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ESSENTIAL CONCEPTS

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ESSENTIAL CONCEPTS

  • Most liver biochemical tests are unchanged during pregnancy.

  • Exceptions are serum albumin, total protein, and bilirubin (decreased) and alkaline phosphatase and cholesterol (increased).

  • Several conditions unique to pregnancy may lead to hepatic impairment:

    • Hyperemesis gravidarum (HG), often in the first trimester, invariably before the 20th week of pregnancy.

    • Intrahepatic cholestasis of pregnancy (ICP), often in the second or third trimester (pruritus and mild liver tests abnormalities).

    • Acute fatty liver disease of pregnancy (AFLP) in the third trimester (nausea and vomiting, abdominal pain, jaundice, oliguria, hypertransaminasemia, hyperbilirubinemia, coagulopathy, thrombocytopenia, renal failure, and hypoglycemia).

    • Preeclampsia (classic triad of hypertension, proteinuria, and edema) and eclampsia (preeclamptic triad plus seizures and coma) in the second or third trimester.

    • HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), between the start of the third trimester and the immediate postpartum period, often manifesting as weight gain, right upper quadrant pain, edema, and hypertension.

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General Considerations

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Various hepatic conditions may occur in pregnancy, and the interpretation of common liver biochemical tests in women who are pregnant can sometimes be challenging. Among the specific conditions unique to pregnancy that may manifest with altered liver tests are HG, ICP, AFLP, preeclampsia/eclampsia, and HELLP syndrome. Other common hepatic conditions, such as viral hepatitis and cirrhosis, are not unique to but can manifest during pregnancy.

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Guntupalli  SR, Steingrub  J. Hepatic disease and pregnancy: an overview of diagnosis and management. Crit Care Med. 2005;33:S332–S339.
[PubMed: 16215356]  
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Hay  JE. Liver disease in pregnancy. Hepatology. 2008;47:1067–1076.
[PubMed: 18265410]  

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INTERPRETATION OF LIVER BIOCHEMICAL TESTS DURING PREGNANCY

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The pregnant state is accompanied by a 30–50% increase in blood volume. As a result, several biochemical values are reduced during pregnancy. These include serum albumin, total protein, and bilirubin (Table 8–1).

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Table Graphic Jump Location
Table 8–1.Liver biochemical test findings in pregnancy.
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The most significant change is noted during the second trimester. The serum alkaline phosphatase level is elevated because of the presence of placental-derived alkaline phosphatase. The biliary-derived alkaline phosphatase remains within the normal range as illustrated by normal levels of γ-glutamyl transpeptidase (GGT) and 5′-nucleotidase (5′ NT). Serum cholesterol also increases to approximately twice its prepregnancy level. Lastly, the hepatic markers of inflammation, alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are unchanged.

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Pathologic conditions that result in abnormal biochemical tests during pregnancy tend to be divided into three broad categories: (1) those that lead to a mild increase in transaminases, (2) those that lead to ...

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