Pregnancy-related liver disease

Reproductive health and liver disease:

Useful patient-friendly article here from the American 2021 AASLD guidance:

https://journals.lww.com/cld/Fulltext/2023/01000/Reproductive_health_and_liver_disease__a.5.aspx

There are 4 main liver problems associated with pregnancy

Intrahepatic Cholestasis of Pregnancy (ICP)

What is ICP?

ICP is a condition that affect the flow of bile through the liver, it occurs in around 1 in 140 pregnancies (0.7%). Bile is a liquid made by the liver and stored in the gallbladder. It works by digesting fats and absorbing essential vitamins.

What causes ICP?

It is poorly understood. Some people are predisposed to developing ICP because of their genes and so it may be more common in their families. Individuals of Indian, Pakistani and Scandinavian background have higher rates.

Another factor leading to ICP relates to increased levels of progesterone or oestrogen during pregnancy. These hormones may slow the flow of bile from the liver.

What are the symptoms of ICP?

• Itching is a major symptom of ICP; the itch can occur all over the body including the soles of the feet and the face. It is often worse at night and disrupts sleep. Some itching can be a part of normal pregnancy and not related to ICP.

• Generally feeling unwell

• Jaundice/ yellowing of the skin, especially the eyes; about 1 in 10 women with ICP will experience this.

How is ICP diagnosed?

• It is important to talk to your doctor if you are concerned or have symptoms. They will need to know about your medical history and if any other women in your family have experienced ICP.

• Your symptoms may be explained by other skin conditions, an allergy or may be a part of normal pregnancy.

• Liver blood tests and bile acid levels in your blood can help to make the diagnosis, and may need to be tested on more than one occasion if ICP is suspected.

• Most commonly the liver enzyme ALT and bile salt levels will be raised.

• A diagnosis of ICP is only fully confirmed after you have delivered your baby and your blood tests have returned to normal.

What is the treatment?

• Treatments aim to manage symptoms and keep mother and baby safe.

• Soothing lotions and certain medications are safe to use and often help with symptoms.

• The most commonly used treatment in ICP is a drug called ursodeoxycholic acid (also known as urso, UDCA)

• ICP will likely persist for the remainder of the pregnancy.

• You will be closely monitored and an early delivery may be advised.

2. Acute Fatty Liver disease of pregnancy (AFLDP)

What is AFLDP?

AFLDP is a rare but severe liver disease that some women can develop in the final 3 months of pregnancy. It occurs in 1 in 20,000 pregnancies. It is more common in first pregnancies and in women carrying male babies or twins.

Why do some women get it?

This is not fully understood. Mothers carrying babies who have a metabolic deficiency may be predisposed. Such babies are unable to metabolise certain fats which can build up suddenly in the mothers liver. AFLDP may also be a variation of pre-eclampsia, which is high blood pressure and protein in the urine in the late stages of pregnancy.

What are the symptoms?

Symptoms are often non-specific which can make early diagnosis difficult. Symptoms include:
Abdominal pain
Excessive thirst
Jaundice
Nausea, vomiting
Fatigue
Confusion

• If your symptoms are very severe you should attend the emergency department immediately. AFLDP is a very serious condition that may be life threatening to mother and baby.

How is AFLDP treated?

If you are diagnosed with AFLDP you will likely need to be admitted to hospital urgently for monitoring. You may be advised to deliver baby early or by Caesarean section.

Most likely your liver will return to normal after delivery and there will be no long term damage, however this may take time and you may feel unwell for a prolonged period. In rare cases you may develop pancreatitis or a serious infection. If the liver does not recover a liver transplant may be advised.

Will it recur in future pregnancies?

AFLDP may recur in future pregnancies. How likely this is remains unclear due to how infrequently we see this condition. However it is important if you or a member of your family has had AFLDP that you make your doctor aware of this and discuss it with them when planning future pregnancy.

3. HELLP syndrome

What is HELLP syndrome?

HELLP stands for

H: Hemolysis, meaning the breaking down of red blood cells

EL: Elevated Liver enzymes

LP: Low Platelets, which are a part of your blood that helps stop bleeding.

HELLP is a rare condition that occurs in the later stages of pregnancy and up to a week after delivery. It is considered a type of pre eclampsia. It causes elevated liver enzymes, low platelets and the breakdown of red blood cells.

What are the symptoms of HELLP?

Symptoms can be similar to pre-eclampsia and involve headaches, blurred vision and leg swelling or they may be more specific and involve abdominal pain, bleeding or excessive bruising.

What are the treatments for HELLP?

• Treatments are supportive and aim to guide mother and baby through to a safe delivery. Treatments may include blood transfusions and steroids.

• Delivery is the only cure for HELLP syndrome. Early delivery may be advised.

Is HELLP a serious condition?

HELLP can be a life threatening condition for both mother and baby. Complications include blood clotting, bleeding, kidney failure, pulmonary oedema (water in the lungs) and placental abruption (the placenta separates from the womb).

Will it recur in future pregnancies?

For the majority of women symptoms will completely resolve after delivery with no long term complications, however if you have previously had HELLP you are at increased risk of developing it again in future pregnancies. It is important to discuss this with your doctor when planning future pregnancies.

4. Hyperemesis Gravidarum (HG)

What is HG?

Nausea and vomiting commonly occurs in early pregnancy. If these symptoms become severe and unrelenting they may lead to dehydration and weight loss. This is then considered HG. It affects between 0.3%–3.6% of pregnancies. Abnormal liver function tests are seen in 50% of cases and in rare cases jaundice (yellowing of the skin) can occur. It is a diagnosis of exclusion which means other causes of nausea, vomiting and abnormal liver tests will be ruled out first.

How is it treated?

Management involves anti-nausea medications and nutritional supplements. In severe cases the pregnant woman may be admitted to hospital for intravenous fluids and nutritional replacement. In most pregnancies symptoms have resolved by week 20.