liver Disease and Asthma in Pregnency

Liver Disease in Pregnency: د. نادية مضر الحلي

liver diseases complicating pregnancy are divided into three 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. 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.

Hepatic Physiology in Pregnancy
Pregnancy may induce appreciable changes in some clinical and laboratory manifestations related to the liver. Findings such as elevated serum alkaline phosphatase, palmar erythema, and spider angiomas, which might suggest liver disease, are commonly found during normal pregnancy. However, histological liver findings with uncomplicated pregnancies are unchanged compared with those of nonpregnant subjects


Obstetric Cholestasis:
This liver disease is specific to pregnancy, characterized by pruritus affecting the whole body but particularly the palms & soles, & abnormal liver function tests.
Aetiology is unknown but relate to genetic predisposition (one third of patients have positive family history) to the cholestatic effect of estrogen.
It is most commonly present in the third trimester (30-32 weeks). Women with pruritus but without rash other than excoriation should have liver function test. Hepatic transaminases are only mildly elevated. Bile acids may be elevated. There may be associated dark urine, pale stool, steatorrhea & malaise.
Obstetric cholestasis is a diagnosis of exclusion & differential diagnosis include extrahepatic obstruction with gall stones, acute & chronic viral hepatitis, primary biliary cirrhosis & chronic active hepatitis.
Investigations should therefore include liver ultrasound, serology for hepatitis A, B, C, Ebstien-Bar virus & cytomegalovirus, & liver autoantibodies (anti- mitochondrial antibodies, & anti-smooth muscle antibody).
The risks with obstetric cholestasis include postpartum haemorrhage (related to vitamin K deficiency secondary to malabsorption of fat), premature labour, meconium-stained liquor, fetal distress in labour & rarely intra-uterine death.



Management:
should involve counselling the woman regarding the above risks. LFT & clotting time should be monitored regularly. In the absence of premature labour, delivery should be induced at 37-38 weeks. Vitamin K should be given to the mother (10 mg orally daily) from the time of diagnosis to reduce the risk of postpartum haemorrhage. Fetal surveillance with CTG & ultrasound.
Control of symptoms may be achieved with a combination of antihistamines & emollients or, if no response ursodeoxycholic acid will induce a rapid reduction in liver function test & pruritus but not the fetal risk.
Following delivery, LFT returns to normal. Symptoms may recur with menstruation (cyclical itching) or with estrogen containing oral contraceptives which should be avoided. Recurrence in subsequent pregnancy is very high.