Disorders of the liver, gallbladder, and pancreas together constitute a formidable list of complications that may arise in pregnancy. Some stem from preexisting conditions, and some are unique to gestation. The relationships of several of these with pregnancy can be intriguing and challenging.
Liver diseases complicating pregnancy are placed into three general categories. The first includes those specific to pregnancy and resolve either spontaneously or following delivery. Hyperemesis gravidarum, intrahepatic cholestasis, acute fatty liver, and HELLP syndrome—which is characterized by hemolysis, elevated liver enzyme levels, and low platelet counts, are examples. The second category involves acute hepatic disorders that are coincidental to pregnancy, such as acute viral hepatitis. Last are chronic liver diseases that predate pregnancy, such as chronic viral or autoimmune hepatitis, cirrhosis, or esophageal varices.
Laboratory testing can aid differentiation of these disorders. Hepatic dysfunction from hyperemesis gravidarum may manifest as mildly elevated serum bilirubin and transaminase levels (Chap. 57, p. 1014). Others listed in Table 58-1 can show more marked findings. One example, severe preeclampsia syndrome, discussed in Chapter 40 (p. 689), can be further complicated by the HELLP syndrome, which can rarely cause liver failure (Casey, 2020).
TABLE 58-1Clinical Findings with Liver Diseases in Pregnancy ||Download (.pdf) TABLE 58-1Clinical Findings with Liver Diseases in Pregnancy
|Diagnosis ||Onset ||Symptoms ||AST (U/L) ||Bili (mg%) ||Cr (mg%) ||Hematological ||Comments |
|Hyperemesis gravidarum ||Early ||N&V ||<300 ||1–4 ||NL or elevated (prerenal) ||NL ||Common, infant vitamin K deficiency, Wernicke encephalopathy, Boerhaave syndrome |
|ICP ||Late ||Pruritus ± jaundice ||<200 ||1–5 ||NL ||NL ||Common (0.5–2%), bile acids (>10 μmol/L), normal hepatic function |
|AFLP ||Late ||N&V (70%), HTN/preeclampsia, RUQ pain ||145–565 ||2–8 ||>0.9 ||Thrombocytopenia, coagulopathy ± DIC, nucleated red cells, hemolysis, echinocytosis ||Low glucose, cholesterol <220 mg/dL, fibrinogen <300 mg/dL |
|HELLP ||Late ||Preeclampsia, RUQ pain ||75–250 (initial) ||1–2 ||<1.0 ||Thrombocytopenia, mild hemolysis ||Common (7–10% of preeclampsia), normal hepatic function |
|Hepatitis || || || || || || || |
| Viral ||Variable, chronic, episodic ||Jaundice, RUQ pain, fatigue ||400–5000 ||20 ||NL ||Coagulopathy if cirrhotic, thrombocytopenia ||Common (1–3%), serological tests for hepatitis A, B, C, E |
|Autoimmune ||Variable, chronic, episodic ||Jaundice, RUQ pain, fatigue ||100–1000 ||3–10 ||NL ||Coagulopathy if cirrhotic, thrombocytopenia ||Uncommon, ANA+, anti-LKM1, anti–smooth muscle |
|NAFLD ||Variable, chronic, episodic ||Obese, diabetes, ± RUQ pain ||NL to slightly elevated ||NL ||NL ||NL ||Common (6–8%), sonographic findings, MR imaging/CT findings, ± metabolic syndrome, NASH, cirrhosis |