Approach to liver disease occurring during pregnancy
- Richard H Lee, MD
Richard H Lee, MD
- Assistant Professor of Clinical Obstetrics and Gynecology
- Division of Maternal Fetal Medicine
- Keck School of Medicine of the University of Southern California
- Tram T Tran, MD
Tram T Tran, MD
- Medical Director of Liver Transplantation
- Liver Disease and Transplant Center at Cedars-Sinai.
- Section Editors
- Keith D Lindor, MD
Keith D Lindor, MD
- Section Editor — Alcoholic and Metabolic Liver Disease
- Professor of Medicine, Mayo Clinic College of Medicine
- Dean, College of Health Solutions
- Arizona State University
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deputy Editors
- Kristen M Robson, MD, MBA, FACG
Kristen M Robson, MD, MBA, FACG
- Assistant Professor
- Tufts University School of Medicine
- Vanessa A Barss, MD, FACOG
Vanessa A Barss, MD, FACOG
- Senior Deputy Editor — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Associate Clinical Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
Hepatobiliary disease occurring in a pregnant woman poses a challenge for the consulting clinician. Hepatic abnormalities occurring during pregnancy require diagnosis in the context of expected physiologic changes. In addition, diagnostic and therapeutic decisions have to consider the implications for both the mother and the fetus.
The types and presentation of hepatobiliary disease during pregnancy are varied.
●Some liver diseases are specific to pregnancy (eg, intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy) and some are multisystemic diseases with hepatic manifestations (eg, preeclampsia). (See "Intrahepatic cholestasis of pregnancy" and "Acute fatty liver of pregnancy" and "Preeclampsia: Clinical features and diagnosis".)
●Pregnancy-related physiologic changes may worsen the severity of, or predispose to hepatobiliary diseases that may also occur in nonpregnant women. Examples include cholelithiasis, thrombotic diseases (such as Budd-Chiari syndrome), and hepatitis E virus infection. (See "Intercurrent hepatobiliary disease during pregnancy".)
●Some diseases are not related to pregnancy but can initially present during pregnancy (eg, acute viral hepatitis). (See "Intercurrent hepatobiliary disease during pregnancy".)
- Riely CA. Liver disease in the pregnant patient. American College of Gastroenterology. Am J Gastroenterol 1999; 94:1728.
- ANTIA FP, BHARADWAJ TP, WATSA MC, MASTER J. Liver in normal pregnancy, pre-eclampsia, and eclampsia. Lancet 1958; 2:776.
- Bacq Y, Zarka O, Bréchot JF, et al. Liver function tests in normal pregnancy: a prospective study of 103 pregnant women and 103 matched controls. Hepatology 1996; 23:1030.
- Potter JM, Nestel PJ. The hyperlipidemia of pregnancy in normal and complicated pregnancies. Am J Obstet Gynecol 1979; 133:165.
- Brizzi P, Tonolo G, Esposito F, et al. Lipoprotein metabolism during normal pregnancy. Am J Obstet Gynecol 1999; 181:430.
- Ellington SR, Flowers L, Legardy-Williams JK, et al. Recent trends in hepatic diseases during pregnancy in the United States, 2002-2010. Am J Obstet Gynecol 2015; 212:524.e1.
- Ch'ng CL, Morgan M, Hainsworth I, Kingham JG. Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut 2002; 51:876.
- Buytaert IM, Elewaut GP, Van Kets HE. Early occurrence of acute fatty liver in pregnancy. Am J Gastroenterol 1996; 91:603.
- Knox TA. Evaluation of abnormal liver function in pregnancy. Semin Perinatol 1998; 22:98.
- Knight M, Nelson-Piercy C, Kurinczuk JJ, et al. A prospective national study of acute fatty liver of pregnancy in the UK. Gut 2008; 57:951.
- Nelson DB, Yost NP, Cunningham FG. Acute fatty liver of pregnancy: clinical outcomes and expected duration of recovery. Am J Obstet Gynecol 2013; 209:456.e1.
- Murali AR, Devarbhavi H, Venkatachala PR, et al. Factors that predict 1-month mortality in patients with pregnancy-specific liver disease. Clin Gastroenterol Hepatol 2014; 12:109.
- Sibai BM, Ramadan MK, Usta I, et al. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993; 169:1000.
- Bacq Y, Sapey T, Bréchot MC, et al. Intrahepatic cholestasis of pregnancy: a French prospective study. Hepatology 1997; 26:358.
- Reau N. Finding the needle in the haystack: predicting mortality in pregnancy-related liver disease. Clin Gastroenterol Hepatol 2014; 12:114.
- THE LIVER DURING NORMAL PREGNANCY
- Physical examination
- Ultrasound examination
- Serum proteins and lipids
- Liver tests
- PREVALENCE OF HEPATOBILIARY DISEASE IN PREGNANCY
- APPROACH TO DIFFERENTIAL DIAGNOSIS
- ROLE OF A LIVER BIOPSY
- Clinical scenarios
- - A patient with elevated aminotransferases
- - A patient with intractable itching
- - A patient with elevated aminotransferases and hypertension
- - A patient with nausea and vomiting in the third trimester
- MATERNAL MORTALITY
- RECURRENCE IN SUBSEQUENT PREGNANCIES
- SUMMARY AND RECOMMENDATIONS