Prospective study of liver dysfunction in pregnancy in Southwest Wales

FIGO guideline on liver disease and pregnancy

The number of women entering pregnancy with chronic liver disease is rising. Gestational liver disorders affect 3% of the pregnant population. Both can be associated with significant maternal and fetal morbidity and mortality. European guidance has recently been published to inform management. This FIGO (the International Federation of Gynecology & Obstetrics) guideline aims to use the latest evidence to inform practice relevant to a global population. The immediate past and present chairs of FIGO's Committee on the Impact of Long-term Health invited the Chair of the European guideline, alongside two trainees with an interest in liver disorders in pregnancy, to develop a guideline relevant to a global audience, thus serving the real-world population and fulfilling FIGO's ambition to enhance their global voice for women's health. Experts in the field with experience in managing liver disorders in pregnancy from a diverse selection of continents helped to develop a guideline. A guideline has been developed including the most common pre-existing and gestational liver disorders. Evidence-based best practice recommendations are summarized in addition to pragmatic recommendations. Printable tables/figures are included in the guideline for ease of use. These include a table of normal ranges of commonly used blood tests, a table outlining safety of investigations, and a table of delivery considerations relevant to a global audience. Figures designed to summarize each section of the guideline and the multidisciplinary approach to managing liver disorders in pregnancy are also included. This guideline incorporates guidance for a global audience aimed at improving the management of women with pre-existing and new liver disease in pregnancy.

Markedly elevated liver enzymes in pregnancy: A 10-year review of cases in a tertiary maternal hospital in Brisbane, Australia

Abnormalities of liver function are common during pregnancy. This retrospective study examined the incidence, aetiology and adequacy of investigation of pregnant women with markedly elevated aspartate aminotransferase and/or alanine transaminase levels (more than 10-fold of the upper limit of normal) over a ten-year period at a tertiary referral maternity hospital in Brisbane, Australia. Three hundred and twenty-three women were found to have markedly elevated liver enzymes, representing 0.56% of pregnancies with known delivery outcomes. Two hundred and sixty-four cases (82%) were due to pregnancy-specific causes. No cause was identified in 12 women (3.8%) despite investigation. No adverse maternal, fetal or neonatal outcome occurred in these pregnancies where no cause was identified for markedly elevated liver enzymes. A further six women (1.9%) did not have comprehensive investigation into underlying aetiologies of elevated liver enzymes.

Maternal Mortality due to Pregnancy-Related Acute Kidney Injury (PRAKI); A Study of the Epidemiological Factors and Possible Solutions

Objective

This prospective observational study aimed to explore the epidemiology, causes, and outcomes of Pregnancy-Related Acute Kidney Injury (PRAKI) in a tertiary care center in North India and identify risk factors for mortality.

Methods

We enrolled adult obstetric patients with PRAKI according to Kidney disease improving global outcomes criteria between February 2021 and April 2022. Data on demographic characteristics, clinical features, causes of PRAKI, and outcomes were collected. Univariate and multivariate analyses were conducted to identify factors associated with mortality. PRAKI prevention bundles for patients and obstetricians were proposed on the basis of key findings of the study.

Results

Of the 89 patients included, pre-eclampsia/eclampsia/HELLP syndrome, hemorrhage, and sepsis were the primary causes of PRAKI. Maternal mortality was alarmingly high at 24.7%. Factors independently associated with mortality were the need for vasopressor support and renal replacement therapy.

Conclusion

This study highlights the urgent need for preventive and therapeutic interventions to reduce maternal mortality related to PRAKI. On the basis of the key findings, PRAKI prevention bundles were proposed. The PRAKI prevention (patient) bundle included regular BP measurement during ANC visits, healthcare check-up if there is fever or drop in urine during pregnancy or immediate postpartum. The PRAKI prevention (obstetrician) bundle included regular BP measurement, urine culture, avoidance of nephrotoxic agents and hourly urine output monitoring during delivery and immediate postpartum. Implementing preventive measures, enhancing obstetric intensive care units, and improving antenatal care compliance may help mitigate the devastating impact of PRAKI.

Association of Adverse Perinatal Outcomes with Blood Components Transfusion in Patients with Acute Fatty Liver of Pregnancy

Purpose

To investigate the rare obstetric emergency with no specific treatments called acute fatty liver of pregnancy. The primary objective was to evaluate association of adverse perinatal outcomes with blood components transfusion. While the secondary objective focused on further establishing the predictive risk factors for adverse perinatal outcomes.

Participants and Methods

This retrospective cohort study included patients, who diagnosed with acute fatty liver of pregnancy without hepatic/malignant diseases in Qilu Hospital of Shandong University over 12-year period (collected 2007-2019, aged 20-41years). Chi-square test was used to explore the relevance between blood transfusion therapy and adverse perinatal outcomes. Meanwhile, logistic regression analysis was performed to identify predictive risk factors.

Results

Of 146 patients, 26 (26/146, 17.8%) received prenatal blood transfusions. These patients had reduced gestational ages and exhibited more severe clinical symptoms. The association between blood transfusion and adverse maternal outcomes yielded a P value of 0.044, while the association with fetal outcomes was highly significant (P<0.001). Multivariate logistic regression analysis identified seven high-risk factors for maternal outcomes and six for fetal outcomes, all demonstrating strong discriminatory capacity.

Conclusion

Blood component transfusion may serve as a marker of disease severity. Prompt identification of patients with high-risk factors is crucial to improve maternal and fetal outcomes.

Approach to Altered Mental Status in Pregnancy and Postpartum

The evaluation and diagnosis of altered mental status in the pregnant or postpartum patient largely parallels the approach used for any other patient; however, there are several critical differences including that some neuroobstetric diagnoses require emergent delivery of the fetus. Being familiar with the physiological changes and medical complications of pregnancy and delivery is therefore essential. This review first addresses pregnancy-specific disorders that may result in altered mental status, such as the hypertensive disorders of pregnancy and pregnancy-related metabolic and endocrinopathies. The focus then shifts to the complex physiologic changes in pregnancy and how these changes contribute to the distinct epidemiology of pregnancy-related cerebrovascular complications like intracranial hemorrhage, ischemic stroke, and reversible cerebral vasoconstriction syndrome. Medical disorders that are not unique to pregnancy, such as infections and autoimmune conditions, may present de novo or worsen during pregnancy and the peripartum period and require a thoughtful approach to diagnosis and management. Finally, the unique nervous system complications of obstetric anesthesia are explored. In each section, there is a focus not only on diagnosis and syndrome recognition but also on the emergent treatment needed to reverse these complications, bearing in mind the unique physiology of the pregnant patient.

Postpartum hepatitis flares in mothers with chronic hepatitis B infection

Postpartum elevation of alanine aminotransferase (ALT) in mothers with chronic hepatitis B (CHB) presents a significant clinical challenge. However, the existing literature demonstrates inconsistencies regarding its incidence and predictors in mothers infected with the hepatitis B virus (HBV). Recent advancements in antiviral prophylaxis against mother-to-child transmission of HBV and postpartum cessation of antiviral therapy further complicate this issue. Our literature review, spanning PubMed, and two Chinese-language databases (CNKI and Wanfang) from 1 January 2000 to 31 December 2023 aimed to consolidate and analyse available data on the frequency and severity of postpartum ALT flares, identify risk factors, and propose a management algorithm. Data from 23 eligible studies involving 8,077 pregnant women revealed an overall incidence of postpartum ALT elevation: 25.7% for mild cases, 4.4% for moderate cases, and 1.7% for severe cases. In the subgroup of mothers who were HBeAg-positive and on antiviral prophylaxis for preventing mother-to-child transmission, postpartum intermediate and severe ALT elevations were reported with pooled rates of 5.9% and 0.8%, respectively. Importantly, none resulted in mortality or necessitated liver transplantation. Identified risk factors for postpartum ALT flares in mothers with CHB included HBV DNA levels, ALT levels during pregnancy, postpartum cessation of antiviral treatment, and HBeAg status. By leveraging this evidence and recent data on predictors of intermediate or severe postpartum ALT flares, we propose a risk-stratified algorithm for managing postpartum ALT elevation and selecting therapy in mothers with CHB, tailoring different approaches for treatment-naive vs treatment-experienced populations. These recommendations aim to provide guidance for clinical decision-making and enhance patient outcomes.

AGA Clinical Practice Update on Pregnancy-Related Gastrointestinal and Liver Disease: Expert Review

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available published evidence and expert advice regarding the clinical management of patients with pregnancy-related gastrointestinal and liver disease.

METHODS

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Gastroenterology. This article provides practical advice for the management of pregnant patients with gastrointestinal and liver disease based on the best available published evidence. The Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because formal systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: To optimize gastrointestinal and liver disease before pregnancy, preconception and contraceptive care counseling by a multidisciplinary team should be encouraged for reproductive-aged persons who desire to become pregnant. BEST PRACTICE ADVICE 2: Procedures, medications, and other interventions to optimize maternal health should not be withheld solely because a patient is pregnant and should be individualized after an assessment of the risks and benefits. BEST PRACTICE ADVICE 3: Coordination of birth for a pregnant patient with complex inflammatory bowel disease, advanced cirrhosis, or a liver transplant should be managed by a multidisciplinary team, preferably in a tertiary care center. BEST PRACTICE ADVICE 4: Early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum. In addition to standard diet and lifestyle measures, stepwise treatment consists of symptom control with vitamin B6 and doxylamine, hydration, and adequate nutrition; ondansetron, metoclopramide, promethazine, and intravenous glucocorticoids may be required in moderate to severe cases. BEST PRACTICE ADVICE 5: Constipation in pregnant persons may result from hormonal, medication-related, and physiological changes. Treatment options include dietary fiber, lactulose, and polyethylene glycol-based laxatives. BEST PRACTICE ADVICE 6: Elective endoscopic procedures should be deferred until the postpartum period, whereas nonemergent but necessary procedures should ideally be performed in the second trimester. Pregnant patients with cirrhosis should undergo evaluation for, and treatment of, esophageal varices; upper endoscopy is suggested in the second trimester (if not performed within 1 year before conception) to guide consideration of nonselective β-blocker therapy or endoscopic variceal ligation. BEST PRACTICE ADVICE 7: In patients with inflammatory bowel disease, clinical remission before conception, during pregnancy, and in the postpartum period is essential for improving outcomes of pregnancy. Biologic agents should be continued throughout pregnancy and the postpartum period; use of methotrexate, thalidomide, and ozanimod must be stopped at least 6 months before conception. BEST PRACTICE ADVICE 8: Endoscopic retrograde cholangiopancreatography during pregnancy may be performed for urgent indications, such as choledocholithiasis, cholangitis, and some cases of gallstone pancreatitis. Ideally, endoscopic retrograde cholangiopancreatography should be performed during the second trimester, but if deferring the procedure may be detrimental to the health of the patient and fetus, a multidisciplinary team should be convened to decide on the advisability of endoscopic retrograde cholangiopancreatography. BEST PRACTICE ADVICE 9: Cholecystectomy is safe during pregnancy; a laparoscopic approach is the standard of care regardless of trimester, but ideally in the second trimester. BEST PRACTICE ADVICE 10: The diagnosis of intrahepatic cholestasis of pregnancy is based on a serum bile acid level >10 μmol/L in the setting of pruritus, typically during the second or third trimester. Treatment should be offered with oral ursodeoxycholic acid in a total daily dose of 10-15 mg/kg. BEST PRACTICE ADVICE 11: Management of liver diseases unique to pregnancy, such as pre-eclampsia; hemolysis, elevated liver enzymes, and low platelets syndrome; and acute fatty liver of pregnancy requires planning for delivery and timely evaluation for possible liver transplantation. Daily aspirin prophylaxis for patients at risk for pre-eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome is advised beginning at week 12 of gestation. BEST PRACTICE ADVICE 12: In patients with chronic hepatitis B virus infection, serum hepatitis B virus DNA and liver biochemical test levels should be ordered. Patients not on treatment but with a serum hepatitis B virus DNA level >200,000 IU/mL during the third trimester of pregnancy should be considered for treatment with tenofovir disoproxil fumarate. BEST PRACTICE ADVICE 13: In patients on immunosuppressive therapy for chronic liver diseases or after liver transplantation, therapy should be continued at the lowest effective dose during pregnancy. Mycophenolate mofetil should not be administered during pregnancy.

Acute liver failure in pregnancy

Liver function abnormalities are noted in a minority of pregnancies with multiple causes for the same. A small proportion of these develop severe liver injury and progress to acute liver failure (ALF). There is a discrete set of etiology for ALF in pregnancy and comprehensive understanding will help in urgent evaluation. Certain diseases such as acute fatty liver of pregnancy, hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome and pre-eclampsia are secondary to pregnant state and can present as ALF. Quick and targeted evaluation with urgent institution of etiology-specific management, especially urgent delivery in patients with pregnancy-associated liver diseases, is the key to avoiding maternal deaths. Pregnancy, as also the fetal life, imparts a further layer of complication in assessment, prognosis and management of these sick patients with ALF. Optimal management often requires a multidisciplinary approach in a well-equipped centre. In this review, we discuss evaluation, assessment and management of pregnant patients with ALF, focussing on approach to pregnancy-associated liver diseases.

Investigating gastrointestinal disorders in pregnancy

This article reviews anatomical and physiological changes and alterations in reference intervals for laboratory tests in healthy pregnancy, pertinent to investigation of the gastrointestinal system. The safety of procedures and radiological investigations relevant to the investigation of gastrointestinal disorders in pregnancy are also reviewed.

Liver imaging and pregnancy: what to expect when your patient is expecting

Liver diseases in pregnancy can be specific to gestation or only coincidental. In the latter case, the diagnosis can be difficult. Rapid diagnosis of maternal-fetal emergencies and situations requiring specialized interventions are crucial to preserve the maternal liver and guarantee materno-fetal survival. While detailed questioning of the patient and a clinical examination are highly important, imaging is often essential to reach a diagnosis of these liver diseases and lesions. Three groups of liver diseases may be observed during pregnancy: (1) diseases related to pregnancy: intrahepatic cholestasis of pregnancy, pre-eclampsia, eclampsia, hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, and acute fatty liver of pregnancy; (2) liver diseases that are more frequent during or exacerbated by pregnancy: acute herpes simplex hepatitis, Budd-Chiari syndrome, hemorrhagic hereditary telangiectasia, hepatocellular adenoma, portal vein thrombosis, and cholelithiasis; (3) coincidental conditions, including acute hepatitis, incidental focal liver lesions, metabolic dysfunction-associated steatotic liver disease, cirrhosis, hepatocellular carcinoma, liver abscesses and parasitosis, and liver transplantation. Specific knowledge of the main imaging findings is required to reach an early diagnosis, for adequate follow-up, and to avoid adverse consequences in both the mother and the fetus.Critical relevance statement Pregnancy-related liver diseases are the most important cause of liver dysfunction in pregnant patients and, in pregnancy, even common liver conditions can have an unexpected turn. Fear of radiations should never delay necessary imaging studies in pregnancy.Key points• Pregnancy-related liver diseases are the most frequent cause of liver dysfunction during gestation.• Fear of radiation should never delay necessary imaging studies.• Liver imaging is important to assess liver emergencies and for the diagnosis and follow-up of any other liver diseases.• Common liver conditions and lesions may take an unexpected turn during pregnancy.• Pregnancy-specific diseases such as pre-eclampsia and HELLP syndrome must be rapidly identified. However, imaging should never delay delivery when it is considered to be urgent for maternal-fetal survival.

Bile acids metabolism in the gut-liver axis mediates liver injury during lactation

AIMS

The obesity epidemic, especially in pregnant women, linked to a higher risk of liver diseases. Bile acids (BAs) are known to participate in liver metabolism, but this function during obesogenic reproductive process remains largely uncertain. The study aims to identify whether a high-fat diet (HFD) during pregnancy negatively disturbs liver metabolism and the potential role of BAs and gut microbiota (GM)in a sow model.

MAIN METHODS

Reproductive (RP) or non-reproductive (NRP) sows were fed a 15 % HFD containing compound oil. Body condition, blood parameters, and BAs levels/profile during gestation and lactation were monitored. The tissues and colonic GM were collected after euthanasia at the end of lactation. HepG2 hepatocytes were used to test the effects of BAs on liver damage and the mechanism.

KEY FINDINGS

Reproductive sows fed an HFD (HF-RP) experienced increased weight loss, and elevated plasma non-esterified fatty acid (NEFA) during lactation, consistent with exacerbated lipolysis, aggravating the risk of liver damage. HF-RP sows exhibited an enlarged BAs pool size and alterations in composition (higher levels of CDCA and LCA species) along with a drastic change in the GM (increased Firmicutes/Bacteroidetes ratio and declined Lactobacillus abundance). Furthermore, the liver FXR-SHP pathway, BAs synthesis and transport underwent adaptive regulation to sustain the BAs homeostasis and hepatic lipid metabolism. CDCA alleviated endoplasmic reticulum (ER) stress induced by palmitic acid via FXR pathway, in HepG2 cells.

SIGNIFICANCE

Lactation BAs metabolism signal in gut-liver axis coordinated the risk of liver damage induced by exacerbated lipolysis in obesogenic pregnancy.

Factors and a model to predict three-month mortality in patients with acute fatty liver of pregnancy from two medical centers

BACKGROUND

Acute fatty liver of pregnancy (AFLP) is an uncommon but potentially life-threatening complication. Lacking of prognostic factors and models renders prediction of outcomes difficult. This study aims to explore factors and develop a prognostic model to predict three-month mortality of AFLP.

METHODS

This retrospective study included 78 consecutive patients fulfilling both clinical and laboratory criteria and Swansea criteria for diagnosis of AFLP. Univariate and multivariate cox regression analyses were used to identify predictive factors of mortality. Predictive efficacy of prognostic index for AFLP (PI-AFLP) was compared with the other four liver disease models using receiver operating characteristic (ROC) curve.

RESULTS

AFLP-related three-month mortality of two medical centers was 14.10% (11/78). International normalised ratio (INR, hazard ratio [HR] = 3.446; 95% confidence interval [CI], 1.324-8.970), total bilirubin (TBIL, HR = 1.005; 95% CI, 1.000-1.010), creatine (Scr, HR = 1.007; 95% CI, 1.001-1.013), low platelet (PLT, HR = 0.964; 95% CI, 0.931-0.997) at 72 h postpartum were confirmed as significant predictors of mortality. Artificial liver support (ALS, HR = 0.123; 95% CI, 0.012-1.254) was confirmed as an effective measure to improve severe patients' prognosis. Predictive accuracy of PI-AFLP was 0.874. Area under the receiver operating characteristic curves (AUCs) of liver disease models for end-stage liver disease (MELD), MELD-Na, integrated MELD (iMELD) and pregnancy-specific liver disease (PSLD) were 0.781, 0.774, 0.744 and 0.643, respectively.

CONCLUSION

TBIL, INR, Scr and PLT at 72 h postpartum are significant predictors of three-month mortality in AFLP patients. ALS is an effective measure to improve severe patients' prognosis. PI-AFLP calculated by TBIL, INR, Scr, PLT and ALS was a sensitive and specific model to predict mortality of AFLP.

Swansea criteria evaluation in acute fatty liver of pregnancy, hemolysis elevated liver enzyme and low platelet syndrome, pre-eclampsia, and viral acute liver failure in pregnancy

Not only AFLP but also HELLP and acute liver failure due to viruses in pregnancy meet the Swansea criteria, meriting a reappraisal and a reevaluation of the criteria.

[Acute Fatty Liver of Pregnancy - Case Series]

With a prevalence of 0,01-0,03%, acute fatty liver in pregnancy (AFLP) is a rare and dangerous complication of pregnancy and is difficult to distinguish from other, sometimes more common, pregnancy diseases such as HELLP syndrome, aHUS and TTP because of its mostly non-specific symptoms. Due to its rarity, AFLP is often not obvious to the obstetrician as a possible differential diagnosis. Yet early diagnosis and the fastest possible delivery is the only causal therapy and is important for the mortality rate. In the present manuscript, the pathophysiology, diagnosis and therapy of acute fatty liver in pregnancy are highlighted for the clinical routine based on case descriptions from three university hospitals, and reference is made to possible findings that are helpful in establishing the diagnosis. The angiogenic preeclampsia marker sFlt-1 plays a role and provides new opportunities to consider pathophysiological approaches.

Acute liver failure in low-income and middle-income countries

Acute liver failure is a rare condition involving the rapid development, progression, and worsening of liver dysfunction, characterised by coagulopathy and encephalopathy, and has a high mortality unless liver transplantation is performed. Population-based studies are scarce, and most published data are from high-income countries, where the main cause of acute liver failure is paracetamol overdose. This Review provides an overview of the scanty literature on acute liver failure in low-income and middle-income countries, where patients are often admitted to primary care hospitals and viral hepatitis (especially hepatitis E), tropical infections (eg, dengue), traditional medicines, and drugs (especially anti-tuberculosis drugs) have an important role. We discuss incidence, cause, occurrence in children and pregnant women, prognostic factors and scores, treatment, and mortality. To conclude, we advocate for international collaboration, the establishment of central registries for the condition, and better diagnostics.

Diagnostic Approach to Elevated Liver Function Tests during Pregnancy: A Pragmatic Narrative Review

Liver disease is not uncommon during pregnancy and is associated with increased maternal and fetal/neonatal morbidity and mortality. Physiological changes during pregnancy, including a hyperestrogenic state, increase in circulating plasma volume and/or reduction in splanchnic vascular resistance, and hemostatic imbalance, may mimic or worsen liver disease. For the clinician, it is important to distinguish among the first presentation or exacerbation of chronic liver disease, acute liver disease non-specific to pregnancy, and pregnancy-specific liver disease. This last group classically includes conditions such as hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, liver disorders associated with the pre-eclampsia spectrum, and an acute fatty liver of pregnancy. All of these disorders often share pathophysiological mechanisms, symptoms, and laboratory findings (such as elevated liver enzymes), but a prompt and correct diagnosis is fundamental to guide obstetric conduct, reduce morbidity and mortality, and inform upon the risk of recurrence or development of other chronic diseases later on in life. Finally, the cause of elevated liver enzymes during pregnancy is unclear in up to 30-40% of the cases, and yet, little is known on the causes and mechanisms underlying these alterations, or whether these findings are associated with worse maternal/fetal outcomes. In this narrative review, we aimed to summarize pragmatically the diagnostic work-up and the management of subjects with elevated liver enzymes during pregnancy.

Systemic Disease and the Liver Part 2: Pregnancy-Related Liver Injury, Sepsis/Critical Illness, Hypoxia, Psoriasis, Scleroderma/Sjogren's Syndrome, Sarcoidosis, Common Variable Immune Deficiency, Cystic Fibrosis, Inflammatory Bowel Disease, and Hematologic Disorders

The liver is involved in many multisystem diseases and commonly may manifest with abnormal liver chemistry tests. The liver test perturbations may be multifactorial in nature, however, as patients are receiving many different medications and can also have intrinsic liver disease that may be exacerbated by the systemic disorder. Some disorders have typical histologic findings that can be diagnosed on liver biopsy, whereas others will show a more nonspecific histology. Clinicians should be aware of these conditions so as to consider the performance of a liver biopsy at the most opportune time and setting to help establish the diagnosis of acute or chronic liver disease.

Acute Liver Failure Guidelines

Acute liver failure (ALF) is a rare, acute, potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease. Due to the rarity of this condition, published studies are limited by the use of retrospective or prospective cohorts and lack of randomized controlled trials. Current guidelines represent the suggested approach to the identification, treatment, and management of ALF and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence was reviewed using the Grading of Recommendations, Assessment, Development and Evaluation process to develop recommendations. When no robust evidence was available, expert opinions were summarized using Key Concepts. Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios.

Maternal Coagulation Disorders and Postpartum Hemorrhage

Coagulation disorders are rare causes of postpartum hemorrhage. Disturbances in coagulation should be suspected in patients with a family history of coagulopathy, those with a personal history of heavy menstrual bleeding, and those with persistent bleeding despite correction of other causes. The coagulopathic conditions discussed include disseminated intravascular coagulation, platelet disorders, and disturbances of coagulation factors. These should not be overlooked in the evaluation of obstetric hemorrhage, as diagnosis and appropriate treatment may prevent severe maternal morbidity and mortality.

Evaluation of living donors for hereditary liver disease (siblings, heterozygotes)

Living donor liver transplantation (LDLT) is recognised as an alternative treatment modality to reduce waiting list mortality and expand the donor pool. Over recent decades, there have been an increasing number of reports on the use of LT and specifically LDLT for familial hereditary liver diseases. There are marginal indications and contraindications that should be considered for a living donor in paediatric parental LDLT. No mortality or morbidity related to recurrence of metabolic diseases has been observed with heterozygous donors, except for certain relevant cases, such as ornithine transcarbamylase deficiency, protein C deficiency, hypercholesterolemia, protoporphyria, and Alagille syndrome, while donor human leukocyte antigen homozygosity also poses a risk. It is not always essential to perform preoperative genetic assays for possible heterozygous carriers; however, genetic and enzymatic assays must hereafter be included in the parental donor selection criteria in the aforementioned circumstances.

Clinical advances: pregnancy in gastroenterologic and hepatic conditions

The fields of gastroenterology and hepatology, along with endoscopic practice, have seen significant changes and innovations to practice in just the past few years. These practice changes are not limited to gastroenterology, but maternal fetal medicine and the care of the pregnant person have become increasingly more sophisticated as well. Gastroenterologists are frequently called on to provide consultative input and/or perform endoscopy during pregnancy. To be able to provide the best possible care to these patients, gastroenterologists need to be aware of (and familiar with) the various nuances and caveats related to the care of pregnant patients who either have underlying gastrointestinal (GI) conditions or present with GI and liver disorders. Here, we offer a clinical update with references more recent than 2018, along with a few words about SARS-CoV-2 infection and its relevance to pregnancy.

Toxic effects of maternal cadmium exposure on the metabolism and transport system of amino acids in the maternal livers

Fetal growth restriction (FGR) is one of the most common obstetric diseases, and affects approximately 10 % of all pregnancies worldwide. Maternal cadmium (Cd) exposure is one of the factors that may increase the risk of the development of FGR. However, its underlying mechanisms remain largely unknown. In this study, using Cd-treated mice as an experimental model, we analyzed the levels of some nutrients in the circulation and the fetal livers by biochemical assays; the expression patterns of several key genes involved in the nutrient uptake and transport, and the metabolic changes in the maternal livers were also examined by quantitative real-time PCR and gas chromatography-time of flight-mass spectrometry method. Our results showed that, the Cd treatment specifically reduced the levels of total amino acids in the peripheral circulation and the fetal livers. Concomitantly, Cd upregulated the expressions of three amino acid transport genes (SNAT4, SNAT7 and ASCT1) in the maternal livers. The metabolic profiling of maternal livers also revealed that, several amino acids and their derivatives were also increased in response to the Cd treatment. Further bioinformatics analysis indicated that the experimental treatment activated the metabolic pathways, including the alanine, aspartate and glutamate metabolism, valine, leucine and isoleucine biosynthesis, arginine and proline metabolism. These findings suggest that maternal Cd exposure activate the amino acid metabolism and increase the amino acid uptake in the maternal liver, which reduces the supply of amino acids to the fetus via the circulation. We suspect that this underlies the Cd-evoked FGR.

COVID-19 related liver injuries in pregnancy

While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) quickly spread across the globe, our understanding of its pathogenic mechanisms evolved. Importantly, coronavirus disease 2019 (COVID-19) is now considered a syndromic multisystem inflammatory disease involving not only the respiratory system but also the cardiovascular, excretory, nervous, musculoskeletal, and gastrointestinal systems. Moreover, a membrane-bound form of angiotensin-converting enzyme 2, the entry receptor for SARS-CoV-2, is expressed on the surface of cholangiocytes and hepatocytes, suggesting the potential of COVID-19 to involve the liver. With the widespread distribution of SARS-CoV-2 throughout the population, infection during pregnancy is no longer a rare occurrence; however, little is known about the course of hepatic injuries and related outcomes in pregnant SARS-CoV-2-positive women. Thus, the understudied topic of COVID-related liver disease during pregnancy poses a great challenge for the consulting gynecologist and hepatologist. In this review, we aim to describe and summarize potential liver injuries in pregnant women with COVID-19.

Protocol for management of pregnant patients requiring emergency minor oral surgical procedures: a prospective study in 52 patients

Objectives

Dental or maxillofacial emergencies are uncommon during pregnancy, but if they occur, they are challenging to treat due to potential risks. The mother should not be denied necessary medical or dental care because of pregnancy. The aim of the study is to observe outcomes of pregnancy in patients requiring emergency minor oral surgical procedures during gestation and to determine the safety of the pregnant woman undergoing the procedure and the fetus.

Materials and Methods

The study was conducted on 52 pregnant women requiring emergency oral surgical procedures. A standard treatment protocol for treatment of specific entities was followed. Close monitoring and observation were the primary goal of treatment. All patients were followed postoperatively until complete recovery from the surgical procedures and then until birth of the baby. A control group of 52 healthy pregnant patients who did not require oral surgical procedures was considered for statistical analysis. The measurements to calculate observation were fetal loss (spontaneous abortion), preterm birth, low-birth weight, or incidence of any congenital anomalies in the baby and its association with surgical procedures.

Results

No fetal loss occurred in any of the cases. However, four patients experienced preterm birth and seven neonates exhibited low birth weights. No congenital abnormalities were discovered. In one instance, a patient who underwent surgery for a mandibular symphysis fracture under general anesthesia in the 31st week of pregnancy experienced labor pain on the fourth postoperative day, requiring an emergency Caesarean section.

Conclusion

The results of our study demonstrate that, compared to the control group, minor emergency surgeries performed during pregnancy have no discernible negative effects on the fetus. These procedures can safely be performed by adhering to our described protocols.

Evaluation of Liver Disease in Pregnancy

Liver disease in pregnancy often requires diagnostic and therapeutic considerations that are unique to pregnancy. Liver disease in pregnancy is commonly thought of as either liver disease unique to pregnancy, chronic liver disease, or liver disease coincidental to pregnancy. This review summarizes the approach to evaluation of liver disease in pregnancy.

How to Differentiate Acute Fatty Liver in Pregnancy (AFLP) with Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) Syndrome in Resource-Limited Settings? - The Importance of Swansea Criteria

•Both AFLP and HELLP syndrome are accounted as liver diseases in pregnancy.•AFLP and HELLP syndrome should be differentiated to make the proper diagnosis, especially in resource-limited settings.•The correct diagnosis holds a pivotal role since prompt therapy markedly improves the outcome of pregnancy.

Living with liver disease in the era of COVID-19-the impact of the epidemic and the threat to high-risk populations

The cardinal symptoms of severe acute respiratory syndrome coronavirus 2 infection as the pandemic began in 2020 were cough, fever, and dyspnea, thus characterizing the virus as a predominantly pulmonary disease. While it is apparent that many patients presenting acutely to the hospital with coronavirus disease 2019 (COVID-19) infection have complaints of respiratory symptoms, other vital organs and systems are also being affected. In fact, almost half of COVID-19 hospitalized patients were found to have evidence of some degree of liver injury. Incidence and severity of liver injury in patients with underlying liver disease were even greater. According to the Centers of Disease Control and Prevention, from August 1, 2020 to May 31, 2022 there have been a total of 4745738 COVID-19 hospital admissions. Considering the gravity of the COVID-19 pandemic and the incidence of liver injury in COVID-19 patients, it is imperative that we as clinicians understand the effects of the virus on the liver and conversely, the effect of underlying hepatobiliary conditions on the severity of the viral course itself. In this article, we review the spectrum of novel studies regarding COVID-19 induced liver injury, compiling data on the effects of the virus in various age and high-risk groups, especially those with preexisting liver disease, in order to obtain a comprehensive understanding of this disease process. We also provide an update of the impact of the new Omicron variant and the changing nature of COVID-19 pathogenesis.

Assessment of Clinical Characteristics and Outcomes of Liver Diseases Unique to Pregnancy at a Tertiary Hospital in Ethiopia: A Retrospective Cohort Study

BACKGROUND

Liver disease is a rare complication of pregnancy that can lead to several consequences and require specific intervention with implications for both the mother and fetus. This study is aimed at assessing the clinical profile and associated complications of liver diseases unique to pregnancy at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. Methodology. This study is a retrospective cohort study of all identified cases admitted to the obstetrics ward and intensive care unit (ICU) from January 2018 to December 2020 at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. Medical records were reviewed for clinical features, biochemical profiles, and fetomaternal complications. Data were analyzed using SPSS version 26. A chi-square test was done to look for an association with a p value less than 0.05 considered statistically significant, and an odds ratio was determined to assess the effect size.

RESULTS

From 95 cases identified, preeclampsia/eclampsia with liver dysfunction accounted for 43 (45%), followed by hemolysis elevated liver enzyme and low platelet (HELLP syndrome) 35 (36.8%), hyperemesis gravidarum with liver dysfunction 9 (9.5%), acute fatty liver of pregnancy (AFLP) 7 (7.4%), and intrahepatic cholestasis of pregnancy 1 (1.1%). When compared to HELLP syndrome, AFLP showed significantly higher median (IQR) values (p < 0.05) for total bilirubin 13.3 (7.3-16.3), direct bilirubin 9.73 (6.87-11.9) mg/dL, prothrombin time 23 (20.4-25.7) seconds, international normalization ratio 2.2 (1.9-2.4), white blood count 23.8 (17.8-26.6)^∗10³/μL, creatinine 3.5 (2.44-5.6) mg/dL, and lower hemoglobin level of 7.9 (6.2-10) g/dL. There were 4 (4.2%) maternal hospital deaths, with a case fatality rate of HELLP syndrome being 8.6% and 14.3% in AFLP. The overall hospital fetal mortality was 33 (34.7%). In this study, 42 patients with HELLP syndrome and AFLP had an increased risk of maternal ICU admission (OR = 25.5, 95% CI: 5.48-118.6, p value = 0.001), acute kidney injury requiring dialysis (OR = 12.2, 95% CI: 1.46-102.2, p value = 0.009), placental abruption (OR = 14.2, 95% CI: 1.72-117.1, p value = 0.004), and stillbirth (OR = 7.2, 95% CI: 2.38-21.7, p value = 0.001).

CONCLUSION

Preeclampsia with liver dysfunction and HELLP syndrome accounted for the majority of cases. It also demonstrated key biochemical characteristics that can be used to distinguish between HELLP syndrome and AFLP. Emphasis has to be given to the risk of requiring maternal ICU admission, dialysis, abruption of the placenta, and stillbirths while managing patients diagnosed with HELLP syndrome and AFLP.

Congenital dysfibrinogenemia misdiagnosed and inappropriately treated as acute fatty liver in pregnancy: A case report and review of literature

BACKGROUND

The purpose of this study was to report the rare case of a pregnant woman with congenital dysfibrinogenemia (CD) misdiagnosed as acute fatty liver. She was treated according to the principles of acute fatty liver but achieved good clinical results.

CASE SUMMARY

A 30-year-old woman presented with 39 (6/7) wk of menopause and 6 h of irregular abdominal pain and attended our hospital. Emergency surgery was performed due to fetal distress. Postoperative management followed the treatment principle of acute fatty liver. DNA sequencing was carried out on the pregnant woman and her pedigree. Coagulation values of the patient on admission were prothrombin time 33.7 s, activated partial thromboplastin time 60.4 s, thrombin time 45.2 s, and fibrinogen 0.60 g/L. DNA sequencing results showed that the woman carried a pathogenic heterozygous variation of the fibrinogen alpha chain gene (FGA), which is closely related to hereditary fibrinogen abnormality, and the mutation site was located in p.R350H. After a follow-up period of 12 mo, the mother and her newborn had a good prognosis without bleeding or thrombosis.

CONCLUSION

Pregnant women with CD may have atypical symptoms, which can easily lead to misdiagnosis. In addition, treatment can be attempted according to the principles of acute fatty liver management. This rare pregnant patient with CD was caused by a novel FGA (p.R350H) gene mutation.

Prevalence of elevated alanine aminotransferase (ALT) in pregnancy: A cross-sectional labor and delivery-based assessment

Since liver tests are not routinely checked in pregnancy, the prevalence of abnormal liver tests and liver-related abnormalities in pregnancy in a US-based population is not known. We sought to determine the prevalence of abnormal alanine aminotransferase (ALT) among pregnant Individuals who present to labor and delivery for evaluation and to evaluate prevalence of underlying diagnosed liver conditions. Prospective study evaluating liver tests in consecutive samples obtained on the labor and delivery unit. Patient characteristics were compared between those with and without abnormal ALT and those with and without abnormal ALT without a liver-related diagnosis made in clinical practice, using t tests for continuous measures and χ2 or Fisher's exact tests as appropriate for categorical measures. Logistic regression was utilized to identify factors associated with abnormal ALT in this subcohort to determine predictors of abnormal ALT in those without a known liver-related diagnosis. We collected 1024 laboratory specimens from 996 patients. Of these patients, 131 of 996 (13.2%) had elevated ALT ≥25 IU/L; 20 (2%) had ALT ≥50, 6 (0.6%) had ALT ≥125 and 3 (0.3%) had ALT ≥250. 61/131 (46.6%) of patients with ALT ≥25 IU/L had not had LTs checked during routine pregnancy care. 20 (15%) of individuals with abnormal LT had preeclampsia; 5 (4%) had cholestasis of pregnancy; 1 (0.8%) had hepatitis C; there were no other chronic liver diseases diagnosed. There were no significant demographic or clinical differences between those with and without ALT ≥25, whether liver disease diagnosis was made or not. We identified an over 10% prevalence of abnormal LTs in consecutive pregnant individuals who presented to L&D, most of whom did not have a liver-related condition diagnosed in clinical practice. Among those with liver-related diagnoses, PE and ICP were the most common among individuals with ALT≥25 IU/mL, with chronic liver disease rarely diagnosed. Further evaluation of the role of ALT testing as part of routine prenatal care is needed, particularly in establishing a baseline prevalence of liver test abnormalities in pregnancy and independent association with pregnancy outcomes.

High-normal liver enzyme levels in early pregnancy predispose the risk of gestational hypertension and preeclampsia: A prospective cohort study

Background

Gestational hypertension (GH) and preeclampsia (PE) are severe adverse gestational complications. Previous studies supported potential link between elevated liver enzyme levels and GH and PE. However, given the transient physiological reduction of liver enzyme levels in pregnancy, little is known whether the associations of the high-normal liver enzyme levels in early pregnancy with GH and PE exist in pregnant women.

Methods

Pregnant women in this study came from a sub-cohort of Shanghai Preconception Cohort, who were with four liver enzyme levels examined at 9–13 gestational weeks and without established liver diseases, hypertension and preeclampsia. After exclusion of pregnant women with clinically-abnormal liver enzyme levels in the current pregnancy, associations of liver enzyme levels, including alkaline phosphatase (ALP), alanine transaminase (ALT), aspartate aminotransferase (AST) and gamma-glutamyl transpeptidase (GGT), with GH and PE status were assessed by multivariable log-binomial regression. Population attributable fraction was measured to estimate the fractions of GH and PE that were attributable to the high-normal liver enzyme levels.

Results

Among 5,685 pregnant women 160 (2.8%) and 244 (4.3%) developed GH and PE, respectively. After adjustment for potential covariates, higher ALP, ALT and GGT levels were significantly associated with the risk of GH (adjusted risk ratio (aRR):1.21 [95% confidence interval, 1.05–1.38]; 1.21 [1.05–1.38]; and 1.23 [1.09–1.39]), as well as the risk of PE(1.21 [1.13–1.29]; 1.15 [1.03–1.28]; 1.28 [1.16–1.41]), respectively. The cumulative population attributable fraction of carrying one or more high-normal liver enzyme levels (at 80th percentile or over) was 31.4% for GH and 23.2% for PE, respectively.

Conclusion

Higher ALT, ALP and GGT levels within the normal range in early pregnancy are associated with increased risk of GH and PE. The documented associations provide new insight to the role of hepatobiliary function in GH and PE pathogenesis.

Magnetic Resonance Imaging of Acute Abdominal Pain in the Pregnant Patient

Evaluation of a pregnant patient presenting with acute abdominal pain can be challenging to accurately diagnose for a variety of reasons, and particularly late in pregnancy. Noncontrast MR remains a safe and accurate diagnostic imaging modality for the pregnant patient presenting with acute abdominal pain, following often an initially inconclusive ultrasound examination, and can be used in most settings to avoid the ionizing radiation exposure of a computed tomography scan. Pathologic processes discussed in this article include some of the more common gastrointestinal, hepatobiliary, genitourinary, and gynecologic causes of abdominal pain occurring in pregnancy, as well as traumatic injuries.

FREQUENCY AND SEVERITY OF LIVER INVOLVEMENT IN HYPERTENSIVE DISORDERS OF PREGNANCY

BACKGROUND

Pre-eclampsia (PE) and eclampsia (E) are among the leading causes of maternal and fetal morbidity and mortality. Both are associated with an evolving spectrum of liver disorders.

OBJECTIVE

The aim of this study was to evaluate the frequency and severity of liver involvement in pregnant women admitted to an intensive care unit with PE/E and to assess its influence on adverse maternal and fetal outcomes.

METHODS

All subjects, hospitalized between January 2012 and March 2019, were retrospectively evaluated for clinical and biochemical liver-related abnormalities and their frequencies were subsequently correlated with maternal-fetal outcomes.

RESULTS

A total of 210 women (mean age 31±6.4 years, mean gestational age 33.8±4.1 weeks) with PE/E were included in the study. Most of them had severe hypertension (n=184) and symptoms of abdominal pain (48%) and headache (40%). Liver enzymes abnormalities were seen in 49% of the subjects, usually less than five times the upper limit of normal. Subcapsular hemorrhage and spontaneous hepatic rupture were identified in one woman who died. No patient had definitive diagnosis for acute fatty liver of pregnancy, neither acute liver failure. A total of 62% of deliveries occurred before 37 weeks. Fetal mortality was observed in 6 (3%) cases. There was no correlation between mean levels of liver enzymes and maternal and fetal outcomes.

CONCLUSION

Biochemical abnormalities of liver enzymes are frequently seen in women with PE/E, but outside the spectrum of HELLP syndrome, they are not associated with adverse maternal and fetal outcomes. Liver-related complications are rare but can be life-threatening.

A predicting model of child-bearing-aged women' spontaneous abortion by co-infections of TORCH and reproductive tract

To develop a predicting model of child-bearing-aged women' spontaneous abortion (SA) by co-infections of TORCH and reproductive tract, in order to provide a reference tool for accurately predicting the risk of SA and guide the early prevention, diagnosis and treatment of SA. A prospective cohort study was designed based on 218 958 child-bearing-aged women following up in Hebei province in China from 2010 to 2017. Multivariable logistic regression analysis was used to select candidate predictive variables. Fisher's discriminant analysis was performed to build a predictive model, and the validity of the model was evaluated. The incidence rate of SA was 2.4%. Multivariable logistic regression analysis showed that age (OR = 3.507), adverse pregnancy history (OR = 1.509), co-infections status of Candida and HBsAg (OR_{Candida positive×HBsAg negative}  = 4.091, OR_{Candida negative×HBsAg positive}  = 3.327, and OR_{Candida positive×HBsAg positive}  = 13.762), and co-infections status of HBsAg, Rubella (IgG) and CMV (IgG) (OR_{HBs-Ag negative×Rubella (IgG) negative×CMV (IgG) positive}  = 1.789, OR_{HBs-Ag positive×Rubella (IgG) positive×CMV (IgG) negative}  = 3.809, and OR_{HBsAg positive×Rubella (IgG) positive×CMV (IgG) positive}  = 11.919) were the independent predictors of SA. The total discriminant rate reached 91%, with 82% of the sensitivity and 91% of the specificity. The predicting model of child-bearing-aged women' SA by co-infections status has a good performance. The co-infection status of TORCH and reproductive tract are suggested to be considered in pre-pregnancy physical examination.

Pregnancy-Associated Liver Diseases

The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.

Diagnosis and management of thrombocytopenia in pregnancy

Thrombocytopenia, defined as platelet count <150×10⁹/L, is frequently observed by physicians during pregnancy, with an incidence of approximately 10% of all pregnancies. Most of the cases of thrombocytopenia in pregnancy are due to gestational thrombocytopenia, which does not confer an increased risk of maternal bleeding. However, because other causes can be associated with life-threatening events, such as severe bleeding, that can affect to maternal and fetal outcomes, differentiating other cause of thrombocytopenia, which includes preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, acute fatty liver of pregnancy, immune thrombocytopenia, hereditary thrombocytopenia, antiphospholipid syndrome, thrombotic thrombocytopenic purpura, and atypical hemolytic uremic syndrome, is important. Understanding the mechanisms and recognition of symptoms and signs are important to decide an adequate line of investigation. In this review, the approach to diagnosis and the management of the thrombocytopenia commonly observed in pregnancy are presented.

Pr-AKI: Acute Kidney Injury in Pregnancy – Etiology, Diagnostic Workup, Management

Despite significant improvements in inpatient and outpatient management, pregnancy-related acute kidney injury (Pr-AKI) remains an important risk factor for early and late maternal and fetal morbidity and mortality. There is a discrepancy between the incidence of Pr-AKI in developing and in developed countries, with the former experiencing a decrease and the latter an increase in Pr-AKI in recent decades. Whereas septic and hemorrhagic complications predominated in the past, nowadays hypertensive disorders and thrombotic microangiopathy are the leading causes of Pr-AKI. Modern lifestyles and the availability and widespread use of in-vitro fertilization techniques in industrialized countries have allowed more women of advanced age to become pregnant. This has led to a rise in the percentage of high-risk pregnancies due to the disorders and comorbidities inherent to or accompanying aging, such as diabetes, arterial hypertension and preexisting chronic kidney disease. Last but not least, the heterogeneity of symptoms, the often overlapping clinical and laboratory characteristics and the pathophysiological changes related to pregnancy make the diagnosis and management of Pr-AKI a difficult and challenging task for the treating physician. In addition to general supportive management strategies such as volume substitution, blood pressure control, prevention of seizures or immediate delivery, each disease entity requires a specific therapy to reduce maternal and fetal complications. In this review, we used the current literature to provide a summary of the physiologic and pathophysiologic changes in renal physiology which occur during pregnancy. In the second part, we present common and rare disorders which lead to Pr-AKI and provide an overview of the available treatment options.

Managing hepatic complications of pregnancy: practical strategies for clinicians

Liver disorders specific to pregnancy are rare but can have potentially serious consequences for mother and fetus. Pregnancy-related liver disorders are the most common cause of liver disease in otherwise healthy pregnant women and pose a challenge to physicians because of the need to take into account both maternal and fetal health. A good knowledge of these disorders is necessary as prompt diagnosis and appropriate management results in improved maternal and fetal outcomes. This review will focus on pregnancy-specific disorders and will aim to serve as a guide for physicians in their diagnosis, management and subsequent monitoring.

Analysis of Causes of Hepatic Dysfunction in Obstetric Patients in India: A Systematic Review

Background

Epidemiology of liver disease in obstetric patients shows geographical variation depending upon the prevalence of preeclampsia, viral hepatitis, and tropical vector-borne diseases like malaria, leptospirosis, etc. We undertook the current systematic review to analyze the causes of hepatic dysfunction in obstetric patients in India and identify the gaps in the literature and reporting.

Materials and methods

We did a systematic review of studies reporting the causes of hepatic dysfunction in obstetric patients in India. A methodological quality assessment was done using a five-point questionnaire.

Results

A total of 21 studies qualified for evaluation. The rate of hepatic dysfunction among obstetric patients in India ranged from 0.15 to 3.3% with a mean and median rate of 1.49 and 0.93%, respectively. Preeclampsia/HELLP (mean = 36.0%, median = 31.4%, range: 3.6–83.8%) and viral hepatitis (mean = 34.1%, median = 35.5%, range: 5.1–61.8%) were the commonest causes of hepatic dysfunction. Other causes were intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, tropical fever (malaria, leptospirosis, dengue, scrub typhus), etc. Maternal mortality ranged from 1.4 to 40% (mean = 12.6%, median = 10.0%) and perinatal mortality was between 16.4 and 38.70% (mean = 31.75%, median = 35.5%).

Conclusion

There is moderate quality evidence to show that preeclampsia/HELLP and viral hepatitis are the commonest causes of hepatic dysfunction in obstetric patients in India.

How to cite this article

Ahmed A, Saxena S, Pandey A, Mishra P, Azim A. Analysis of Causes of Hepatic Dysfunction in Obstetric Patients in India: A Systematic Review. Indian J Crit Care Med 2022;26(1):114–122.

Occurrence of Liver Damage and Obstetric Outcomes in Pregnant Women Diagnosed with Pruritus during Pregnancy: A Retrospective Study

AIM

A retrospective study of the occurrence of liver damage and obstetric outcomes in pregnant women diagnosed with pruritus.

METHODS

The following parameters were monitored in patients: aspartate aminotransferase (AST), alanine aminotransferase, gamma-glutamyl transferase, bilirubin (direct and total), hemoglobin, platelets, serum bile acid level, age of pregnant women, parity, pregnancy weight gain, birth weight, and gestational age at delivery. A total of 107 patients were included during a five-year period (2016-2020) and classified into three groups. Group A included 17 pregnant women with pruritus without elevated liver enzymes and bilirubin. Group B included 50 pregnant women with pruritus, elevated liver enzymes, and bilirubin. Group C included 40 pregnant women with pruritus and elevated bile acids (regardless of liver enzyme levels).

RESULTS

The groups did not significantly differ in patients' age and parity, but there was a statistically significant between-group difference in weight gain during pregnancy. The values of AST, ALT, GGT, LDH, and direct bilirubin were the highest in group B, and serum bile acids were expectedly the highest in group C. There was no statistically significant variation in the onset of labor and mode of delivery between groups. However, groups significantly differed in gestational age at delivery, newborn birthweight, and pregnancy prolongation from the onset of pruritus to delivery.

CONCLUSION

Further study is needed to assess the pathophysiologic mechanisms underlying intrahepatic cholestasis of pregnancy as well as any significant liver damage associated with pregnancy.

Jaundice Caused by Hyperemesis Gravidarum

Background: Hyperemesis gravidarum is characterized by intractable vomiting and associated with weight loss exceeding 5% of prepregnancy body weight, dehydration, and ketosis. Hyperemesis gravidarum occurs during the first trimester and typically resolves by 16 to 20 weeks of gestation. Approximately half of all hospitalized females with hyperemesis gravidarum have a mild elevation in liver enzymes; however, jaundice and hepatic synthetic dysfunction are uncommon. Case Report: A 22-year-old gravida 1 para 0 in her ninth week with a singleton gestation was hospitalized with persistent nausea, vomiting, weight loss of 11% of her prepregnancy body weight, dehydration, hypokalemia, and jaundice. Liver function tests showed hyperbilirubinemia of 7.1 mg/dL and alanine aminotransferase levels high as 676 U/L. Other hepatobiliary diseases were excluded. Thyroid function tests revealed thyrotoxicosis. Gestational thyrotoxicosis is often associated with hyperemesis gravidarum because of their shared pathophysiology of high human chorionic gonadotropin levels during the first trimester. After supportive management including hydration, correction of electrolyte disturbance, vitamin supplementation, and antiemetic treatment, the patient's symptoms resolved. Liver and thyroid dysfunction returned to normal after resolution of vomiting. The patient delivered a healthy child at 38 weeks' gestation. Conclusion: Elevation of aminotransferase and bilirubin levels may occur in patients with hyperemesis gravidarum. Although jaundice and highly elevated liver enzymes have been reported, investigations to exclude preexisting and concurrent liver diseases are required. Management of hyperemesis gravidarum is supportive, and outcomes are generally favorable.

Liver pathology in pregnancy

Liver dysfunction occurs in up to 3% of pregnancies and can be due to pregnancy-associated liver injury, exacerbation of pre-existing liver disease, or co-incident with pregnancy. The most common form of pregnancy-associated liver injury is intrahepatic cholestasis of pregnancy (ICP). This condition is typically benign and self-limited, but is associated with fetal morbidity and mortality with high levels of serum bile acids. Acute fatty liver of pregnancy (AFLP) and the hypertensive disorders of pregnancy (including pre-eclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets [HELLP] syndrome) are more commonly associated with maternal and fetal complications and may necessitate expedient delivery. Histologically, ICP shows nonspecific features of cholestasis, while AFLP and the hypertensive disorders have more characteristic histologic findings. While not a true liver disease, hyperemesis gravidarum can cause elevated liver enzymes. Pregnant patients are at increased risk of developing severe hepatitis E and herpesvirus infections, Budd-Chiari syndrome, and gallstones, and they may also experience worsening of known chronic liver disease. Mass lesions in pregnancy including hemangiomas, focal nodular hyperplasia, and hepatocellular adenomas and carcinomas can present unique challenges for diagnosis and management. This review will explore the pathophysiology, presentation, histologic features, and management of these conditions.

A Nomogram for Predicting Non-Rebound in HBV-Infected Pregnant Women With Mother-to-Child Transmission Prevention

Background: Current guidelines recommend that pregnancies with mother-to-child transmission (MTCT) prevention can cease antiviral treatment after delivery. We aimed to develop a nomogram for predicting non-rebound in HBV-infected pregnant women with MTCT prevention after post-partum nucleos(t)ide analogs (NAs) withdrawal based on parameters before treatment cessation.

Methods: Pregnant women receiving antiviral therapy for MTCT prevention and who withdrew from taking NAs after delivery were included in this study. We used the least absolute shrinkage and selection operator (LASSO) logistics and a two-way stepwise regression to select prognostic factors for the risk model, and the concordance index (C-index) was used to assess its discrimination. Internal validation was performed through bootstrapping.

Results: Of 92 included patients, 16 and 76 experienced non-rebound and virologic rebound within 48 weeks of post-partum NAs cessation, respectively. Platelet to lymphocyte ratio (PLR) at 34 ± 2 weeks of gestation, a reduction in hepatitis B surface antigen (HBsAg) from baseline to 34 ± 2 weeks of gestation, and hepatitis B virus (HBV) DNA declining from baseline to the end of treatment (EOT) were entered into the final risk model. Its C-index was 0.91 (95% CI, 0.82–0.99), and it reached as high as 0.88 after bootstrapping validation. The decision curve and decision tree were further developed to facilitate the application of this model.

Conclusions: We developed a nomogram for predicting non-rebound in pregnant women with MTCT prevention after the withdrawal of antiviral agents, which facilitates physicians in making appropriate treatment recommendations.

Gestational Diabetes Mellitus Complicated by Hemolysis, Elevated Liver Enzymes, and Low Platelet Count After Decreased Need for Insulin: 2 Cases

BACKGROUND When a woman becomes pregnant, the placenta produces human placental lactogen (hPL). The anti-insulin effect of hPL raises maternal blood glucose levels, allowing the fetus to use glucose as a nutrient. Because hPL is produced by the placenta until delivery, insulin requirements in patients with gestational diabetes mellitus (GDM) typically increase, but in some cases, they may decrease. We retrospectively examined data from women with GDM who received insulin and delivered at our hospital. CASE REPORT From April 2019 to March 2020, we targeted patients who were diagnosed with GDM, received insulin, and delivered at our hospital. GDM was diagnosed based on the guidelines from the Japanese Society of Obstetrics and Gynecology. The rate of change in insulin dosage was calculated as: (insulin dosage at delivery - insulin dosage 14 days before delivery) divided by 14. Two patients whose insulin dosage was significantly reduced developed a syndrome of hemolysis, elevated liver enzymes, and low platelet count or acute fatty liver of pregnancy and underwent emergency cesarean section. CONCLUSIONS The present case report suggests that a decrease in insulin requirement in pregnant patients with GDM can predict maternal abnormalities due to placental dysfunction.