Pregnancy and liver disease

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.

Pregnancies With Cirrhosis Are Rising and Associated With Adverse Maternal and Perinatal Outcomes

INTRODUCTION

Cirrhosis incidence in pregnancies from outside the United States (US) is rising, although contemporary data including maternal and perinatal outcomes within the United States are lacking.

METHODS

Using discharge data from the racially diverse US National Inpatient Sample, temporal trends of cirrhosis in pregnancies were compared with noncirrhotic chronic liver disease (CLD) or no CLD. Outcomes included preterm birth, postpartum hemorrhage, hypertensive complications (preeclampsia, eclampsia, and/or hemolysis, elevated liver enzymes, and low platelets syndrome), and maternal or fetal death. Logistic regression was adjusted for age, race, multiple gestation, insurance status, and prepregnancy metabolic comorbidities.

RESULTS

Among 18,573,000 deliveries from 2012 to 2016, 895 had cirrhosis, 119,875 had noncirrhotic CLD, and 18,452,230 had no CLD. Pregnancies with cirrhosis increased from 2.5/100,000 in 2007 to 6.5/100,000 in 2016 (P = 0.01). On adjusted analysis, cirrhosis was associated with hypertensive complications (vs no CLD, OR 4.9, 95% confidence intervals [CI] 3.3-7.4; vs noncirrhotic CLD, OR 4.4, 95% CI 3.0-6.7), postpartum hemorrhage (vs no CLD, OR 2.8, 95% CI 1.6-4.8; vs noncirrhotic CLD, OR 2.0, 95% CI 1.2-3.5), and preterm birth (vs no CLD, OR 3.1, 95% CI 1.9-4.9; vs noncirrhotic CLD, OR 2.0, 95% CI 1.3-3.3, P ≤ 0.01). Cirrhosis was statistically associated with maternal mortality, although rarely occurred (≤ 1%).

DISCUSSION

In this racially diverse, US population-based study, pregnancies with cirrhosis more than doubled over the past decade. Cirrhosis conferred an increased risk of several adverse events, although maternal and perinatal mortality was uncommon. These data underscore the need for reproductive counseling and multidisciplinary pregnancy management in young women with cirrhosis.

Pre-existing liver disease in pregnancy: Cirrhosis, autoimmune hepatitis and liver transplantation

Liver disease during pregnancy is one of the least studied topics, but it links the interests of hepatologists, gynaecologists and family physicians. Approximately 3% of pregnant woman experience some type of liver disease. Liver disease can occur as a result of pregnancy, before pregnancy and coincidence-related during pregnancy. Pregnancy in women with pre-existing liver disease is essential that the clinicians are familiar with this disorder so they can respond promptly and appropriately in all of these situations. So, because of the complications for both mother and child, it is important that liver disease is recognized in a timely manner to avoid undesirable outcomes.

Body mass index in early pregnancy and future risk of severe liver disease: a population-based cohort study

BACKGROUND

In young men, high body mass index (BMI) has been linked to liver disease later in life, but it is unclear if this also applies to women.

AIM

To study the association between BMI early in life and development of liver disease later in life in women.

METHODS

We obtained data on early pregnancy BMI from 1 139 458 Swedish women between 1992 and 2015. National registers were used to ascertain incident severe liver disease, defined as cirrhosis, decompensated liver disease (hepatocellular carcinoma, oesophageal varices, hepatorenal syndrome or hepatic encephalopathy) or liver failure. A Cox regression model was used to investigate associations of BMI with incident severe liver disease adjusting for maternal age, calendar year, country of birth, smoking, civil status and education.

RESULTS

During an average follow-up of 13.8 years, 774 women developed severe liver disease. Compared to women with a low normal BMI (18.5-22.4), an increased risk of severe liver disease was found in women with BMI between 22.5 and 24.9 kg/m² (adjusted hazard ratio [aHR] 1.25, 95% CI 1.04-1.50), 25.0 and 29.9 kg/m² (aHR 1.27, 95% CI 1.05-1.53) and BMI ≥ 30 kg/m² (aHR 1.77, 95% CI 1.40-2.24). When examining BMI as a continuous variable, the aHR increased by 4% per kg/m² (95% CI 1.02-1.05). A diagnosis of diabetes was associated with an increased risk of severe liver disease independent of baseline BMI.

CONCLUSION

A high BMI early in life in women is associated with a dose-dependent, increased risk for future severe liver disease.

Outcomes of Pregnancy in Mothers With Cirrhosis: A National Population-Based Cohort Study of 1.3 Million Pregnancies

There are limited data on pregnancy outcomes in women with cirrhosis. To address this gap, we examined the records of singleton births from Sweden’s National Patient Register (NPR), Cause of Death Register (CDR), and Medical Birth Register (MBR) between 1997 and 2011 to assess exposure and pregnancy‐related and liver‐related outcomes of pregnant women with cirrhosis. Exposure status was defined as having an International Classification of Diseases (ICD) code for cirrhosis obtained prior to or during pregnancy. Poisson regression with cluster‐robust standard errors was used to estimate relative risks (RRs) adjusted for maternal age, smoking, and body mass index (BMI). We identified 103 pregnancies in women with cirrhosis and compared these to 1,361,566 pregnancies in women without cirrhosis. Pregnancies in women with cirrhosis were at increased risk of caesarean delivery (36% versus 16%, respectively; adjusted RR [aRR], 2.00; 95% confidence interval [CI], 1.47‐2.73), low birth weight (15% versus 3%; aRR, 3.87; 95% CI, 2.11‐7.06), and preterm delivery (19% versus 5%; aRR, 3.51; 95% CI, 2.16‐5.72). Rates of maternal mortality during pregnancy (no cases), gestational diabetes, preeclampsia, small for gestational age, congenital malformations, and stillbirth were not increased when compared to the pregnant women without cirrhosis. There were 12 hospitalizations during pregnancy due to liver‐related events, including one case with bleeding esophageal varices. Conclusion: Women with cirrhosis are at increased risk for adverse pregnancy outcomes. However, severe maternal and fetal adverse events were rare in our study, and most pregnancies in women with cirrhosis ended without complications.

Pregnancy in liver transplant recipients: A single center outcomes

AIM

Liver transplantation (LT) is the only effective treatment for the end-stage liver disease. Although pregnancy after LT is considered to be safe, these patients are difficult to manage for obstetricians. In this study, we aimed to determine maternal and fetal outcomes in pregnancies after LT.

METHODS

We conducted a retrospective review of liver transplant recipients who had received prenatal care and delivered pregnancy at İstanbul University İstanbul Medical Faculty, Department of Obstetrics and Gynecology January 2010 and January 2017.

RESULTS

A total of eight pregnancies were identified during the study period. The mean age of the patients at the time of LT was 25.6 ± 5.3 years (range 19-36 years), and the mean age at conception was 30.1 ± 5.2 years (range 25-41 years). The mean interval between transplantation and conception was 54.2 ± 18.6 months (range 24-82 months). There was no a miscarriage or a stillbirth was observed in any of patients. Mean birth week was 37.2 ± 2.1 weeks and mean birthweight was 2852 ± 562 g (range 2150-3470 g). Three of eight deliveries (37.5%) occurred before 37 gestational weeks. Preeclampsia was detected in one patient, one pregnancy was complicated by intrauterine growth retardation and one case with gestational diabetes mellitus. Mean postnatal follow-up period was 3.2 ± 2.4 years (range 1-7 years) and all of the babies were healthy. Graft rejection occurred in one patient after delivery.

CONCLUSION

More favorable pregnancy outcomes can be achieved with a multidisciplinary team and satisfactory counseling is mandatory either preconception and through the pregnancy to reduce maternal-fetal risks.

Medical and Obstetric Complications Among Pregnant Women With Liver Cirrhosis

OBJECTIVE

To evaluate clinical characteristics and obstetric outcomes in pregnant women with liver cirrhosis.

METHODS

This was a retrospective matched cohort study of women with liver cirrhosis between January 2005 and January 2016 in a university hospital. Women in a case group were matched to women in a control group according to year of delivery, age, body mass index, and parity in a 1:4 ratio. Bivariable and multivariable analyses were performed to compare the prevalence of the primary composite outcome, which included any one of the following: fetal or neonatal demise, placental abruption, preeclampsia, preterm delivery at less than 37 weeks of gestation, and small-for-gestational age neonate between women in the case group and those in the control group.

RESULTS

During the study period, the number of deliveries was approximately 110,000. Of these, 33 women with liver cirrhosis were identified, yielding an estimated frequency of cirrhosis of 1 per 3,333 pregnancies [95% confidence interval (CI) 3,313-3,353]. Thirty-one of these 33 women met all inclusion criteria. The most common etiology of cirrhosis was alcoholic liver disease. The rate of the primary outcome was 61% in women with cirrhosis and 12% in women in the control group. There were no cases of maternal death, and the livebirth rate was 97%. Women with cirrhosis were more likely to be non-Hispanic black, have chronic hypertension, and use alcohol. Multivariable logistic regression demonstrated that cirrhosis in pregnancy was associated with the composite outcome (adjusted odds ratio 9.4, 95% CI 3.4-26.2).

CONCLUSION

Despite lower rates of maternal and fetal mortality compared with earlier studies, pregnancy in women with liver cirrhosis is still associated with a high risk of adverse obstetric outcomes.

Contraceptive Considerations for Women with Gastrointestinal Disorders

Gastroenterologists are in a unique position to assist women with chronic gastrointestinal disorders in order to optimize their health prior to pregnancy. Women, whether with chronic conditions or not, and their infants are more likely to be healthy when pregnancies are planned. Achieving a planned pregnancy at the ideal time or preventing pregnancy altogether requires the use of appropriate contraceptives. There is a broad range of contraceptives available to women in the USA, and the majority of women with digestive diseases will be candidates for all effective methods. Guidance from the Centers for Disease Control and Prevention aids clinicians in prescribing appropriate contraceptives to women with medical disorders. This review will focus on contraception for women with inflammatory bowel disease and chronic liver disease, including liver transplant.

Anesthetic considerations for liver diseases unique to pregnancy

Liver diseases that are most unique to pregnancy consist of hyperemesis gravidarum, acute fatty liver of pregnancy, intrahepatic cholestasis of pregnancy, and hemolysis, elevated liver enzymes and low platelets syndrome. In this review, risk factors, etiology, symptoms, diagnosis, prognosis and treatment of each entity followed by principles of anesthetic management based on the case reports or retrospective records will be addressed.

Pregnancy and liver disease

Pregnancy associated liver diseases affect up to 3% of pregnant women and are the most frequent cause of liver dysfunction in pregnancy. When severe, they are associated with significant morbidity and mortality for both mother and infant. A rapid evaluation to distinguish them from non-pregnancy related liver dysfunction is essential, in order to facilitate appropriate management. Liver disease unrelated to pregnancy can present de novo in pregnancy, or pregnancy can occur in women with preexisting liver pathology (Table 1). Research and subsequent advances in medical care have resulted in improved but still not satisfactory maternal and fetal outcomes. In this review we provide an overview of the liver diseases specific to the pregnant state and an update on their pathogenesis, treatment and outcomes. The risks of pregnancy in women with pre-existent liver pathology is detailed and recent advances in our understanding of specific risks and outcomes are discussed.

Outcomes of pregnancy following liver transplantation: The King's College Hospital experience

Reports of pregnancy in liver transplantation (LT) patients have largely favorable outcomes. Concerns remain with regards to maternal and graft risk, optimal immunosuppression (IS), and fetal outcomes. We review all post-LT pregnancies at our center with regard to the outcomes and safety for the patient, graft, and fetus. A total of 117 conceptions occurred in 79 patients. Median age at conception was 29 years. Maternal complications included graft loss (2%), acute cellular rejection (ACR; 15%), pre-eclampsia/eclampsia (15%), gestational diabetes (7%), and bacterial sepsis (5%). ACR was significantly more common in those women who conceived within 12 months of LT (P = 0.001). The live birth rate was 73%. Prematurity occurred in 26 (31%) neonates, and 24 (29%) neonates were of low or very low birth weight. IS choice (cyclosporine versus tacrolimus) had no significant effect on pregnancy outcomes and complications. No congenital abnormalities occurred, and only 1 child born at 24 weeks had delayed developmental milestones. In conclusion, pregnancy following LT has a favorable outcome in the majority, but severe maternal risks remain. Patients should be counseled with regard to the above information so informed decisions can be made, and pregnancy must be considered high risk with regular monitoring by transplant clinicians and specialist obstetricians.

Recent trends in hepatic diseases during pregnancy in the United States, 2002-2010

OBJECTIVE

While pregnancy-related severe liver disorders are rare, when they occur morbidity and mortality rates are increased for mothers and infants. The objective of this study was to examine the prevalence and trends of hepatic diseases during pregnancy hospitalizations from 2002 through 2010 in the United States.

STUDY DESIGN

Hospital discharge data were obtained from the Nationwide Inpatient Sample, the largest all-payer hospital inpatient care database in the United States that provides nationally representative estimates. Pregnancy hospitalizations with the following diagnoses were identified: hepatitis B, hepatitis C, gallbladder disease/cholelithiasis, liver disorders of pregnancy, chronic/alcohol-related liver disease, biliary tract disease, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. Age, insurance status, hospital location, and hospital region were compared among women with and without hepatic diseases using a χ(2) test. Trends in rates of pregnancy hospitalizations and mean charges were analyzed using multivariable logistic and linear regression, respectively.

RESULTS

From 2002 through 2010 there were an estimated 41,479,358 pregnancy hospitalizations in the United States. Gallbladder disease and liver disorders of pregnancy were the most common hepatic diseases (rates = 7.18 and 4.65/1000 pregnancy hospitalizations, respectively). Adjusted rates and mean charges significantly increased for all hepatic diseases during pregnancy over the study period. All hepatic diseases were associated with significantly higher charges compared to all pregnancy hospitalizations. HELLP syndrome was associated with the highest mean charges.

CONCLUSION

This large study among a representative sample of the US population provides valuable information that can aid policy planning and management of these hepatic diseases during pregnancy in the United States.

The pro-fibrotic effects of pregnancy in a carbon-tetrachloride-induced liver injury in mouse model

BACKGROUND & AIMS

Immune cells interact with hepatic-stellate-cells (HSCs) in the development of liver fibrosis. Little is known about the influence of pregnancy on the development and progression of hepatic-fibrosis. In this study, we explored the influence of pregnancy on progression of hepatic fibrosis.

METHODS

Female mice (C57Blc) were induced by 4 injections of peritoneal carbon-tetrachloride (CCl4) within 10 days, starting at day 10 of documented pregnancy. At end of experiment, serum samples were obtained for ALT and estradiol determination. Harvested livers were histological evaluated for liver injury and for protein αSMA expressions. Isolated intra-hepatic lymphocytes were assessed by flow cytometry. Isolated lymphocytes and serum samples were in- vitro co-cultured for 48 h with primary isolated naïve HSCs. Washed cells were analyzed for adherence (anti-αSMA+/anti-CD45 + ) and proliferations (CSFE).

RESULTS

CCl4-model for liver injury was well tolerated when induced in pregnancy similar to non-pregnant state. Hepatic-fibrosis (Masson Trichrome Stain, Sirius red stain and αSMA expressions) and necro-inflammation (H&E stain and serum ALT levels) significantly increased in pregnancy. Increased liver injury was accompanied with pro-fibrotic lymphocyte profile; CD8 subsets increased and NK cells decreased. HSCs activation significantly increased when in-vitro cultured with lymphocytes from pregnant as compared to non-pregnant fibrotic ones. Pro-fibrotic profile was also explained by decreased NK activity (CD107a marker) and of their phagocytosis. Serum estradiol levels although elevated in fibrosis conditions of pregnancy was not associated with the pHSCs activations.

CONCLUSION

Liver fibrosis in our murine model was severe in pregnant model; via pro-fibrotic lymphocyte and serum alterations.

Clinical features and outcome of acute hepatitis B in pregnancy

Background

The impact of pregnancy on the clinical course of acute hepatitis B (AHB) is still largely unclear, mainly because most studies have not included matched controls. This study was conducted to investigate the clinical features and outcome of AHB in pregnancy using matched controls.

Methods

Consecutive AHB inpatients who were admitted to Jinan Infectious Disease Hospital, Jinan, between January 2006 and December 2010 were evaluated and followed. Demographic data, clinical manifestations, and results of laboratory tests were compared between pregnant patients and age and sex matched non-pregnant patients at admission, discharge, and final follow-up.

Results

A total of 618 AHB inpatients were identified during the study period. 22 pregnant patients and 87 age and sex matched non-pregnant patients were enrolled in this study. Prodromal fever was less common (0% vs. 20.7%, P = 0.02), serum alanine aminotransferase levels were significantly lower, and HBsAg > 250 IU/mL rate and serum bilirubin levels were significantly higher in pregnant patients than in non-pregnant patients. After a mean (range) of 7(5.2-8.3) months follow-up, 18.2% pregnant patients and 4.6% non-pregnant patients were still HBsAg positive (P = 0.03). For pregnant patients, the relative risk (95% confidence interval) of HBsAg positive at the end of follow-up was 4.6 (1.1-20.2). The median (95% confidence interval) days of HBsAg seroclearance form disease onset in pregnant and non-pregnant patients were 145.0 (110.5-179.5) and 80.0 (62.6-97.4), respectively.

Conclusions

The HBsAg loss and seroconversion were delayed and lower in pregnant patients. Pregnancy might be a possible risk of chronicity following acute HBV infection.

Liver disease in pregnancy

Changes in the liver biochemical profile are normal in pregnancy. However, up to 3% to 5% of all pregnancies are complicated by liver dysfunction. It is important that liver disease during pregnancy is recognized because early diagnosis may improve maternal and fetal outcomes, with resultant decreased morbidity and mortality. Liver diseases that occur in pregnancy can be divided into 3 different groups: liver diseases that are unique to pregnancy, liver diseases that are not unique to pregnancy but can be revealed or exacerbated by pregnancy, and liver diseases that are unrelated to but occur coincidentally during pregnancy.

Model for end-stage liver disease score predicts outcome in cirrhotic patients during pregnancy

BACKGROUND & AIMS

Pregnancy is rare among patients with cirrhosis, and data about complications and outcomes are sparse. We evaluated the utility of prognostic models of severity of cirrhosis in determining outcomes in pregnant women with cirrhosis.

METHODS

We evaluated all cirrhotic patients who self-reported pregnancy at our center and correlated prognostic scores at the time of conception with outcomes.

RESULTS

Sixty-two pregnancies occurred in 29 women. The median model for end-stage liver disease (MELD) score at conception was 7 (range, 6-17), the median MELD sodium score was 9 (range, 6-17), the median United Kingdom end-stage liver disease (UKELD) score was 44 (range, 36-53), and the median Child-Pugh score was 5 (range, 5-8). The live birth rate was 58%; the median gestational age was 36 weeks. Higher MELD (P = .01), MELD sodium (P = .01), UKELD (P = .01), and Child-Pugh (P = .03) scores were associated with gestation <37 weeks. Maternal complications (ascites, encephalopathy, or variceal hemorrhage) occurred in 10% of patients and were associated with higher MELD (P = .01) and UKELD (P = .02) scores. Receiver operator curve analysis demonstrated that a MELD score ≥10 predicted, with 83% sensitivity and 83% specificity, which patients were likely to have significant, liver-related complications (area under curve, 0.8); a UKELD score ≥47 had 83% sensitivity and 79% specificity (area under curve, 0.8). No patient who had a MELD score ≤6 or a UKELD score ≤42 developed any significant hepatologic complications.

CONCLUSIONS

MELD and UKELD scores at the time of conception can be used to predict specific clinical outcomes in pregnant women with cirrhosis.

Liver disease in pregnancy

Severe liver disease in pregnancy is rare. Pregnancy-related liver disease is the most frequent cause of liver dysfunction in pregnancy and provides a real threat to fetal and maternal survival. A rapid diagnosis differentiating between liver disease related and unrelated to pregnancy is required in women who present with liver dysfunction during pregnancy. Research has improved our understanding of the pathogenesis of pregnancy-related liver disease, which has translated into improved maternal and fetal outcomes. Here, we provide an overview of liver diseases that occur in pregnancy, an update on the key mechanisms involved in their pathogenesis, and assessment of available treatment options.

The outcomes of pregnancy in patients with cirrhosis: a population-based study

BACKGROUND

The outcomes of pregnancy in patients with cirrhosis are poorly described. Our objective was to assess obstetric outcomes in cirrhotic women and their infants from a population-based perspective.

METHODS

We analysed the 1993-2005 US Nationwide Inpatient Sample database to identify obstetric hospitalizations among patients with cirrhosis (n=339) and controls matched on age, hospital and year (n=6625). The effect of cirrhosis on maternal and fetal outcomes was evaluated using regression models with adjustment for patient and hospital factors.

RESULTS

Between 1993 and 2005, 114 antepartum and 225 delivery admissions in cirrhotic patients were identified. The estimated mean number of deliveries nationwide increased from 68 to 106 annually between 1993 and 1999 and 2000 and 2005 (P=0.0004). Patients with cirrhosis were more likely to deliver by caesarean [42 vs. 28%; adjusted odds ratio (OR) 1.41; 95% confidence interval (CI) 1.06-1.88]. Maternal (1.8 vs. 0%; P<0.0001) and fetal mortality (5.2 vs. 2.1%; P<0.0001), antepartum admission (OR 2.97; 95% CI 2.24-3.96), and maternal (OR 2.03; 95% CI 1.60-2.57) and fetal complications (OR 3.66; 95% CI 2.74-4.88) were greater among cirrhotic patients than controls. Gestational hypertension, placental abruption and uterovaginal haemorrhage were more common in patients with cirrhosis; their infants had higher rates of prematurity and growth restriction. Hepatic decompensation occurred in 15%, including ascites in 11% and variceal haemorrhage in 5%. In women with decompensation, maternal and fetal mortality were 6 and 12% respectively.

CONCLUSIONS

Although rare, pregnancies among women with cirrhosis are increasing. Cirrhotic patients and their infants have an increased risk of obstetric complications, emphasizing the importance of close maternal-fetal monitoring during pregnancy.

Pregnancy and cirrhosis

As the treatment of cirrhosis improves, pregnancy in patients with cirrhosis is likely to become more common. Although maternal and fetal mortality is expected to similarly improve, pregnant patients with cirrhosis face unique risks. These include higher rates of spontaneous abortion and prematurity and a potential for life-threatening variceal hemorrhage, hepatic decompensation, splenic artery aneurysm rupture, and postpartum hemorrhage. Pregnancy outcome may be influenced by the underlying etiology of liver disease, as in viral and autoimmune hepatitis. Medications also impact the course of pregnancy, and must be tailored appropriately during this time.

Intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy is one of the primary disorders of the liver that adversely affects maternal well-being and fetal outcome. Early identification of this condition, careful interdisciplinary monitoring, and prompt delivery at fetal maturity can improve outcomes in the mother and child. Although the cause is unclear, IHCP probably arises from a genetic predisposition for increased sensitivity to estrogens and progestogens and altered membrane composition and expression of bile ducts, hepatocytes, and canalicular transport systems. As a result, the elevations in maternal levels of bile acids and their molar ratios seen in healthy pregnancy rise further in IHCP patients. Also, as the normal fetal-to-maternal transfer of bile acids across the trophoblast is impaired, the excess bile acids with abnormal profiles accumulate and are toxic to the fetus. The management of IHCP is dictated by the increased risks of fetal distress, spontaneous preterm delivery, and sudden death, as well as by alleviating pruritus in the mother. These risks to the fetus rise progressively to delivery, regardless of serum levels of bile acids and ALT. Close monitoring of these markers is essential but does not prevent sudden fetal distress and death. Provision should be made to induce labor as soon as fetal lung maturity has been established. Ursodeoxycholic acid is the only therapy that has proven effective, albeit in small studies, in alleviating pruritus and restoring towards normal the abnormal profiles of bile acids and sulfated steroids in serum and other body fluids. Ursodeoxycholic acid seems to have no obvious adverse effects on the fetus, but experience is insufficient to draw conclusions regarding teratogenicity and prevention of adverse outcomes.

Pregnancy and its outcome in patients with noncirrhotic portal hypertension

There is paucity of data in the literature on the occurrence of pregnancy and its outcome in patients with noncirrhotic portal hypertension. The present study was undertaken to assess the fertility pattern, fetal loss, and consequences of variceal bleeding during pregnancy in these patients. Fifty-five women of child-bearing age with a diagnosis of noncirrhotic portal hypertension (including 32 with noncirrhotic portal fibrosis and 23 with extrahepatic portal venous obstruction) and 44 age-matched controls were studied. A detailed history of obstetric events and bleeding episodes was recorded in all patients. Any complication of portal hypertension was managed accordingly. Patients were classified into three groups for analysis: group 1-obstetric events after the diagnosis of portal hypertension in patients; group II-obstetric events before the diagnosis of portal hypertension in patients; and group III-obstetric events in controls. A total of 116 pregnancies took place in 44 patients. Of these, 36 occurred after and 80 before the diagnosis of portal hypertension was made. In the 44 controls, 118 pregnancies took place. The mean fertility rates of groups I, II and III were 0.20+/-0.24, 0.18+/-0.21, and 0.22+/-0.12 pregnancies per year, respectively, which were not statistically different (P>0.05). The numbers of fetal losses in groups I, II and III were 3/36 (8.3%), 6/80 (7.5%), and 12/118 (10.17%) pregnancies, respectively. Menstrual irregularities were found in 7/55 (12.72%) patients and 6/44 (13.6%) controls (P>0.05). Five episodes of variceal bleeding occurred in 36 pregnancies after the diagnosis of portal hypertension (13.88%). All five were successfully managed with endoscopic sclerotherapy. In conclusion, noncirrhotic portal hypertensive patients have normal fertility and outcome of pregnancy. Variceal bleeding episodes are not common and endoscopic sclerotherapy is safe and effective in pregnancy.

Evaluation of abnormal liver function in pregnancy

Liver disease in pregnancy may present in a subtle or dramatic fashion. An approach using the pattern of liver function abnormalities, time of gestation, and constellation of symptoms will narrow the diagnostic possibilities. Diagnostic tests, including serology, ultrasonography of the hepatobiliary tree, and liver biopsy, can make a definitive diagnosis.

Pregnancy and cirrhosis: management of hematemesis by Warren shunt during third trimester gestation

Considerable pathophysiologic changes accompany cirrhosis. Elevation of portal venous pressure predisposes to esophageal varices and hematemesis. The physiologic changes associated with pregnancy may exacerbate these conditions. Medical management of cirrhosis-associated problems may fail, necessitating surgical intervention. The anesthetic management of a pregnant cirrhotic patient for a Warren shunt is complicated by concerns for pre-existing hepatic dysfunction and pregnancy-induced physiologic changes as well as fetal well-being. The management of such a case is reviewed and relevant pathophysiology discussed.

Hypertension in pregnancy

Hypertension, which is the most common complication of pregnancy, is a leading cause of both maternal and perinatal morbidity. Advances in research related to hypertensive disorders in pregnancy have facilitated a better general understanding of the pathophysiologic processes associated with this disease. Strategies of prevention, early diagnosis, and newer treatments have contributed to a more favorable outcome for mothers and their babies. The exact cause of preeclampsia remains elusive; however, recent investigations suggest that endothelial cell injury due to free radical-mediated lipid peroxidation may be the initiator of the pathophysiologic events of preeclampsia. Future challenges in this area should include efforts to elucidate mechanisms involved in free radical cell-mediated vascular disturbances and antioxidant defenses.

Hepatic emergencies in pregnancy

Although liver disease during pregnancy is a rare event, it can have devastating effects on the mother and the child. This article reviews diseases uniquely associated to pregnancy, such as fatty liver of pregnancy, toxemia, and others. It also details new advances in diseases such as viral hepatitis and pregnancy and intrahepatic cholestasis of pregnancy.

Hepatic cytosolic oestrogen receptors in patients with liver disease

Patients with liver disease present many of the features of 'feminized' hepatic metabolism. Oestrogens exert their effects through interaction with specific cellular high-affinity receptors (ER). We measured hepatic ER in 102 needle biopsies from patients with chronic alcoholic and non-alcoholic liver disease using an enzyme immunoassay. Fifteen patients with no or minimal changes in liver histology served as controls. The hepatic ER concentrations were significantly (P = 0.05) lower in the 44 men (median 13 fmol mg-1 protein, interquartile range 7-17 fmol mg-1 protein) compared to the 58 women (median 15 fmol mg-1 protein, interquartile range 10-21 fmol mg-1 protein). Patients with alcoholic liver disease (n = 63) had significantly (P < 0.05) lower ER concentrations than controls (n = 15) (median 13 fmol mg-1 protein, interquartile range 7-17 fmol mg-1 protein vs. median 16 fmol mg-1 protein, interquartile range 10-26 fmol mg-1 protein), and compared with patients with non-alcoholic liver disease (n = 24) (P < 0.05, median 20 fmol mg-1 protein, interquartile range 11-24 fmol mg-1 protein). ER concentrations were significantly lower (P < 0.05) in patients with alcoholic liver disease and alcoholic hepatitis (n = 21) compared to those without alcoholic hepatitis (n = 42) (medians 10 vs. 14 fmol mg-1 protein, interquartile ranges 6-15 fmol mg-1 protein vs. 9-18 fmol mg-1 protein), while ER concentrations did not differ significantly (P > 0.05) between actively drinking (median 13 fmol mg-1 protein, interquartile range 7-17 fmol mg-1 protein) and abstaining alcoholic patients (median 13 fmol mg-1 protein. interquartile range 7-18 fmol mg-1 protein). In summary, the small but significant variation in hepatic ER concentrations reflects variation in liver function rather than an effect of ethanol.

Vasoconstrictive effect of bile acids on isolated human placental chorionic veins

Intrahepatic cholestasis of pregnancy (ICP) is a rare complication of late pregnancy associated with a high rate of premature delivery, antepartum fetal death and fetal hypoxia. Since the principal biochemical feature of ICP is a marked elevation of maternal serum bile acid levels, a role of these substances in the pathophysiology of fetal complications has been suggested. In this study, the effect of bile acids on isolated human placental chorionic veins is described. High concentrations of bile acids, especially cholic acid, have a dose-dependent vasoconstrictive effect, which suggests that these substances could exert a detrimental effect on the fetus by increasing the resistance in chorionic veins through a vasospasm of the placental chorionic surface. An abrupt reduction of the oxygenated blood flow at the level of the placental chorionic plate may cause an acute impairment of the fetal perfusion and oxygenation, leading to fetal asphyxia. This is the first report that provides experimental evidence of the possible role of bile acids in those mechanisms that trigger fetal asphyxia in pregnancies complicated by ICP.

Ruptured subcapsular haematoma of the liver in pregnancy; a case report

A case of ruptured subcapsular haematoma of the liver, a rare and potentially lethal complication of pre-eclampsia, is presented. The lack of characteristic signs and symptoms is highlighted. This case serves to remind clinicians of the high maternal and perinatal mortality rates associated with complications of hypertension in pregnancy.

Liver disease in pregnancy

The entire spectrum of liver diseases may occur in pregnancy. It is useful to consider those disorders uniquely associated with pregnancy and those that are coincidental. The most common cause of jaundice during pregnancy is viral hepatitis. Intrahepatic cholestasis and fatty liver may be peculiar to pregnant women. Early recognition of these situations may be life-saving.

Hepatitis B viral markers in pregnant women and newborn infants in Korea

A study of the 5,284 pregnant women who delivered at St. Columban’s Hospital in Mokpo City between April 1, 1985 to June 30, 1987 was conducted to determine the presence of hepatitis B viral (HBV) markers in the mothers and infants and to evaluate their effects. Medical histories, physical examinations, liver function studies and the ELISA test for HBV markers were reviewed. The following results were obtained: 1. Of the 5,284 pregnant women, 448 (8.48%) were positive for HBsAg. Three hundred and thirty four women tested positive for HBsAg; 130 (38.92%) were HBeAg positive, 105 (31.44%) were HBeAg and anti-HBe negative, and 99 (29.64%) were anti-HBe positive. 2. Women positive for HBsAg exhibited a slight increase in toxemia (p<0.1), and no significant difference in postpartum hemorrhage (0.05< p <0.1) and the severity of hyper-emesis. 3. SGPT was significantly higher in HBeAg positive women than in HBeAg negative women (p<0.01), and it was significantly more elevated in both eclamptic and preeclamptic women than in normal pregnant women (p<0.005). 4. The frequency of congenital malformation, spontaneous abortion, infantile death and physiologic jaundice was increased in the newborns of chronic HBV carriers, while women with active hepatitis B experienced more premature births. 5. Mother to infant transmission of HBsAg and HBeAg was high in the HBeAg positive group (18.0%, 42.7%) respectively, but very low in the HBeAg negative group (7.8%, 0.0%). Mother to infant transmission of antibodies was in the order of anti-HBc (95.5%), anti-HBe (91.2%) and anti-HBs (75.0%). The effects of the HBV carrier state in pregnant women included increases in toxemia, postpartum hemorrhage, congenital malformations and premature births, however none of them were statistically significant. There was a significant difference in the elevation of SGPT between toxemic and normal pregnant women, and between HBeAg positive and HBeAg negative carrier women. The mother to infant transmission rate of HBeAg was more frequent than that of HBsAg.

Intrahepatic cholestasis of pregnancy with marked elevation of transaminases in a black American

A case of intrahepatic cholestasis of pregnancy (ICP) in a black American is presented. This is the first case reported in a black. Marked elevation of transaminases with mild biochemical evidence of cholestasis was initially suggestive of viral hepatitis. A clinical course characterized by pruritus with minimal constitutional symptoms, rapid resolution of biochemical abnormalities after delivery, and negative hepatitis A and B serologies was consistent with the diagnosis of ICP. Review of the classic features of ICP with emphasis on some unusual aspects of the disorder is included.

Routine hepatitis screening in adolescent pregnancies: is it cost effective?

In most obstetric centers routine serum screening for hepatitis B is not part of standard prenatal care. This study was designed to determine whether hepatitis B screening is cost effective for routine prenatal testing. In a prenatal population of 585 adolescents the cost-benefit ratio of hepatitis B screening was compared with that of routine syphilis screening. Eight positive results were detected, with a cost of $1755 per positive case. This compared favorably with the frequency and cost of detection of syphilis in the same population. Routine hepatitis B screening is recommended for consideration in similar prenatal populations.

The role of hepatic ornithine transcarbamylase deficiency in the orotic aciduria of pregnant mice

Groups of normal and heterozygote sparse-fur (spf) mutant mice were studied at various stages of gestation, to assess the effects of normal pregnancy on orotate excretion, hepatic mitochondrial urea cycle enzymes and any predisposition to the development of fatty liver. Results show a higher total daily excretion of urinary orotate by normal pregnant mice on the 8th and 15th days of gestation, which came to within the usual basal range of excretion of non-pregnant mutant heterozygotes with hereditary ornithine transcarbamylase deficiency. Liver ornithine transcarbamylase and carbamyl phosphate synthetase-I activities were reduced in pregnant mice on the 16th day of gestation (P less than 0.05). No fatty change, bile stasis or glycogen depletion was discernible on optical microscopy in normal or mutant mice. Nonspecific changes were seen on ultrastructural examination. Orotic aciduria seen in pregnant mice may be directly related to a physiological deficiency of liver ornithine transcarbamylase. However, the depletion of both the mitochondrial urea cycle enzymes, seen on the 16th day of pregnancy, may be indicative of a metabolic stress at the mitochondrial level.

Liver disease in pregnancy

The diseases which affect the liver in pregnancy can be subdivided into those which occur simultaneously with gestation and those which occur in the context of and exclusively during pregnancy. This review deals with the latter group and describes the histopathological features of acute fatty liver of pregnancy and liver disease in toxaemia of pregnancy, hyperemesis gravidarum and intrahepatic cholestasis of pregnancy.

Serum copper and zinc concentrations in intrahepatic cholestasis of pregnancy: a controlled study

A prospective, controlled study was undertaken in parturients with normal pregnancy and in parturients with intrahepatic cholestasis of pregnancy (IHC) to assess changes in maternal serum copper and zinc concentrations. Cord serum levels of these trace metals were measured, as well. Copper and zinc were measured by particle-induced X-ray emission (PIXE) analysis on two occasions during pregnancy; and immediately, 5 days and 5 weeks after delivery. Maternal serum copper was significantly higher in the IHC group as compared to the control group at 36-40 weeks of pregnancy and immediately and 5 days after delivery. There were no statistically significant differences between the control and study groups for maternal and cord serum zinc and cord copper concentrations. A positive correlation between maternal serum copper and serum aspartate aminotransferase was observed.

Acute fatty liver of pregnancy: a clinicopathologic study of 35 cases

Acute fatty liver of pregnancy is a disease of the third trimester which is generally considered to be rare and to have a grave prognosis. This study found an optimistic outlook for patients with acute fatty liver of pregnancy due to early termination of the pregnancy as well as the recognition of milder cases. In prospectively followed women, a maternal mortality of 8% and a fetal mortality of 14% were observed. The disorder also appears to be more common than previously suspected and should be considered in all women with liver dysfunction in late pregnancy, even if they are anicteric. Histologically, the characteristic fine droplet steatosis usually produces distinct vacuolization in sections stained with hematoxylin-eosin. However, early in the course of the illness, liver cells have a ballooned appearance and the presence of lipid is masked. When accompanied by a significant necroinflammatory reaction, this stage may be difficult to distinguish from acute viral hepatitis. Whenever acute fatty liver of pregnancy is suspected, a small piece of the biopsy should be reserved for special stains to confirm the presence of lipid in frozen sections. Significant loss of hepatic parenchyma is a regular accompaniment of acute fatty liver of pregnancy and is due to hepatocytolysis, acidophilic degeneration and liver cell atrophy. Extramedullary hematopoiesis and giant mitochondria are often present; the latter change is probably an adaptive or degenerative response to an altered metabolic environment. Despite the frequent presence of signs and symptoms of toxemia in patients with acute fatty liver of pregnancy, no histologic overlap was observed, suggesting that they represent distinct etiologic entities.

Gallbladder function and maternal bile acids in intrahepatic cholestasis of pregnancy

Ultrasonic measurement of the gallbladder volume was taken in 8 nonpregnant, healthy women, in 7 women with normal pregnancies and in 7 women whose pregnancies were complicated by intrahepatic cholestasis of pregnancy, in the fasting state and 30, 60, 120 and 180 min after a test meal. At the same time the serum concentrations of cholic acid and chenodeoxycholic acid were measured. The fasting and ejection volumes of the gallbladder in cholestasis of pregnancy were greater than in normal pregnancy. The fasting volume of the gallbladder was greater, but the ejection volume smaller in normal pregnancy than in nonpregnant women. No difference in the ultrasonic appearance of the intra- and extrahepatic bile ducts was found between the groups. Serum bile acids were increased in cholestasis of pregnancy and did not display any decreasing tendency after the postprandial rise during the following 3 h. The results indicate that in cholestasis of pregnancy the gallbladder function and the enterohepatic circulation of bile acids are different from normal pregnancy. This may be associated with the great tendency to gallstones in these women. The large size of the gallbladder in cholestasis of pregnancy has differential diagnostic importance in the ultrasonic evaluation of a pregnant woman with liver disease.