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  • Most liver biochemical tests are unchanged during pregnancy.
  • Exceptions are albumin, total protein, and bilirubin (decreased) and alkaline phosphatase and cholesterol (increased).
  • Several conditions unique to pregnancy may lead to hepatic impairment:
    • Hyperemesis gravidarum, often in the first trimester, invariably before the 20th week of pregnancy.
    • Intrahepatic cholestasis of pregnancy (IHCP), often in the third trimester (pruritus and mild liver tests abnormalities).
    • Acute fatty liver disease of pregnancy (AFLP) in the third trimester (nausea and vomiting, jaundice, and oliguria; typically mild increase in transaminases, hyperbilirubinemia, coagulopathy, thrombocytopenia, 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 with right upper quadrant pain, edema, and hypertension.

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 hyperemesis gravidarum, IHCP, 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.

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

Table 8–1. Liver Biochemical Test Findings in Pregnancy.

The pregnant state is accompanied by a 30–50% increase in blood volume. As a result, several biochemical tests have reduced values during pregnancy. These include albumin, total protein, and bilirubin.

The most significant change is noted during the second trimester. The alkaline phosphatase level is elevated because of the presence of placental-derived alkaline phosphatase. The biliary-derived alkaline phosphatase stays within the normal range as illustrated by normal levels of γ-glutamyl transpeptidase (GGT) and 5′-nucleotidase (5′ NT). Cholesterol also increases to approximately twice its prepregnancy level. Lastly, the hepatic markers of inflammation, alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are unchanged.

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 marked increase in transaminases, and (3) those that result in predominantly cholestatic biochemical abnormalities. Conditions that lead to mild increase in transaminases include AFLP, preeclampsia, eclampsia, HELLP syndrome, Budd-Chiari syndrome, IHCP, ...

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