Liver disease in pregnancy

Infectious aetiology of jaundice among pregnant women in Angola

The contribution of viral hepatitis, human immunodeficiency virus (HIV) infection and malaria to jaundice among pregnant women in Luanda, Angola, was studied. 20 pregnant women with jaundice (cases) were identified in 2 large maternity hospitals and compared with 40 pregnant women without jaundice (controls). Among the cases 6 patients died, whereas no death occurred in the control group (p < 0.001). Five spontaneous abortions and 6 stillbirths were also noted among the cases, implying foetal loss in 55% and stillbirth in 30%. One stillbirth was registered among control women. Of the cases 40% had anti-hepatitis E virus antibodies compared with 13% of the controls (p = 0.02). Plasmodium falciparum parasitaemia occurred in 47.5% and 5% of cases and controls, respectively (p < 0.001). There was no difference in the prevalence of antibodies against hepatitis C or HIV among cases and controls. The carriership of hepatitis B surface antigen was 10% in both groups. In conclusion, jaundice during pregnancy is often associated with maternal mortality in Luanda, women suffering from jaundice during pregnancy have an extremely high case fatality rate, and P. falciparum and hepatitis E are associated with jaundice in the setting studied.

Focus on primary care: pruritic dermatological conditions in pregnancy

This article reviews the literature that evaluates pruritic urticarial papules and plaques of pregnancy, herpes gestationis, and intrahepatic cholestasis of pregnancy and their impact on the fetus. Using MEDLINE years 1966 to 1999, a literature search was performed using the terms pregnancy, dermatology, pruritic urticarial papules and plaques of pregnancy, herpes gestationis, and intrahepatic cholestasis of pregnancy. References from the selected papers were then reviewed for additional sources. Thirty-seven studies were reviewed. Both original studies and review articles were included in the sources. The results of each study as originally reported are included to provide the reader the finding of each. The available literature reports no risk with pruritic urticarial papules and plaques of pregnancy; however, the current opinion of most was that there is an increased risk with herpes gestationis and intrahepatic papules and plaques of pregnancy. Although much information is known concerning these unique conditions, a consensus regarding their effect on the fetus has yet to be reached. Pregnancies affected by herpes gestationis and cholestasis of pregnancy should be considered high risk until more definitive evidence can be gained.

The specific dermatoses of pregnancy: a re-appraisal

Pregnancy is associated with immunological, endocrine, metabolic and vascular changes that may adversely affect the skin. The specific dermatoses of pregnancy are disease entities almost exclusively related to the pregnancy or the puerperium.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be aware of the main entities of the specific pregnancy dermatoses, their clinical presentations, the main diagnostic criteria and therapeutic options.

Dermatoses of pregnancy

Several reported dermatoses of pregnancy have not survived the scrutiny of time and thus including them in current classification schemes does not serve any useful purpose. This review resolves issues in the existing conflicting literature.

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a review of diagnosis and management

Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a form of severe preeclampsia that threatens the gravida and her fetus. In this report, the diagnostic criteria and maternal and fetal risks of HELLP are defined. Prompt recognition and treatment in tertiary centers is emphasized, because the prognosis can be adversely affected by delayed or less than optimal diagnosis and treatment. Management guidelines are offered for treating this disorder. The potential roles of corticosteroids, plasmapheresis, and expectant management are critically evaluated. Subsequent pregnancy outcome, contraception, and preventative strategies are considered.

Gastrointestinal surgery during pregnancy

Gastrointestinal surgical problems often mimic symptoms and signs of nonsurgical conditions that occur during pregnancy. This mimicry presents a particular challenge to diagnosis because avoiding a delay in treatment is critical to successful management. Some of these conditions, such as acute appendicitis and biliary colic, are common in younger women; however, the anatomic and physiologic changes of pregnancy can alter their usual manner of presentation. Many elective and urgent operations can be performed during pregnancy with minimal risk to the mother and fetus. The mother's condition should always take priority because her proper treatment usually benefits the fetus as well.

Electrophysiological effects of progesterone on hepatocytes

The addition of progesterone (1-100 mumol/l) to the extracellular fluid bathing rat hepatocytes led to a rapid and fully reversible depolarization of the cell membrane. The progesterone-induced depolarization was paralleled by a decrease of potassium selectivity and an increase of cell membrane resistance and was abolished in the presence of the potassium channel blocker barium. Accordingly, in whole cell recordings, progesterone led to a decrease of the cell membrane conductance. 17 alpha-Hydroxyprogesterone and beta-estradiol were less effective by a factor of 10, whereas cholesterol, corticosterone and hydrocortisone did not significantly alter the potential difference across the cell membrane. In conclusion, acute administration of progesterone depolarized rat hepatocytes by decreasing the potassium conductance of the cell membrane.

The surgical management of intra-abdominal inflammatory conditions during pregnancy

The timely diagnosis and treatment of intra-abdominal conditions during pregnancy can challenge the surgical consultant. Familiarity with the anatomic and physiologic changes present in normal pregnancy is essential, as is the knowledge of relative risk by trimester. The general surgeon will be called upon to diagnose and treat appendicitis, biliary tract disease (including pancreatitis), and liver disease. Knowledge of how these conditions become manifest is essential. The surgical consultant should be aware that virtually all complications that occur in the management of these conditions are caused by delay in the detection of the disease process.

[Liver transplantation and pregnancy: 1994 perspectives]

The authors report a case of pregnancy in a 24-year-old, gravida-3, para-1 patient who had previously undergone liver transplantation for alveolar echinococcosis. Pregnancy and delivery were uneventful with no obstetrical or liver complications. Pregnancy seems to have little effect on liver transplants and rejection is seldom observed. Primary maternal complications are hypertension, preeclampsia, anemia and hyperbilirubinemia. Primary fetal complications include premature delivery and growth retardation. The mode of delivery depends on the obstetrical situation. Cyclosporin may be used during pregnancy. The risk of breastfeeding has not been clearly established. Pregnancy after liver transplantation is possible after 9 to 12 months but requires strict multidisciplinary surveillance. Barrier methods remain the preferred method of contraception for liver transplant patients.

Acute fatty liver of pregnancy

Acute fatty liver of pregnancy is a serious complication of the 3rd trimester associated with high rates of maternal-fetal morbidity and mortality. Prompt diagnosis and treatment are essential to achieve optimal maternal-fetal outcomes. Collaboration between critical-care and perinatal nursing staffs is a crucial component of managing patient care. A recent case of acute fatty liver of pregnancy is reported. A team approach resulted in the survival of the patient and the delivery of healthy twins.