Liver disease in pregnancy

Acute liver failure

Acute liver failure is a rare disorder with high mortality and resource cost. In the developing world, viral causes predominate, with hepatitis E infection recognised as a common cause in many countries. In the USA and much of western Europe, the incidence of virally induced disease has declined substantially in the past few years, with most cases now arising from drug-induced liver injury, often from paracetamol. However, a large proportion of cases are of unknown origin. Acute liver failure can be associated with rapidly progressive multiorgan failure and devastating complications; however, outcomes have been improved by use of emergency liver transplantation. An evidence base for practice is emerging for supportive care, and a better understanding of the pathophysiology of the disorder, especially in relation to hepatic encephalopathy, will probably soon lead to further improvements in survival rates.

Diagnosis and treatment of hypertensive disorders during pregnancy

Pregnancy is a cardiovascular and metabolic challenge to the human female body. This review summarizes current knowledge on the regulation of blood pressure and plasma volume in normal and hypertensive pregnant women. During pregnancy, systemic vascular resistance and blood pressure decrease, whereas cardiac output and blood volume increase to safeguard an adequate circulation in the utero-placental arterial bed. Hypertension affects 10% of all pregnancies and is accompanied by an increase in foetal and maternal morbidity and mortality. Hypertension in pregnancy includes a wide spectrum of conditions, including pre-eclampsia and eclampsia, pre-eclampsia superimposed on chronic hypertension, chronic hypertension, and gestational hypertension. Endothelial dysfunction, oxidative stress and an exaggerated inflammatory response are features related to hypertensive disorders. Microangiopathic disorders can easily mimic hypertensive disorders during pregnancy. Although they have some symptoms in common, they require another type of management. To reduce the risk of maternal and foetal complications due to haemodynamic maladaptations, the current management includes rest at home or in the hospital, close monitoring of maternal and foetal signs and symptoms, early start of antihypertensive therapy, and timely delivery regarding maternal and foetal survival chances. Thresholds to initiate blood pressure lowering treatment during pregnancy are 160 mmHg systole or 110 mmHg diastole. Below these thresholds, treatment must be individualized because current evidence does not support aggressive medical interventions. Alpha-methyldopa and dihydropyridinic calcium channel blockers are among the recommended antihypertensives.