Liver disease in pregnancy

The Impact of the Association Between Nonalcoholic Fatty Liver Disease and Intrahepatic Cholestasis of Pregnancy on Maternal and Fetal Outcomes

Backgroundː Intrahepatic cholestasis of pregnancy (ICP), a hepatic condition that causes severe itching in late pregnancy, is linked to nonalcoholic fatty liver disease (NAFLD) due to disrupted bile acid balance. It poses maternal risks such as preterm labor and gestational diabetes and fetal risks such as preterm birth and respiratory distress. The study examined NAFLD's impact on ICP in pregnant women, highlighting management and research implications. Methodsː This retrospective study examined pregnant women (≥18 years) with ICP, assessing fatty liver with follow-up ultrasounds. Participants were divided into ICP only and ICP with fatty liver (FL) groups, excluding heavy alcohol users and incomplete data. Maternal age, medical history, and comorbidities were evaluated alongside abdominal ultrasounds to identify FL. Resultsː In this study of 43 pregnant women, the mean maternal age was 27 years. Patients with ICP and FL had significantly higher bile acid levels than those with ICP alone. However, no significant differences were found between the two groups regarding the history of gestational diabetes mellitus (GDM), dyslipidemia, polycystic ovarian syndrome (PCOS), parity, and hypothyroidism. Among women with ICP and FL, 51.85% underwent lower segment cesarean section (LSCS), while 43.75% with ICP without FL underwent LSCS. Conclusionsː ICP with FL did not show significant adverse effects on maternal and neonatal outcomes, including mode of delivery, gestational age, maternal complications, neonatal intensive care unit (NICU) admissions, and low birth weight (LBW) with asphyxia. However, additional research is required to fully comprehend the relationship between ICP, NAFLD, and their impact on pregnancy outcomes.

First-Trimester Screening for HELLP Syndrome—Prediction Model Based on MicroRNA Biomarkers and Maternal Clinical Characteristics

We evaluated the potential of cardiovascular-disease-associated microRNAs for early prediction of HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Gene expression profiling of 29 microRNAs was performed on whole peripheral venous blood samples collected between 10 and 13 weeks of gestation using real-time RT-PCR. The retrospective study involved singleton pregnancies of Caucasian descent only diagnosed with HELLP syndrome (n = 14) and 80 normal-term pregnancies. Upregulation of six microRNAs (miR-1-3p, miR-17-5p, miR-143-3p, miR-146a-5p, miR-181a-5p, and miR-499a-5p) was observed in pregnancies destined to develop HELLP syndrome. The combination of all six microRNAs showed a relatively high accuracy for the early identification of pregnancies destined to develop HELLP syndrome (AUC 0.903, p < 0.001, 78.57% sensitivity, 93.75% specificity, cut-off > 0.1622). It revealed 78.57% of HELLP pregnancies at a 10.0% false-positive rate (FPR). The predictive model for HELLP syndrome based on whole peripheral venous blood microRNA biomarkers was further extended to maternal clinical characteristics, most of which were identified as risk factors for the development of HELLP syndrome (maternal age and BMI values at early stages of gestation, the presence of any kind of autoimmune disease, the necessity to undergo an infertility treatment by assisted reproductive technology, a history of HELLP syndrome and/or pre-eclampsia in a previous gestation, and the presence of trombophilic gene mutations). Then, 85.71% of cases were identified at a 10.0% FPR. When another clinical variable (the positivity of the first-trimester screening for pre-eclampsia and/or fetal growth restriction by the Fetal Medicine Foundation algorithm) was implemented in the HELLP prediction model, the predictive power was increased further to 92.86% at a 10.0% FPR. The model based on the combination of selected cardiovascular-disease-associated microRNAs and maternal clinical characteristics has a very high predictive potential for HELLP syndrome and may be implemented in routine first-trimester screening programs.

Ruptured Subcapsular Liver Hematoma: A Rare Complication of HELLP Syndrome

Subcapsular liver hematoma (SLH) is a rare complication of HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. We report a previously healthy 16-year-old female presenting with pre-eclampsia requiring emergent C-section, who developed immediate postoperative bleeding and abdominal distention. Abdominal computed tomography angiography (CTA) revealed a large encapsulated liver hematoma with active extravasation. The patient was successfully treated with a multidisciplinary approach with medical and surgical management.

Acute liver failure in pregnancy: Challenges and management

Acute liver failure (ALF) in pregnancy negatively affects both maternal and foetal outcome. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver functions leading to significant morbidity and even mortality. In this comprehensive review, we searched articles published as review articles, clinical trials, and case series in the Medline from 1970 to 2012. The overall outcome of ALF in pregnancy depends on the aetiology, timely diagnosis, prompt management, and early referral to a centre equipped in managing medical or obstetric complication. The foetal outcome is affected by the stage of pregnancy in which the mother has a deterioration of the liver function, with a worst prognosis associated with first or second-trimester liver failure. When ALF complicates pregnancy, liver transplantation is the one of the viable options. Management protocols need to be individualised for each case keeping in mind the risk versus benefit to both the mother and the foetus.

Management of adults with paediatric-onset chronic liver disease: strategic issues for transition care

Advances in the management of children with chronic liver disease have enabled many to survive into adulthood with or without their native livers, so that the most common of these conditions are becoming increasingly common in adult hepatology practice. Because the aetiologies of chronic liver disease in children may vary significantly from those in adulthood, adults with paediatric-onset chronic liver disease may often present with clinical manifestations unfamiliar to their adulthood physician. Transition of medical care to adult practice requires that the adulthood medical staff (primary physicians and subspecialists) have a comprehensive knowledge of childhood liver disease and their implications, and of the differences in caring for these patients. Pending still unavailable Scientific Society guidelines, this article examines causes, presentation modes, evaluation, management, and complications of the main paediatric-onset chronic liver diseases, and discusses key issues to aid in planning a program of transition from paediatric to adult patients.

Antenatal detection of abnormal liver function tests - a marker for poor perinatal outcome

The purpose of this study was to examine (a) the incidence of liver disease diagnosed in our antenatal population, (b) the diagnostic value of initial symptoms and liver function tests (LFTs), (c) the adequacy of investigation and management of the liver disorder and (d) the obstetric and neonatal outcome in this group of patients. Women with abnormal LFTs that delivered at our hospital over a 2-year period were identified from computerised hospital records and data was obtained from chart review. Forty-six out of a total of 13 181 (0.35%) women had liver disease diagnosed in pregnancy: Diagnoses included intrahepatic cholestasis of pregnancy (13), pre-eclampsia and the HELLP syndrome (eight), acute fatty liver of pregnancy (three), hyperemesis gravidarum (one), hepatitis C (13), B (four) and hepatitis A (one), cholelithiasis (two) and hepatitis of unknown aetiology (one). Symptoms at presentation were more predictive of the final diagnosis than the initial LFT profile. Investigation of the liver disorder was incomplete in 50% of cases. One mother required intensive care for 6 weeks postpartum and three others had significant postpartum haemorrhage. There was one neonatal death and 24 neonates were admitted to the special care baby unit. Eighteen women attended for their postnatal check up at 6 weeks. Eight of these women were referred to a hepatologist. Detection of liver disease in pregnancy identifies a group at risk of poor neonatal and maternal outcome. Structured guidelines should be implemented in obstetric units to facilitate appropriate investigation, treatment and referral patterns for these women.

Disseminated intravascular coagulation complicating HELLP syndrome: perioperative management

HELLP syndrome may lead to disseminated intravascular coagulation (DIC) which can make emergency surgery a serious challenge. A 29-year-old female presented with haematuria, epistaxis and hypertension in the emergency ward and a diagnosis of DIC complicating HELLP in preeclampsia was made. She had continuous epistaxis and elective tracheal intubation was carried out. During emergency caesarean section the patient was managed with blood products, antihypertensive drugs and general anaesthesia together with invasive monitoring. She required postoperative ventilatory support. HELLP syndrome may progress to DIC in 15-38% of patients. The prothrombin time, activated partial thromboplastin time and serum fibrinogen levels are normal in HELLP syndrome but are prolonged in DIC. Evaluation of more sensitive markers of DIC, such as antithrombin III, α-2 antiplasmin, plasminogens, fibrin monomer and D-dimers, differentiates DIC from HELLP syndrome. Aggressive treatment is indicated and delivery should be expedited, by caesarean section if necessary although vaginal delivery is not contraindicated, along with control of blood pressure and coagulation abnormality. We conclude that patients with DIC complicating HELLP syndrome and preeclampsia require great vigilance and multimodal management in the perioperative period for uneventful outcome.

Pregnancy-associated liver disorders

Liver disorders associated with pregnancy include hyperemesis gravidarum (HG), intrahepatic cholestasis of pregnancy (ICP), preeclampsia, syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP), and acute fatty liver of pregnancy (AFLP). These conditions are relatively common and unique to pregnancy and are more likely to occur at certain terms of gestation specific to each condition. They can be associated with significant maternal and fetal morbidity and mortality. Although managing such patients may be very challenging, spontaneous resolution of the disease occurs shortly after termination of the pregnancy, usually without hepatic sequellae. Early diagnosis and timely treatment is a key to therapeutic success. This article explores the clinical features, pathophysiology, and management of these disorders.

Hepatic disorders severely affected by pregnancy: medical and obstetric management

Hepatic disorders severely affected by pregnancy include choledochal cysts that can be compressed by the gravid uterus and potentially rupture; hepatic adenomas that exhibit accelerated growth because of hyperestrogenemia during pregnancy; acute intermittent porphyria that is exacerbated by increased female sex hormones during pregnancy; splenic artery aneurysms that can rupture during pregnancy because of compression by the gravid uterus; Budd-Chiari syndrome that is promoted by hyperestrogenemia; and hepatitis E and herpes simplex hepatitis that are particularly severe during pregnancy. Hepatic disorders unique to pregnancy include intrahepatic cholestasis of pregnancy; acute fatty liver of pregnancy; preeclampsia and eclampsia; and hemolysis, elevated liver function tests, and low platelet count (HELLP) syndrome. Most disorders uniquely related to pregnancy are treated by prompt fetal delivery as soon as the fetus is sufficiently mature.

Hepatic disorders mildly to moderately affected by pregnancy: medical and obstetric management

Hepatic, biliary, and pancreatic disorders are often complex and clinically challenging during pregnancy. Hepatic disorders can affect the pregnancy and vice versa. The differential diagnosis of hepatic diseases is particularly broad during pregnancy because it includes disorders related to, and unrelated to, pregnancy. This article discusses the physiologic effects of pregnancy on liver function; the differential diagnosis of hepatic findings during pregnancy; modifications of abdominal imaging and hepatobiliary endoscopic procedures during pregnancy; and the medical and obstetric management of hepatic, biliary, and pancreatic diseases that are mildly to moderately affected by pregnancy.

Stéatose hépatique aiguë gravidique. À propos de 22 cas

OBJECTIVE

To report the clinical experience, biochemical findings, complications and maternal outcome in patients with acute fatty liver of pregnancy (AFLP).

PATIENTS AND METHODS

Retrospective study over a period of 11 years (1993-2003). The diagnosis of AFLP was confirmed by liver biopsy in 15 women. However, in 7 women a medical committee that took into account clinical symptoms, and laboratory findings assessed the diagnosis.

RESULTS

Were included in this study, 22 women with a mean age of 30+/-5.4 years. Only 22.7% of cases were primigravid. The mean gestational age was 36+/-2.76 weeks (range 31-41 weeks). The fetus was a male infant in 75% of cases. Ten women were admitted in the hospital without jaundice. However 15 women had developed an icterus since their hospital admission or during ICU stay. The mean SAPS II on the ICU admission was of 24.86+/-11.2 points. Biological disturbances observed were mainly: liver cytolysis in 91% of cases, a trend to hypoglycaemia in 86%, a hypoprotidemia in 66.7% and CIVD in 32%. During their ICU stay, 19 women (86.4%) developed one or several organ failures associated to the hepatic failure and 18 women required blood transfusion. After an average stay of 7.5 days, evolution was marked by the death of seven patients (31.8%). Factors correlated with a poor prognosis were: the delay of medical consultation, the development of jaundice, the development of encephalopathy, respiratory or a circulatory failure.

DISCUSSION AND CONCLUSION

AFLP is a rare but life-threatening complication. Furthermore AFLP shares features with other more common and less perilous illnesses. An early diagnosis and appropriate therapy of this pathology should improve the poor prognosis in our country.

Neurologic disorders in pregnancy

BACKGROUND

Neurologic dysfunction, coma, and seizures are common in obstetric patients in the intensive care unit.

OBJECTIVE

To review common neurologic disorders resulting in critical illness in pregnancy.

REVIEW

Obstetric disorders causing coma and seizures include eclampsia, acute fatty liver of pregnancy, and amniotic fluid embolism. Preexisting disorders such as epilepsy may worsen in one-third of pregnant patients, and seizures are common during labor. Changes in hemodynamics, blood volume, and hormonal effects on the vessel wall increase risk of bleeding from berry aneurysms and arteriovenous malformations during pregnancy and the postpartum period. Acute intermittent porphyria produces seizures and hypertension, closely mimicking eclampsia. Cerebral venous sinus thrombosis is common in postpartum patients, especially in developing countries. Brain tumors invariably enlarge during pregnancy because of fluid retention and the presence of estrogen and progesterone receptors on tumor cells. Infections such as cerebral malaria and acute viral hepatitis with fulminant hepatic failure are common causes of coma and seizures during pregnancy in tropical regions of Asia, Africa, and Latin America. Patients may be admitted to the intensive care unit with type II respiratory failure due to myasthenic crisis, Guillain-Barre syndrome and spinal cord disease. Relapses of multiple sclerosis are infrequent during pregnancy but increase in the postpartum period.

CONCLUSIONS

In all instances, the effects of the disorders, diagnostic tests, and treatment on the fetus must be carefully weighed. Prompt delivery may be lifesaving for mother and fetus in conditions such as eclampsia and acute fatty liver of pregnancy; expectant treatment may be more appropriate in others.

Hyperemesis gravidarum, a literature review

Hyperemesis gravidarum (HG) is a condition causing severe nausea and vomiting in early pregnancy often resulting in hospital admission. The incidence of HG is approximately 0.5% of live births, said to be higher in multiple pregnancies, hydatidiform mole and other conditions associated with increased pregnancy hormone levels. Both the aetiology and pathogenesis of HG remain unknown. We conducted a literature review (1966-now) to summarize the current evidence on the aetiology and pathogenesis of HG. The potential role of pregnancy-related hormones such as progesterone, estrogen and HCG has been widely studied; however, various other hormones such as leptin, placental growth hormone, prolactin, thyroid and adrenal cortical hormones have been implicated in the aetiology of HG. In addition to endocrinological hypotheses, the rationale and evidence considering infectious, immunological, psychological, metabolic and anatomical causes for HG have been analysed here. Many studies suffer from the low number of patients included, the variable definition used for HG and varying assay methodology used in studies of hormone measurement. This review highlights the need for more extensive studies addressing the pathogenesis and aetiology of HG.

Cholestasis of pregnancy: a review of the evidence

Intrahepatic cholestasis of pregnancy is a rare disorder, predominately occurring during the third trimester of pregnancy and characterized by pruritus, jaundice, and biochemical disturbances in liver enzymes. While intrahepatic cholestasis of pregnancy poses little maternal risk, there is significant risk to the fetus such as preterm delivery, non-reassuring fetal status, meconium staining, and perinatal mortality. Current evidence proposes susceptibility to derangements in the sulfation of steroid compounds, affecting the metabolism of progesterone and bile acids in the fetal/placental compartment. Treatment with ursodeoxycholic acid is suggested, coupled with close maternal-fetal surveillance and delivery as close to term as possible.

The role of plasma exchange in HELLP syndrome

Plasma exchange therapy has been successfully used in selected patients with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome who have organ failure or refractory to treatment. There is no prospective study regarding plasma exchange and its effect in HELLP syndrome. The aim of this study was to investigate the effects of early postpartum use of plasma exchange in patients with HELLP syndrome on outcomes. The mortality rate and the recovery times were compared in patients with HELLP syndrome treated with plasma exchange and historic control group of patients treated conservatively. During a 3-year period (between April 2000 and December 2003), 29 consecutive patients with HELLP syndrome were treated with single or multiple plasma exchange by using fresh-frozen plasma at post-partum period. The control group consist of 26 patients with HELLP syndrome treated between 1993 and 1999. Maternal mortality rate was 23.1% in the control group; there was no death in plasma exchange group; and the mortality rate was significantly higher in the control group (p=0.006). The length of stay at the intensive care unit was shorter in the plasma exchange group (p<0.0001). Rapid improvement of the platelet, aspartate aminotransferase, alanine aminotransferase, and lactic dehydrogenase levels were observed in the plasma exchange group. This study showed that postpartum early plasma exchange therapy improves treatment outcomes in patients with severe HELLP syndrome.

Liver emergencies during pregnancy

Liver disease is an uncommon complication of pregnancy, although one that must be recognized early because of its potential for grave consequences for mother and child. Because of increased awareness and rapid triage of patients, maternal and fetal outcomes have improved significantly over the last 30 years.

Midtrimester triple test levels in women with severe preeclampsia and HELLP syndrome

BACKGROUND

The levels of midtrimester triple test constituents are known to be altered in hypertensive disorders of pregnancy.

OBJECTIVE

Our aim was to determine whether midtrimester triple test constituent levels differ in women with severe preeclampsia and those who also develop HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome.

METHODS

A retrospective chart analysis of 106 women with severe preeclampsia for whom midtrimester triple test data were available was made. None of these patients had fetuses with abnormal karyotype, nor did they deliver infants with malformations. The levels of midtrimester maternal serum alpha-fetoprotein (MSAFP), human chorionic gonadotropin (MShCG) and unconjugated estriol (MSuE3) of 74 patients with severe preeclampsia were compared with those of 32 patients who also developed HELLP syndrome.

RESULTS

The mean MShCG was significantly higher and the mean MSuE3 was significantly lower in patients with HELLP syndrome than in those with only severe preeclampsia [1.78 multiple of the medians (MoM), standard error (SE) 0.18 vs. 1.27 MoM, SE 0.07, p=0.015 and 0.86 MoM, SE 0.05 vs. 1.04 MoM, SE 0.07; p = 0.03, respectively]. The two groups did not differ significantly with regard to MSAFP levels.

CONCLUSION

Unexplained high levels of midtrimester MShCG and low levels of MSuE3 may be associated with the development of HELLP syndrome in women with severe preeclampsia.

Results of the pregnancies with HELLP syndrome

In this study, clinical features, developing complications, and results of thirty-six patients, which were followed up in our Obstetrics and Gynecology and Nephrology departments between 1997 and 2001, with the diagnosis of HELLP syndrome were searched retrospectively. The mean age of the cases followed up with diagnosis of HELLP syndrome were 30.2 +/- 5.9 (17-46) years. HELLP syndrome was diagnosed on average in the 32.6 +/- 4.8th (23-41) week of gestations. Seventy percent of the cases were with severe preeclampsia and 30% of the cases were with mild preeclampsia. Eleven cases (30%) were nullipara and twenty-five cases (70%) multipara. The average of arterial systolic blood pressure of the cases were 161.6 +/- 26 mmHg, and that of diastolic blood pressure was 98.5 +/- 16.8 mmHg. In thirteen cases (36%) acute renal failure (ARF), six cases (17%) placenta detachment, two cases disseminate intravascular coagulation (DIC), one case Adult Respiratory Distress Syndrome (ARDS) were developed. In seven cases (19%) intrauterine dead fetuses were detected. In twenty-three cases by cesarian section (64%), in thirteen cases by induction (36%) the pregnancies were terminated in 72 h after diagnosing HELLP syndrome. Birth weights of eleven babies (30%) were below 1500 g. Five of the eleven babies were dead in the neonatal period. Six of the thirteen patients who had ARF were given hemodialysis. Two patients died because of the development of ARF + DIC and ARDS. No predicting factors for the development of HELLP syndrome could be detected, but severe preeclampsia. Therefore we think that preeclamptic pregnancies must be followed up very closely and if HELLP syndrome develops, termination of the pregnancy would be proper as soon as possible.

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.

Liver and kidney diseases

The spectrum of renal disease in patients with liver disease is expanding. The recognition of renal complications of liver diseases is essential in the management of these patients. As liver transplantation is a treatment option for many patients with chronic liver disease, the presence of renal complications impacts the decision regarding transplantation and influences the course of these patients after transplantation, especially with regard to the use of immunosuppressive therapy. The involvement of the liver and kidney in systemic conditions is common and adds to the morbidity and mortality of patients.

Treatment of itching associated with intrahepatic cholestasis of pregnancy

OBJECTIVE

To review the drug therapy for the treatment of itching associated with intrahepatic cholestasis of pregnancy (ICP).

DATA SOURCES

A comprehensive literature search was conducted in MEDLINE (1966-July 2002) using the following MeSH terms: pregnancy, itching, intrahepatic cholestasis, cholestyramine, ursodeoxycholic acid, and phenobarbital. Current Contents (1966-July 2002), International Pharmaceutical Abstracts (1970-June 2002), and Cochrane Database were also searched using those terms. Web of Science search was used to search references found in articles.

DATA SYNTHESIS

Eight clinical trials and several observational studies were identified evaluating the safety and efficacy of ursodeoxycholic acid (UDCA) in the treatment of ICP. Although these studies were small and inconsistent, improvement in maternal and fetal morbidity was demonstrated. Observational studies suggest that cholestyramine may be associated with improved maternal morbidity without a documented improvement in fetal outcome. Two observational studies evaluated the efficacy of phenobarbital for ICP treatment. Phenobarbital use was not associated with improved maternal or fetal morbidity/mortality.

CONCLUSIONS

Data from large, well-designed, randomized, controlled trials of treatment of ICP are lacking. Data that are available support the use of UDCA as a first-line agent and cholestyramine as a second-line agent for treatment of ICP. There is little evidence to recommend phenobarbital in the treatment of itching associated with that condition.

Thrombocytopenic purpura and cardiomyopathy in pregnancy reversed by combined plasma exchange and infusion

Thrombocytopenia and hemolytic anemia have been seen with thrombotic thrombocytopenic purpura (TTP), HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), and hemolytic uremic syndrome (HUS). Differentiating between TTP, HUS, and HELLP syndrome is often difficult. Coexistence of TTP and HELLP is possible. Cardiomyopathy occurring in pregnancy can be idiopathic or associated with TTP. We describe a previously healthy woman who developed thrombocytopenia and hemolysis at 34 wk gestation. The patient underwent delivery after transfusion with platelets and RBCs. The suspicion of TTP was raised, and plasma exchange was begun by the third hospital day. On the seventh day of treatment, the patient developed shortness of breath, and an echocardiogram showed global hypokinesis with an ejection fraction of 25%. Plasma infusion, one unit q 4 h, was initiated in addition to the daily plasma exchange. The patient improved and her ejection fraction normalized. Plasma exchange and infusion and corticosteroids were gradually tapered off. von Willebrand factor (vWF) protease activity in the plasma upon transfer was completely deficient with the presence of inhibitor. This case illustrates that vWF protease assay and detection of inhibitor can be used for the diagnosis of TTP during pregnancy; and a severe cardiomyopathy in TTP can be reversed rapidly with combined plasma exchange and infusion.

Outcome of pregnancy with severe liver disease

OBJECTIVES

To study the incidence, presentation, and outcome of patients with severe liver disease in an urban Indian population.

METHOD

26 patients with severe liver disease were identified in the study period of one year at a teaching tertiary care institute in Mumbai. Investigations included bedside Bleeding and Clotting Time (BT/CT), coagulation profiles and liver and renal function tests. Management was directed towards initial stabilization followed by early delivery in an intensive care setting.

RESULT

80.71% of the patients had HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome. The remaining were cases of acute fulminant hepatitis and acute fatty liver of pregnancy. The most consistent finding was thrombocytopenia (88.46%). Disseminated Intravascular Coagulopathy (DIC) was the most common complication (65%). BT/CT were 100% sensitive for the diagnosis of DIC. Maternal and perinatal mortality were 42.3% and 61.5% respectively.

CONCLUSION

Intensive care facilities and an early diagnosis are essential for the management of mothers with severe liver disease. Prognosis is poor for patients with fulminant hepatitis and acute fatty liver. Screening for DIC is a must. Delay in recovery of biochemical parameters may indicate atypical disease. Patient education is essential at discharge.

Perioperative care of a patient with acute fatty liver of pregnancy

Acute fatty liver of pregnancy (AFLP) is a late gestational complication with biochemical similarities to the inherited disorders of mitochondrial fatty acid oxidation and clinical similarities to fulminant hepatic failure. The following case illustrates our perioperative management of this rarely encountered disorder.

Liver disease in pregnancy and fetal fatty acid oxidation defects

Acute fatty liver of pregnancy (AFLP) and the syndrome of hemolysis, elevated liver enzymes, and low platelets (the HELLP syndrome) are serious disorders of the third trimester with high maternal and perinatal morbidity and mortality. Over the past decade, several clinical observations have demonstrated an association between these maternal syndromes and a recessively inherited fatty acid oxidation disorder, long chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency. Many women who carried LCHAD-deficient fetuses developed maternal liver disease. Over the past few years, we and others have made significant progress in understanding the molecular basis for this fetal-maternal interaction. Here, we review the studies in literature that led to the establishment of this causative association with particular emphasis on the molecular analysis that delineated the molecular basis of this association. The likely mechanisms for the genotype-phenotype correlations in pediatric LCHAD deficiency and the fetal-maternal interaction are discussed. Finally, the potential implications of our current knowledge for families with pediatric LCHAD deficiency and for women who develop AFLP and HELLP syndrome are discussed.

Intrahepatic cholestasis of pregnancy: a critical review

Intrahepatic cholestasis of pregnancy (ICP) is a disease predominantly of the third trimester of pregnancy, characterized primarily by pruritus, biochemical disturbances in liver enzymes, and less frequently jaundice. Although maternal pruritus can be severe, overall maternal morbidity and mortality associated with ICP is low. However, fetal morbidity and mortality are significant with associated risks for meconium-stained amniotic fluid, acute onset of fetal compromise, spontaneous preterm labor, and intrauterine fetal demise. Current literature recommends obstetric management that includes frequent fetal surveillance with delivery when fetal lung maturity has been established.

Inborn errors of mitochondrial fatty acid oxidation

Inborn errors of the mitochondrial beta-oxidation of long-chain fatty acids represent an evolving field of inherited metabolic disease. Fatty acid oxidation defects demonstrate an abnormal response to the process of fasting adaptation and affect those tissues that utilize fatty acids as an energy source. These tissues include cardiac and skeletal muscle and liver. Muscle directly uses fatty acids as an energy source whilst hepatic metabolism of fatty acids is mostly directed toward the synthesis of ketone bodies for energy utilization by tissues such as brain. The clinical phenotypes of fatty acid oxidation disorders include disease of one or more of these fatty acid-metabolizing tissues. In this review, we provide an overview of the pathway, discuss the disorders that are well established, and describe recent advances in the field. Currently available diagnostic procedures are critically evaluated.

Inherited long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency and a fetal-maternal interaction cause maternal liver disease and other pregnancy complications

Fetal-maternal interactions are critical determinants of maternal health during pregnancy and perinatal outcome. This review explores the causative relationship of a fetal disorder of mitochondrial fatty acid oxidation, long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency, and the serious maternal liver diseases of pregnancy-preeclampsia, the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet counts), and acute fatty liver of pregnancy. Features of the metabolic adaptation necessitated during the fetal-neonatal transition; common phenotypes of pediatric fatty acid oxidation disorders, including neonatal hypoketotic, hypoglycemia and hepatic crisis; and clinical abnormalities of HELLP and acute fatty liver of pregnancy are presented. Evidence that a common mutation in the alpha-subunit (LCHAD) of trifunctional protein, E474Q, is always one of the mutant alleles in fetal isolated LCHAD deficiency associated with these disorders of pregnancy that cause high maternal, fetal, and newborn morbidity and mortality is reviewed. Recommendations for molecular testing for LCHAD deficiency in families with life-threatening maternal liver disease are given.

Maternal cholestasis does not affect the ontogenic pattern of expression of the Na+/taurocholate cotransporting polypeptide (ntcp) in the fetal and neonatal rat liver

To assess the effects of cholestasis during pregnancy on fetal and neonatal mRNA expression, protein mass, and function of the Na+/taurocholate cotransporting polypeptide (Ntcp), common bile duct ligation (BDL) was performed in pregnant rats on day 14 of pregnancy (maternal cholestasis [MC] group), and livers were harvested at days 20 and 21 of fetal life, as well as at days 4, 7, 14, 21, and 28 after birth. Sham-operated rats and their litters were used as controls. Ntcp steady-state mRNA levels, protein mass, and function were determined by Northern blotting, immunoblotting, and taurocholate (TC) transport studies in isolated short-term cultured hepatocytes, respectively. In addition, protein mass and function of the organic anion transporting polypeptide (Oatp1), another sinusoidal bile acid transporter, were studied at 4 weeks of age. The majority of pregnant cholestatic rats (94%) were able to carry pregnancy to term. Body and liver weights of the offspring from the MC group were lower than those from sham-operated animals at all postnatal time points. Ntcp steady-state mRNA levels, protein mass, and function were unaffected by MC. The ontogenic pattern of expression was identical in offspring from MC and controls with detection of the Ntcp mRNA at day 21 of fetal life. There was a significant increase in mRNA postnatally, reaching adult levels by 7 days of age. Protein mass and function of Ntcp as well as of Oatp1 were similar in offspring from MC and control groups at 4 weeks of age. In conclusion, maternal obstructive cholestasis during the last third of pregnancy does not affect the fetal/neonatal expression of the basolateral bile acid transporters, Ntcp and Oatp1. This suggests that the impaired bile acid excretion described in this experimental model is not related to altered uptake of bile acids in the affected neonate.

Cholestatic liver diseases in adults

Cholestatic liver diseases are a diverse group of disorders that are recognized by either increases in laboratory studies or the appearance of jaundice, fatigue, pruritus, and/or complications of cirrhosis. The etiologies for most forms of these diseases are unknown. In this paper, diagnostic and therapeutic strategies are reviewed for select forms of cholestatic disorders and for the management of shared complications of cholestatic illness.