Disorders of the liver, gallbladder, and pancreas together comprise a formidable list of complications that may arise in pregnancy from preexisting conditions or from some that are unique to pregnancy. The relationships of several of these with pregnancy can be fascinating, intriguing, and challenging.
It is customary to divide liver diseases complicating pregnancy into three general categories. The first includes those specifically related to pregnancy that resolve either spontaneously or following delivery. Examples are hepatic dysfunction from hyperemesis gravidarum, intrahepatic cholestasis, acute fatty liver, and hepatocellular damage with preeclampsia—the HELLP syndrome—hemolysis, elevated serum liver aminotransferase levels, and low platelet counts (Mufti, 2012; Reau, 2014). The second category includes acute hepatic disorders that are coincidental to pregnancy, such as acute viral hepatitis. The third category includes chronic liver diseases that predate pregnancy, such as chronic hepatitis, cirrhosis, or esophageal varices.
There are several pregnancy-induced physiological changes that induce appreciable liver-related clinical and laboratory manifestations (Chap. 4, Endocrine System, and Appendix, Serum and Blood Constituents). Findings such as elevated serum alkaline phosphatase levels, palmar erythema, and spider angiomas, which might suggest liver disease, are commonly found during normal pregnancy. Metabolism is also affected, due to altered expression of the cytochrome P450 system that is mediated by higher levels of estrogen, progesterone, and other hormones. For example, in pregnancy, hepatic CYP1A2 expression is decreased, whereas that of CYP2D6 and CYP3A4 is increased. Importantly, cytochrome enzymes are expressed in many organs besides the liver, most notably the placenta. The net effect is complex and likely influenced by gestational age and organ of expression (Isoherranen, 2013). Despite all of these functional changes, no major hepatic histological changes are induced by normal pregnancy.
Pernicious nausea and vomiting of pregnancy may involve the liver. There may be mild hyperbilirubinemia with serum aminotransferase levels elevated in up to half of women hospitalized. However, these levels seldom exceed 200 U/L (Table 55-1). Liver biopsy may show minimal fatty changes. Hyperemesis gravidarum is discussed in detail in Chapter 54 (Laparotomy and Laparoscopy).
TABLE 55-1Clinical and Laboratory Findings with Acute Liver Diseases in Pregnancy ||Download (.pdf) TABLE 55-1 Clinical and Laboratory Findings with Acute Liver Diseases in Pregnancy
| || || ||Hepatic ||Renal ||Hematological and Coagulation |
|Disorder ||Onset in Pregnancy ||Clinical Findings ||AST (U/L) ||Bili (mg/dL) ||Cr (mg/dL) ||Hct ||Plat ||Fib ||DD ||PT ||Hemolysis |
|Hyperemesis ||Early ||Severe N&V ||NL–300 ||NL–4 ||↑ ||↑↑ ||NL ||NL ||NL ||NL ||No |
|Cholestasis ||Late ||Pruritus, jaundice ||NL–200 ||1–5 ||NL ||NL ||NL ||NL ||NL ||NL ||No |
|Fatty liver ||Late ||Moderate N&V, ± HTN, liver failure ||200–800 ||4–10 ||↑↑↑ ||↑↑↑ ||↓↓ ||↓↓↓ ||↑ ||↑↑ ||↑↑↑ |
|Preeclampsia ||Mid to late ||HA, HTN ||NL–300 ||1–4 ||↑ ||↑ ||↓↓ ||NL...|