud Farouk Midan Professor Mahmoud Farouk Midan . Prof. & Head of Obstetrics & Gynecology Dept Faculty of Medicine Faculty of Medicine Al­Azhar University Introduction Introduction Liver disease is a rare complication of pregnancy, but when it occurs it may do so in a dramatic and tragic fashion for both mother and infant. Diseases such as acute fatty liver of pregnancy (AFLP) may begin innocuously with mild symptoms and liver enzyme abnormalities but, if left untreated, can progress to jaundice, liver failure, and death. (Bacq & Riely , 2004) • Some of the normal physiologic changes of pregnancy can mimic abnormalities associated with liver disease. • Telangiectasia, particularly on the chest, back, and face, and palmer erythema occur in up to 60 percent of normal pregnant women but disappear after delivery. (Riely, 2001) Extreme vigilance is needed to detect early signs and symptoms of liver dysfunction and to distinguish these from the anticipated benign hepatic changes of pregnancy. Prompt management can save the life of the mother and the baby. Management of liver disease in pregnancy requires a concerted effort between the primary care physician, liver specialist, obstetrician, and, on rare occasions, a liver transplant team. (Moskovitz et al., 2004) Anatomical, Physiological, and Anatomical, Physiological, and Biochemical changes during pregnancy. :Anatomic Changes Anatomic Changes • Liver weight increases during pregnancy has not been documented. Liver size is difficult to estimate in pregnancy, but records fail to show any substantial increase in liver weight in comparison with nonpregnant controls. • Therefore, detection of hepatomegaly is strong evidence for the presence of liver disease. (Fagan, 1986) Physiology Physiology • Hepatic blood flow is maintained at a constant • rate in pregnancy despite marked changes in the cardiovascular system. Blood flow increases to the kidneys and other organs, but hepatic blood flow is unaltered, which results in a decline of approximately 35% in the proportion of cardiac output delivered to the liver. (Fagan, 1986) Biochemical changes during Biochemical changes during pregnancy • The total serum protein concentration declines approximately 20% in midpregnancy, primarily a result of the substantial decline in serum albumin which may be attributed to simple dilution caused by the increase in total blood volume, although most other serum proteins either remain unchanged or increase in concentration. (Maher et al., 1993) • A significant rise in serum fibrinogen regularly • accompanies pregnancy. As a consequence of increase fibrinogen synthesis. Other coagulation proteins, including factors VII, VIII, IX, and X, may be increased during pregnancy or after estrogen treatment. (Steingrub, 2005) • Most studies have failed to document significant bilirubin Elevation in the absence of specific cause during normal pregnancy. Therefore, an increased serum bilirubin level in pregnancy should be considered presumptive evidence for the presence of liver or hematologic disease. (Steingrub, 2004) • Alkaline phosphatase activity is increased during the third trimester both because of leakage of placental alkaline phosphatase into the maternal circulation and because of increased maternal bone turnover. (Riely, 1999) Serum bile acid level is quite helpful in any form of Serum bile acid level is quite helpful in any form of cholestasis. The serum level is normal in normal pregnancy. Levels of serum aminotransferase­aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are normal in normal pregnancy. Therefore, these two serum enzyme determinations remain sensitive indicators of liver damage during pregnancy. The ALT is especially useful, because significant elevation of this enzyme does not occur with injury to tissues other than liver. (Bacq et al., 2004) Summary of physiological changes in the liver during Summary of physiological changes in the liver during pregnancy • • • • • • • • • • • • • • • Increased: Blood volume and cardiac ouput rise by 35%–50% Alkaline phosphatase levels rise threefold or fourfold due to placental production Clotting factor changes create a hypercoagulable state Decreased: Gallbladder contractility Hemoglobin Uric acid levels Albumin, total protein, and antithrombin III concentrations No change: Liver aminotransferase levels (aspartate aminotransferase, alanine aminotransferase, gamma­glutamyl transferase) Bilirubin level Prothrombin time Spectrum of liver diseases in Spectrum of liver diseases in pregnancy ((Fleming & Zein, 2005 • Preexistent liver diseases – Portal hypertension, cirrhosis, primary biliary cirrhosis – Autoimmune hepatitis – Wilson disease – Chronic infection with hepatitis B or hepatitis C virus – Alcoholic liver disease • Liver diseases coincidental with but not induced by pregnancy – Acute viral hepatitis and other viral infections – Alcohol­related diseases – Gallstone disease – Budd­Chiari syndrome • Liver diseases induced by pregnancy – First trimester • Hyperemesis gravidarum – Second and third trimesters • Intrahepatic cholestasis of pregnancy • Preeclampsia, eclampsia, and the HELLP syndrome • (hemolysis, elevated liver enzymes, low platelet • counts) Acute fatty liver of pregnancy • Preexistent liver diseases – Portal hypertension, cirrhosis, primary biliary cirrhosis – Autoimmune hepatitis – Wilson disease – Chronic infection with hepatitis B or hepatitis C virus – Alcoholic liver disease • Pregnancy is uncommon in women with established liver cirrhosis, including primary biliary cirrhosis, because they tend to be past childbearing age or infertile due to the condition. A life­threatening complication of liver cirrhosis is variceal bleeding associated with portal hypertension. Treating bleeding esophageal varices with nonselective beta­blockers, band ligation, and octreotide is safe and effective during pregnancy. (Helmy &Hayes, 2001) • Ursodeoxycholic acid (FDA category B) at doses of 10 to 13 mg/kg is treatment of choice for primary biliary cirrhosis and may be continued during pregnancy and breastfeeding. (Sternlieb, 2005) • The presence of severe portal hypertension with esophageal varices is associated with an increased risk of hemorrhage during pregnancy . The use of sclerotherapy for bleeding varices during pregnancy may provide a safe alternative to portacaval anastomosis and has been reported to be effective. (Pauzner et al., 1991) • Preexistent liver diseases – Portal hypertension, cirrhosis, primary biliary cirrhosis – Autoimmune hepatitis – Wilson disease – Chronic infection with hepatitis B or hepatitis C virus – Alcoholic liver disease • Women with autoimmune hepatitis can become pregnant and can still carry a successful pregnancy. The course of the disease is unpredictable. Although spontaneous remission may occur, maternal death and exacerbation during pregnancy and after delivery have been reported. (Heneghan et al., 2001) Corticosteroids are the treatment of choice in Corticosteroids autoimmune hepatitis and appear to be safe in pregnancy. They seem to induce rapid remission of autoimmune hepatitis, whether during the initial onset or during a flare. Although azathioprine is in FDA category D (positive evidence of risk), we have little evidence that it is toxic in pregnancy. Data from patients with inflammatory bowel disease suggest it is likely to be safe in pregnancy at dosages less than 100mg/day. (Moskovitiz et al., 2004) • Preexistent liver diseases – Portal hypertension, cirrhosis, primary biliary cirrhosis – Autoimmune hepatitis – Wilson disease – Chronic infection with hepatitis B or hepatitis C virus – Alcoholic liver disease Wilson disease is a rare disorder characterized by cirrhosis, neurological abnormalities, and less commonly hematological and renal dysfunction. D­Penicillamine and trientine have been used during pregnancy. However, the dosage should be reduced to the minimum necessary dose, which is about 25% to 50% of the dose the patient had been taking before the pregnancy. (Roberts & Schilsky, 2003) • Zinc is the agent of choice for Wilson disease during pregnancy because of its safety for the fetus. It should be maintained throughout the pregnancy at 50 mg three times a day. (Brewer et al., 2000) Liver diseases coincidental Liver diseases coincidental with but not induced by pregnancy Liver diseases coincidental with but not Liver diseases coincidental with but not induced by pregnancy – Acute viral hepatitis and other viral infections – Alcohol­related diseases – Gallstone disease – Budd­Chiari syndrome Hepatitis A Hepatitis A Characteristics Hepatitis A Older name Infectious hepatitis Virus type RNA Virus size 27 nm Incubation period 15 – 50 days Transmission Fecal – oral Vertical transmission to fetus Not observed Serologic diagnosis Maximum infectivity Carrier state Acute clinical forms Chronic clinical forms Hepatitis A antibody IgM and IgG types Prodrome None Asymptomatic to fulminant None • The clinical syndrome of acute HAV infection • consists of vague flu­like symptoms with fatigue, weakness, nau­sea, and loss of appetite. The onset is usually abrupt. A variety of extrahepatic manifestations including myalgia, arthralgias, arthritis, and urticaria, may occur. Other forms of HAV infection include cholestatic hepatitis, with a prolonged course marked by itching and jaundice. (Willner, et al., 1998) • The characteristic changes in liver function test find­ings include marked elevations in AST and ALT. Most often, these reach levels of 1000 to 2000 U during the early part of the infection. Elevations in bilirubin and alkaline phosphatase also occur but are more unpre­dictable. (Fiore, et al., 2003) • There is substantial evidence that pregnancy does not alter the course of HAV infection. However, a higher incidence of fulminant disease during pregnancy has been reported in developing nations. Concurrent malnutrition has been a suspected cause. If the course of HAV infection is severe, it may precipitate premature labor in women in the third trimester of pregnancy. There is no evidence that HAV causes birth defects, and there is no evidence of maternal­fetal transmission. (Atkinson, et al., 2002) • Clinical management of pregnant patients with • HAV infection does not differ from that of those who are not pregnant. However, hospitalization may be indicated, specially during the last trimester and in the presence of severe anorexia, nausea, and vomiting. In rare circumstances in which the mother has acute HAV infection at the time of delivery, immune serum globulin may be administered to the infant. Even under these conditions, the risk of transmission to the infant seems very small. (Fiore, et al., 2003) Hepatitis B Hepatitis B Characteristics Hepatitis B Older name Serum hepatitis Virus type DNA Virus size 42 nm Incubation period 30 – 180 days Transmission Parentral or body fluid Vertical transmission to fetus Common Serologic diagnosis HBs Ag, HBs Ab, IgM, and IgG types HBe Ag, Ab, Hepatitis B virus DNA Maximum infectivity Prodrome or HBe Ag Positive Carrier state 5 – 10% Acute clinical forms Asymptomatic to fulminant Chronic clinical forms Chronic persistent hepatitis Chronic active hepatitis Cirrhosis The incidence of the HBV carrier state among preg­nant women is variable and depends on the patient group studied. The incidence of HBV carriers is considerably higher in populations in which drug abuse is common­place or with n high incidence of sexual promiscuity. (Van Zonneveld, et al., 2003) • Evidence suggests that transmission of HBV to • infants is common when mothers have acute infection in the third trimester or when they are chronic carriers of HBV infection and have positive results of serum tests for HBeAg or HBV DNA. The risk of transmission is highest in mothers who are HBeAg ­ positive at the time of delivery. (Su, et al., 2004) • In women with chronic hepatitis B infection, taking lamivudine before becoming pregnant and continuing to take it throughout the pregnancy has been reported to lower rates of transmission of the virus from mother to newborn. Lower transmission rates have also been seen in pregnant women with a high viral DNA load. (Su, et al., 2004) • The administration of hyperimmune globulin and HBV vaccine protects 90% to 95% of infants from HBV infection. It is recommended that 0.5 ml, of HBIG be given at birth and that three doses of HBV vaccine be given beginning at birth. (Sehgal, et al., 1992) • Universal vaccination of all infants at birth for HBV is now the standard of care. Vaccinations for all children previously not immunized is recom­mended as they enter puberty, in future generations, the specter of viral hepatitis B and its complications could be eliminated. Vaccine for pregnant women exposed to hepatitis B is safe. (Watson, 2002) Hepatitis C Hepatitis C Characteristics Hepatitis C Older name Non A non B hepatitis Virus type RNA Virus size 30-60 nm Incubation period 30 – 160 days Transmission Parentral sporadic Vertical transmission to fetus Uncommon Serologic diagnosis Hepatitis C antibody RNA by PCR Maximum infectivity HIV co- infected Carrier state 50 – 85% Acute clinical forms Asymptomatic to sever relapsing Chronic clinical forms Chronic persistent hepatitis Chronic active hepatitis Cirrhosis • The rate of vertical transmission of hepatitis C is less than 5%. The risk is higher if the mother is co­infected with human immunodeficiency virus (HIV), if she is viremic at the time of delivery, if her viral DNA load is greater than 1 million copies/ml, and if the time from the rupture of membranes to delivery is more than 6 hours. • The mode of delivery does not seem to influence the rate of transmission from mother to child. (Ceci et al., 2001) • Breastfeeding is not considered a risk factor for transmission, even though viral RNA has been detected in breast milk. Spontaneous resolution of infection in the mother and in the newborn may occur. (Steininger et al., 2003) • Newborns of infected mothers should be tested at 12 to 18 months of age, when IgG antibodies to hepatitis C virus that may have passively transferred from the placenta to the fetus would have been lost, and the persistence of hepatitis C viral RNA would indicate infection with hepatitis C. (Ferrero et al., 2003) • Interferon is in FDA category C, and ribavirin is in category X. Both drugs are contraindicated in pregnancy. If a woman gets pregnant while on combination therapy, then both drugs should be stopped, and she should be advised that she has already put the fetus at risk of teratogenicity. (Resti et al., 2003) Hepatitis E Hepatitis E Hepatitis E (HEV) is a nonenveloped, single­ stranded RNA virus. It is endemic in developing countries and shares the route of transmission, risk factors, and chronicity rate with HAV. During pregnancy, HEV can cause fulminant hepatitis indistinguishable from AFLP. There is a significant mortality rate of 16% in pregnant women with acute HEV infection. (Aggarwal & Krawczynski, 2000) • Transmission occurs intrapartum and peripartum through close contact of mother and neonate. Evidence suggests significant vertical transmission among HEV­RNA positive mothers of up to 50%. Among women with symptomatic infection the rate of transmission is up to 100%, with significant perinatal morbidity and mortality. (Singh et al., 2003) Management of Acute Viral Management of Acute Viral Hepatitis in Pregnancy Establish type by serologic test Institute appropriate isolation and precautions Determine need for contact prophylaxis with scrum globulin preparation and/or vaccine Activity: determined by tolerance Diet: patient preference, parentral if necessary Antiemetics: phenothiazines may be used Corticostcroids: not indicated Immunoprophylaxis of infant: if hepatitis B is present Herpes simplex virus Herpes simplex virus • It can cause fulminant liver failure and death if infection occurs during pregnancy, and the rate of transmission to the fetus can reach 30% to 50% if the primary episode occurs at delivery. c y c a t e g o r y B ) i s v e r y e f • About 90% of pregnant women with this infection have abnormal liver enzyme tests and an abnormal prothrombin time. Acyclovir (FDA pregnancy category B) is very effective if promptly given at doses of 400 mg three times daily for 5 to 7 days, and early delivery is not required. (Nigro , et al., 2003) Cytomegalovirus Cytomegalovirus • Infection may remain asymptomatic in pregnant women, and the prognosis is favorable. The risk of transmission to the fetus and of congenital abnormalities is highest when acute infection occurs in the first 22 weeks of pregnancy. Termination of the pregnancy may be an option after appropriate counseling regarding the potential serious risks to the infected fetus. (Benachi A, et al., 2003) Liver diseases coincidental with but not Liver diseases coincidental with but not induced by pregnancy – Acute viral hepatitis and other viral infections – Alcohol­related diseases – Gallstone disease – Budd­Chiari syndrome Alcohol use Alcohol use • Women are two to four times more likely than men to develop alcoholic liver disease for the same amount of alcohol ingested, and they exhibit a tendency to disease progression even with abstinence. (Pares et al., 1986) • Continued drinking during pregnancy may lead to miscarriage, stillbirth, prematurity, growth retardation, and the fetal alcohol syndrome (growth retardation, behavioral disturbances, brain defects, cardiac defects, spinal defects, and craniofacial anomalies). Alcohol abstinence throughout pregnancy should be emphasized. (Lemoine et al., 2003) Liver diseases coincidental with but not Liver diseases coincidental with but not induced by pregnancy – Acute viral hepatitis and other viral infections – Alcohol­related diseases – Gallstone disease – Budd­Chiari syndrome Gallstone disease Gallstone disease • Pregnancy is a risk factor for sludge and gallstone formation. By the end of the third trimester, 10% to 12% of pregnant women have gallstones. Most gallstones disappear spontaneously without causing symptoms. If symptoms develop, the treatment may be conservative or surgical, depending on the severity of the symptoms. • Laparoscopic surgery seems to be safe and should be considered. The optimal time for it appears to be during the second trimester, when fetal organogenesis is completed and the size of the uterus does not interfere with the surgery. (Halpern , 1998) Liver diseases coincidental with but not Liver diseases coincidental with but not induced by pregnancy – Acute viral hepatitis and other viral infections – Alcohol­related diseases – Gallstone disease – Budd­Chiari syndrome Budd­Chiari syndrome Budd­Chiari syndrome • Budd­Chiari syndrome is very rare and often insidious, manifesting after delivery. It is characterized by thrombosis of the hepatic veins and portal hypertension. Its clinical manifestations include ascites, hepatomegaly, and abdominal pain. (Singh et al., 2000) • Proper diagnosis and management require imaging studies such as Doppler ultrasonography and CT and liver biopsy. Treatment with anticoagulants, thrombolytics (warfarin is contraindicated in pregnancy), diuretics, and portocaval shunting may be required. Liver transplantation is indicated when hepatic decompensation develops. (Deltenre et al., 2001) • Liver diseases induced by pregnancy – First trimester • Hyperemesis gravidarum – Second and third trimesters • Intrahepatic cholestasis of pregnancy • Preeclampsia, eclampsia, and the HELLP syndrome • (hemolysis, elevated liver enzymes, low platelet • counts) Acute fatty liver of pregnancy Hyperemesis Gravidarum Hyperemesis Gravidarum • Hyperemesis gravidarum can be defined as excessive nausea and vomiting in pregnancy that result in dehy­dration and ketosis, severe enough to necessitate hospitalization. Although this is not primarily a liver disorder, it affects the liver in up to 50% of patients. (Jeffrey et al., 2003) • The origin of the liver disease associated with hyperemesis gravidarum is unclear. Not all affected patients have liver disease; therefore, the vomiting does not appear to be secondary to the liver involvement. Starvation alone does not seem to be an adequate explanation for the liver dysfunction, particularly in as much as biopsy in affected patients fails to show the fatty infiltration typical of starvation. (Mazzotta & Magee, 2000) • Factors thought to favor an increased risk for hyperemesis gravidarum include obesity, nulliparity, and twin gestation. (Goodwin, 1998) • Affected patients present in the first trimester, usually by weeks 10 to 12. They have persistent nausea and vomiting and experience weight loss, often of significant amounts. They also have ptyalism (excessive spitting). (Lammert et al., 2000) • Laboratory testing demonstrates abnormal liver values in up to 50% of affected patients; the most sensitive test is the ALT, which may rise as high as 1000 U. • Severely affected patients also have elevations in bilirubin. (Jeffrey et al., 2003) Improvement in the nausea and vomiting and resolution of the liver test abnormalities occur when most affected patients are given intravenous fluids and put to gut rest. Antiemetic therapy is helpful. Corticosteroid therapy has been reported with success. Patients affected with hyperemesis gravidarum have no increased rate of prematurity, infants with low birth weight, or infants with birth defects. (Tsang et al., 1996) • Liver diseases induced by pregnancy – First trimester • Hyperemesis gravidarum – Second and third trimesters • Intrahepatic cholestasis of pregnancy • Preeclampsia, eclampsia, and the HELLP syndrome • (hemolysis, elevated liver enzymes, low platelet • counts) Acute fatty liver of pregnancy Intrahepatic Cholestasis of Intrahepatic Cholestasis of Pregnancy • The syndrome has been variously called recurrent jaundice of pregnancy, cholestatic jaundice of pregnancy, jaundice of late pregnancy, and hepatosis of pregnancy. ICP, however, is the preferred term, because jaundice is inconstant in any type of cholestatic disorder. (Gonzalez­Peralva et al., 1996) • The frequency of ICP is clearly higher among certain ethnic groups, including Scandinavians and Chileans. In the latter group, ICP may appear in 2.4% or more of pregnan­cies, the highest reported incidence in the world. The incidence is quite high (20.9%) in twin pregnancies. • Several studies have demonstrated a familial and genetic predisposition to the syndrome in Sweden, Chile, and the United States. (Lammert, et al., 2000) Clinical Description Clinical Description Pruritus is the dominant and initial symptom and appears in the third trimester in more than 70% of cases. Most of the remaining patients date their onset of symptoms to the second trimester. The symptom may become very severe and usually involves the trunk and the extremities, including the palms and the soles of the feet. As a result of the pru­ ritus, insomnia, fatigue, and even mental disturbances have been reported (Milkiewicz et al., 2002) Many patients report the appearance of Many patients report the appearance of dark urine without frank jaundice shortly after the onset of pruritus. Only a minority of patients develop obvious jaundice, and this is usually mild. It is notable that abdominal pain, biliary colic, fever, anorexia, nausea, vomiting, and arthralgias are absent. (Milkiewicz et al., 2002) • The improvement in both pruritus and jaundice begins to occur quite promptly after delivery, most often within 24 hours. However, jaundice may continue for several days after delivery, and some of the abnormal chemistry profiles persist for as long as several months. • Subsequent pregnancies are frequently accompanied by recurrences of the syndrome. (Mazella et al., 2001) Biochemical Changes Biochemical Changes CLINICAL FEATURES Pruritus Jaundice* No Anorexia or malasie 2nd or 3rd trimester onset* Recurrent* Familial* BIOCHEMICAL CHANGES Serum bile acid Alkaline Phosphatase 5' Nucleotidase GGTP Bilirubin (total) AST/ALT Prothrombin time Cholesterol Triglyceride 10-to 100 fold 7- to 10 fold ↑ Two Folds↑ Normal to slight ↑ Normal to 5 mg/dL ↑↑ Normal to twofolds↑ Two to Fourfolds ↑ Normal to twofolds ↑ *These clinical features are not invariably present. ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGTP, γ ­ glutamyl­transpeptidase. ↑, increase. Effects on the Mother Effects on the Mother • Although earlier reports suggested that the only effect of ICP on the mother was related to the discomfort of pruritus, more recent studies have suggested more serious compli­cations. These include an increased risk of postpartum hemorrhage, especially in those given cholestyramine, and an increased risk for the development of gallstones after pregnancy. (Glantz, et al., 2005) Effects on the Fetus Effects on the Fetus • The implications of ICP for the fetus are considerably more ominous. An increased incidence of prematurity and fetal death has been reported in several studies. Fetal distress is reported in one third of patients, leading to cesarean section in 30% to 60% of cases and prematurity in over 50% in some series. Stillbirths are recorded in more than 9%. These outcomes are more likely if the disorder begins earlier in pregnancy. Thus, ICP very clearly increases the risks to the fetus. (Glantz, et al., 2004) Treatment Treatment • Therapy is directed at alleviating pruritus in the mother. Ursodeoxycholic acid has been used successfully in the treatment of cholestasis in other settings, most prominently primary biliary cirrhosis. Improvement in both liver function test results and the symptom of pruritus has been documented in women with ICP treated with a standard 15­mg/kg/day dosage. A larger dosage, 20 to 25 mg/kg/day has been shown to be effective with no adverse affects on either mother or baby. (Mazella et al., 2001) • Phenobarbital in a dosage of 100 mg/day has • been reported to be effective in approximately 50% of patients. Cholestyramine may be somewhat effective and is usually given in a dosage of 4 g four or five times per day. Cholestyramine may worsen the malabsorption of fats and fat­soluble vitamins. Therefore, the prothrombin time must be monitored in patients treated with this regimen, and parenteral vitamin K should be given before delivery. (Eloranta et al., 2002) • Intravenous or oral S'­adenosyl­1.­ methionine has been reported to lead to a significant improvement in pruritus and in serum transaminase and bilirubin levels, perhaps by reducing the negative effects of estrogens on bile secretion. (Frezza et al., 1999) • Some investigators recommend elective induction at 38 weeks or as early as 36 weeks in the presence of jaundice or if the fetus's lungs have matured. (Rioseco et al., 1994) • Liver diseases induced by pregnancy – First trimester • Hyperemesis gravidarum – Second and third trimesters • Intrahepatic cholestasis of pregnancy • Preeclampsia, eclampsia, and the HELLP syndrome • (hemolysis, elevated liver enzymes, low platelet • counts) Acute fatty liver of pregnancy Preeclampsia and eclampsia Preeclampsia and eclampsia • Preeclampsia affects up to 5% to 10% of pregnancies, usually occurring in the late second and third trimesters and less frequently occurring before 20 weeks’ gestation. Preeclampsia commonly occurs in nulliparous women or multiparous women who are nonwhite; are older than 34; or have new partners, past or current history of hypertension, or previous postpartum hemorrhage. (Benedetto et al., 2002) • The disease is characterized by a triad of hypertension, proteinuria, and peripheral edema, and hypertension and proteinuria characteristically regress after delivery. Eclampsia is characterized by seizures, coma, and other signs of preeclampsia, including hypereflexia, funduscopic changes in severe cases, cerebral edema, hepatic infarction, acute renal failure, congestive heart failure, and acute respiratory distress syndrome. (von Dadelszen et al., 2000) Pathophysiology Pathophysiology • A uteroplacental mismatch, whereby the demands of the fetal placenta exceeds the maternal circulatory supply leads to placenta hypoperfusion, local hypoxia, endothelial cell dysfunction, abnormal expression of inflammatory mediators, alteration of vasomotor tone, and activation of the coagulation cascade. (Sawhney et al., 2000) Clinical manifestations Clinical manifestations • The clinical course of preeclampsia includes nausea, vomiting, and epigastric pain and is associated with elevated levels of LDH, alkaline phosphatase, AST, ALT, and uric acid. The level of uric acid is an excellent marker for assessing disease severity and progression. Liver function tests are abnormal in 20% to 30% of patients with preeclampsia and may be attributed to vasoconstriction of the hepatic vascular bed. (Maki et al., 2000) Therapy and outcome Therapy and outcome • Women who develop preeclampsia before 32 weeks of gestation are 22 fold more likely to die than women who develop the condition at term. (MacKay et al., 2001) • The maternal mortality rate is less than 1% at institutions with special skills in treating preeclampsia. Approximately 80% of maternal deaths are attributed to central nervous system complications, usually cerebral edema. Hepatic complications, including sub­capsular hematoma and rupture, infarction, and hepatic failure, account for the remaining causes of mortality. (Rolfes & Ishak, 1986) • Fetal complications include abruptioplacenta, prematurity, and IUGR. Severe disseminated intravascular coagulation (DIC) is a rare complication in the absence of placenta abruption. • The only effective treatment for preeclampsia is delivery of the fetus and placenta, particularly if the condition is severe or develops after 36 weeks of gestation or if the fetal lungs are mature. Most authorities suggest that the presence of Multi Organ system Dysfunction (MOSD), fetal distress, or gestational age greater than 34 weeks warrants immediate delivery (Sibai et al., 1994) • If mild preeclampsia is evident in the third trimester, expectant management with intensive monitoring may enhance fetal lung maturity; however, any sign of maternal or fetal deterioration requires emergent delivery. If eclampsia develops, magnesium sulfate is a treatment of choice for seizure prophylaxis. (Bernard et al., 2001) • Liver diseases induced by pregnancy – First trimester • Hyperemesis gravidarum – Second and third trimesters • Intrahepatic cholestasis of pregnancy • Preeclampsia, eclampsia, and the HELLP syndrome (hemolysis, elevatedliver enzymes, low platelet counts) • Acute fatty liver of pregnancy HELLP Syndrome HELLP Syndrome • The HELLP syndrome is a multi­system disease variant of severe preeclampsia that is characterized by microangiopathic hemolytic anemia (MAH), hepatic dysfunction (hepatic necrosis), thrombocytopenia (platelet count, <100,000/ mm3), and, in the syndrome’s most severe form, DIC. • HELLP syndrome is more common among older • • multiparous women. HELLP syndrome affects up to 20% of pregnancies involving severe preeclampsia. Although up to 11% of the cases occur before 27 weeks of gestation, most cases (70%) occur between 27 and 36 weeks of gestation and about a third occur after delivery. Exacerbations may occur after delivery, followed by recovery within 72 hours. (Martin et al., 1999) Clinical manifestations Clinical manifestations • Several conditions mirror HELLP syndrome, and timing of illness and findings may assist in differentiating HELLP syndrome from other diseases. (Winbery & Blaho., 2001) differential diagnosis of HELLP differential diagnosis of HELLP syndrome Thrombotic coagulopathies Consumptive disorders Miscellaneous Hemolytic uremic syndrome Thrombotic thrombocytopenia purpura Drug-induced hemolytic anemia Sepsis DIC AFLP Sepsis DIC Abruptio placentae Amniotic fluid embolism Systemic lupus Antiphospholipid syndrome Cholecystitis Appendicitis • Frequent presenting symptoms include nausea, malaise, epigastric or right upper quadrant abdominal pain (65%–90% of cases), and edema. In a large series, HELLP syndrome was observed with DIC (21% of patients), abruption placenta (16%), acute renal failure (8%), and pulmonary edema (6%). The maternal mortality rate is approximately 1% to 4%, and the perinatal mortality rate ranges from 10% to 20%, depending on gestational age and severity of the condition at the time of delivery. (Sibai et al., 1993) Maternal morbidity in HELLP syndrome can Maternal morbidity in HELLP syndrome can be classified into the following four categories (in decreasing order of frequency) • Coagulation disorders associated with hemorrhagic complications, • Cardiopulmonary dysfunction, • Central nervous system disorder and • Hepatic or gastrointestinal dysfunction. (Isler et al., 1999) • Women with HELLP syndrome should be considered to be at increased risk for obstetrical complications in subsequent pregnancies (preterm deliveries, IUGR, abruption­placenta), and the risk for recurrence ranges from 4% to 25% . Infants born to mothers with HELLP syndrome are at risk for thrombocytopenia. (Sibai et al., 1995) Laboratory investigation Laboratory investigation Risk factors for HELLP syndrome include the following: • LDH level, > 1400 IU/L • AST level, > 150 IU/L • ALT level, > 100 IU/L • Platelet count, < 50,000/mm3 • Uric acid level, > 7.8 mg/dL • Creatinine level, > 1.0 • Creatine phosphokinase level, > 200 IU/L Liver function Liver function • Patients usually are not jaundiced. Total bilirubin • concentration rarely exceeds 1 to 2 mg. HELLP syndrome rarely leads to subcapsular hemorrhage; hepatic rupture often leads to death of the mother and fetus. Typically, these patients present with shock and hemoperitoneum. The condition also may manifest hepatic infarcts with associated fevers, high levels of aminotranferase (N5000 IU/L), and anemia. (Krueger et al., 1995) Therapy and outcome Therapy and outcome • The maternal morbidity rate has been reported to be as high as 24%, but it ranges between 1% to 4% in optimal medical environments. In patients who died, the mean gestational age was 31 weeks, and death was attributed to sepsis, hemorrhagic shock, intracerebral insults, and cardiac pulmonary failure. Investigators found 16% maternal death rate attributed to hepatic complications. (Martin et al., 1999) • The neonatal mortality rate associated with HELLP syndrome (10%–20%) has been attributed to placenta ischemia leading to abruption, extreme prematurity, and intrauterine asphyxia. Factors associated with perinatal survival in preterm pregnancies with HELLP syndrome include achievement of a birth weight of at least 600g, elapsed time of 48 hours after medical therapy with steroids for perinatal lung maturity, and caesarian delivery. (Barton & Sibai, 1992) • Termination of pregnancy and the removal of the chorionic villi is the only therapy that minimizes maternal and fetal compromise. Timing of delivery depends on the severity of the maternal condition (DIC, MOSD, abruption), fetal condition, placenta reserve, and gestational age. With few exceptions, patients with pregnancies of at least 34 weeks’ gestation and class I pregnant patients with HELLP syndrome require prompt delivery. • HELLP syndrome ­ antepartum management • assess and stabilize the maternal condition • correct coagulopathy if DIC is present • give intravenous magnesium sulfate to prevent • • • seizures provide treatment for severe hypertension to prevent stroke transfer to tertiary center if appropriate if subcapsular hematoma of liver, computed tomography or ultrasound of the abdomen • HELLP syndrome ­ antepartum management – evaluate fetal well­being • non stress test • biophysical profile – timing of delivery • if > 34 weeks gestation, deliver • if < 34 weeks gestation, administer corticosteroids, then deliver in 48 hours • HELLP syndrome ­ management for cesarean birth – use general anesthesia if platelet count is < 75,000 / mm3 – transfuse 5 to 10 units of platelets before surgery if platelet count is < 50,000 / mm3 – leave vesicouterine peritoneum open – install subfascial drain • HELLP syndrome ­ management for cesarean birth – schedule secondary closure of skin incision or subcutaneous drain – administer postoperative transfusions as needed – perform intensive monitoring for at least 48 hours postpartum – consider dexamethasone (10 mg IV every 12 hours) until postpartum resolution of disease occurs • HELLP syndrome ­ management of women with a subcapsular liver hematoma – general considerations ­ blood bank aware for potential need of many units of blood – general or vascular surgeon consultation – avoid direct and indirect manipulation of liver – closely monitor hemodynamic status – management of hematoma depends on whether it is ruptured or not • Liver diseases induced by pregnancy – First trimester • Hyperemesis gravidarum – Second and third trimesters • Intrahepatic cholestasis of pregnancy • Preeclampsia, eclampsia, and the HELLP syndrome (hemolysis, elevated liver enzymes, low platelet counts) • Acute fatty liver of pregnancy Acute Fatty Liver of Pregnancy Acute Fatty Liver of Pregnancy • Sheehan, first recognized this disorder as a distinct syndrome in 1940. • He named it Acute yellow atrophy but it is now more commonly known as acute fatly liver of pregnancy. (Sheehan, 1940) • (AFLP) is rare, encountered in a tertiary maternity hospital approx­imately once a year, with a reported incidence of 1 in 13,000 to 1 in 16,000 deliveries. • Preeclampsia is present in 50% or more of cases of AFLP and may play a role in its origin. (Vigil­De, 2001) • Reports of occasional recurrent cases and an asso­ciation with a deficiency of long­ chain 3­hydroxyacyl­cocnzyme A (Co A) dehydrogenase, raise the interesting notion that, at least in some instances, this disease results from an inborn error of metabolism. (Ibdah et al., 1999) Clinical Characteristics Clinical Characteristics • AFLP occurs in the latter half of pregnancy, usually close to term. As with HELLP syndrome, affected patients may present after delivery. It is reported to occur more commonly in a first pregnancy and in the presence of multiple pregnancy, also prevalent in preeclampsia. There are reports of an association between AFLP and gestation of a male fetus. (Castro et al., 1999) • Affected women have nonspecific symptoms, including, promi­nently, nausea and vomiting, malaise and fatigue, jaun­ dice, thirst, headache, and altered mental status. These can be signs and symptoms of acute hepatic failure. • In severe cases that go untreated, there is progression over hours or days to fulminant hepatic failure, with hepatic coma, hypo­glycemia, severe coagulopathy with hemorrhage from the gastrointestinal tract or the uterus and death. • Most affected women have signs of coexistent preeclampsia, including modest elevations in blood pressure, hyperuricemia, and proteinuria. Polydipsia With or without polyuria, frequently is an early symptom in AFLP. symptom The patient may drink 2 or 3 liters of liquids The overnight. it often exceeds the magnitude of vomiting. It has been interpreted as a transient diabetes insipidus. (Cammu et al., 1987) (Cammu Laboratory tests Laboratory tests Clinical features Nausea, Vomiting Malaise, Fatigue Jaundice Abd. Pain Preeclampsia Coma Bleeding Onset in second half of gestation; postpartum onset possible Biochemical changes Bilirubin (total) AST/ALT GGTP Prothrombin time Fibrinogen Uric acid Ammonia Glucose Leukocytes platelets Slight ↑, normal ↑normal to 1000 U Slight↑ ↑↑ ↓ ↓ ↑ ↑ ↓ ↑ ↔, ↑ • Imaging may be useful; fat in the liver has been demonstrated in AFLP with ultrasonography and CT scanning. • Liver biopsy is not indicated for diagnosis (Barton et al., 1998) Characteristics of HEELP syndrome and AFLP Characteristics of HEELP syndrome and AFLP HELLP AFLP Early Platelet count, 50,000-150,000/mm3 LDH level, 600-1400 IU/L Bilirubin/PT levels, Normal Early Platelet count, >100,000/mm3 Uric acid – abnormal LDH level, normal PT- Abnormal Bilirubin/PT levels, abnormal Late Platelet count, <50,000/mm3 LDH level, >1400 IU/L Bilirubin/PT levels, abnormal late Platelet count, <100,000/mm3 LDH level, < 600 IU/L Hypoglycemia PT- Abnormal Complications Complications cerebral edema, cerebral renal failure )60%(, hypoglycemia )53%(, hypoglycemia infections )45%( infections gastrointestinal hemorrhage )33%(, gastrointestinal coagulopathy )30%(, coagulopathy ffetal death etal severe postpartum hemorrhage Course and Management Course and Management • Patients with undiagnosed AFLP are at risk for • • progres­sion, with an unpredictable but often short time course, to fulminant hepatic failure and death for both mother and fetus. Now it is rare for a patient to die, with appropriate diagnosis and aggressive management. Similarly, the outlook for the fetus of the affected pregnancy has also improved, although it remains worse than that of the mother. (Usta et al., 1994) All patients should be hospitalized as hospitalized soon as the diagnosis of AFLP is suspected Moderate or severely affected patients (encephalopathic, deeply jaundiced, with a prothrombin time less than 40% of the control), or with any extrahepatic complications, should be attended in intensive care units. it seems convenient to maintain glucose infusions . Because of the glucose risk of a sudden hypoglycemia until a full metabolic recovery is obtained. full • Treatment of AFLP begins with delivery. The route should be guided by obstetric indications. Cesarean section is not always necessary; vaginal delivery can be accomplished. • With delivery, repair of the liver disease begins, the initial sign of improvement being a fall in prothrombin time elevation. • The management should include maximal support in an intensive care unit by a team that includes both obstetri­cians and hepatologists. Liver transplantation for AFLP has been reported. (Paternoster et al., 2004) • There are no residua after AFLP, and complete recovery of the affected patient should be expected. Cases of recur­rent AFLP, as well as cases of nonketotic hypoglycemia in the offspring, have been reported. Pregnancy Following Liver Pregnancy Following Liver Transplantation • With advances in transplantation, and particularly in immunosuppression, it is unnecessary to discourage pregnancy of most female liver transplant recipients at reproductive age. (Parolin et al., 2004) The first report of successful pregnancy after liver transplantation was published in 1978. (Miniero et al., 2005) • Pregnancy after liver transplantation is often successful, but it must be regarded as a high risk, associated with hypertension, preeclampsia, intrauterine growth retardation, and prematurity. It is best delayed until 1 to 2 years after grafting. Pregnancy planned at least 2 years after liver transplantation with stable allograft function can have excellent maternal and neonatal outcome. (Nagy et al., 2003) • In most female recipients studied, pregnancy does not appear to cause excessive or irreversible problems in graft function if the function of transplanted organ is stable prior to pregnancy, including twins if the woman has stable hepatic function before pregnancy. (Nagy et al., 2003) • In female recipients in contrast to the general population, a high incidence of low birth­weight and prematurity has been a consistent outcome. Immunosuppressive agents may cause hypertension, preeclampsia and renal dysfunction in these recipients. However, there has been no specific pattern of malformation in their newborns or any apparent increase in the incidence of small­for­gestational­age newborns. (Armenti et al., 2000) • immunosuppression during pregnancy is not teratogenic and does not lead to congenital anomalies. • Nearly 70% of pregnancies after systemic administration of tacrolimus resulted in a favourable outcome without any significant effect on intrauterine growth. (Jabiry et al., 2005) • Also, it was found that tacrolimus may decrease the incidence of onset of hypertension and toxemia of pregnancy. Thus, during pregnancy, the female recipient may continue the immunosuppressive regimen to stabilize the transplanted liver function but prevent the effect on the intrauterine growth. • To the present, 37 cases of pregnancies after liver transplantation have been reported worldwide. • In conclusion: Under careful monitoring a childbearing age woman with stable and adequate liver function may have a successful pregnancy and a delivery after liver transplantation. (Pan et al., 2007) ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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