Pregnancy-related liver disorders

Abstract

Pregnancy-related liver disorders accounted for 8% of all maternal deaths at our center from 1999 to 2011. Of the three pregnancy-related liver disorders (acute fatty liver of pregnancy (AFLP), HELLP (Hemolysis, elevated liver enzymes, low platelets) syndrome and pre-eclamptic liver dysfunction, which can lead to adverse maternal and fetal outcome, AFLP is most typically under - diagnosed. Risk of maternal death can be minimised by timely recognition and early/aggressive multi-specialty management of these conditions. Urgent termination of pregnancy remains the cornerstone of therapy for some of these life threatening disorders, but recent advancements in our understanding help us in better overall management of these patients. This review focuses on various aspects of pregnancy-related liver disorders.

Keywords: AFLP, acute fatty liver of pregnancy; CS, Caesarean; FAO, fatty acid oxidation; HELLP syndrome; HELLP, hemolysis elevated liver enzymes and low platelets; HG, hyperemesis gravidarum; HbsAg, hepatitis B surface antigen; ICP, intrahepatic cholestasis of pregnancy; LCHAD, long chain hydroxyacyl coA dehydrogenase; LDH, lactate dehydrogenase; LFT, liver function tests; MP, malarial parasite; MTP, mitochondrial tri-functional protein; PFIC, progressive familial intra-hepatic cholestasis; PRLD, pregnancy-related liver disorders; PT, prothrombin time; UDCA, ursodeoxycholic acid; acute fatty liver of pregnancy; maternal mortality; pre-eclampsia.

Figure 1

Contribution of pregnancy-related liver disorders to the maternal mortality at Christian Medical College, Vellore between 1999 and 2011.

Figure 2

Role of placenta in the pathogenesis of acute fatty liver of pregnancy. (adapted from ref. 21); FA : Fatty acids.

Figure 3

Contribution of AFLP and other pregnancy-related liver disorders (PRLD) to maternal mortality over 13 years at Christian Medical College, Vellore; PRLD: Pregnancy-related liver disorders.

Figure 4

Management protocol for pregnancy related liver disorders complicating late pregnancy (late 2nd, and 3rd trimesters) in labour room. *Reports of other hepatitis viral serology may not be available immediately, **patient to be shifted to Intensive care unit after delivery for monitoring and management. LFT: liver function tests; PT: prothrombin time; MP: malarial parasite, HBsAg: hepatitis B surface antigen; LDH: lactate dehydrogenase; HELLP: hemolysis, elevated liver enzymes, low platelets; AFLP: acute fatty liver of pregnancy; CS: Caesarean section.