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Arora A, Kumar A, Anand AC, Puri P, Dhiman RK, Acharya SK, Aggarwal K, Aggarwal N, Aggarwal R, Chawla YK, Dixit VK, Duseja A, Eapen CE, Goswami B, Gujral K, Gupta A, Jindal A, Kar P, Kumari K, Madan K, Malhotra J, Malhotra N, Pandey G, Pandey U, Puri RD, Rai RR, Rao PN, Sarin SK, Sharma A, Sharma P, Shenoy KT, Singh KR, Singh SP, Suri V, Trehanpati N, Wadhawan M. Indian National Association for the Study of the Liver-Federation of Obstetric and Gynaecological Societies of India Position Statement on Management of Liver Diseases in Pregnancy. J Clin Exp Hepatol 2019; 9:383-406. [PMID: 31360030 PMCID: PMC6637074 DOI: 10.1016/j.jceh.2019.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/25/2019] [Indexed: 12/12/2022] Open
Abstract
Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.
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Key Words
- ABCB4, ATP-binding cassette subfamily B member 4
- AFLP, Acute fatty liver of pregnancy
- ALF, Acute liver failure
- ALP, Alkaline phosphatase
- ALT, Alanine transferase
- ART, Antiretroviral therapy
- AST, Aspartate aminotransferase
- BCS, Budd-Chiari syndrome
- CT, Computerized tomography
- DIC, Disseminated intravascular coagulation
- DNA, Deoxyribonucleic acid
- DPTA, Diethylenetriamine pentaacetic acid
- ERCP, Endoscopic retrograde cholangiopancreatography
- FDA, Food and Drug Administration
- FOGSI, Federation of Obstetric and Gynaecological Societies of India
- GGT, Gamma-glutamyl transpeptidase
- GI, Gastrointestinal
- GRADE, Grading of Recommendations Assessment Development and Evaluation
- HBIG, Hepatitis B immune globulin
- HBV, Hepatitis B virus
- HBeAg, Hepatitis B envelope antigen
- HBsAg, Hepatitis B surface antigen
- HCV, Hepatitis C virus
- HELLP syndrome
- HELLP, Hemolysis, elevated liver enzymes, low platelet count
- HG, Hyperemesis gravidarum
- HIV, Human immunodeficiency virus
- HV, Hepatic vein
- ICP, Intrahepatic cholestasis of pregnancy
- INASL, Indian National Association for the Study of Liver
- IVF, In vitro fertilization
- LFT, Liver function test
- MDR, Multidrug resistance
- MRI, Magnetic resonance imaging
- MTCT, Mother-to-child transmission
- NA, Nucleos(t)ide analog
- PIH, Pregnancy-induced hypertension
- PT, Prothrombin time
- PUQE, Pregnancy-Unique Quantification of Emesis
- PegIFN, Pegylated interferon
- RNA, Ribonucleic acid
- TAF, Tenofovir alafenamide
- TDF, Tenofovir disoproxil fumarate
- TIPS, Transjugular intrahepatic portosystemic shunt
- UDCA, Ursodeoxycholic acid
- UGI, Upper gastrointestinal
- ULN, Upper limit of normal
- acute fatty liver of pregnancy
- hyperemesis gravidarum
- intrahepatic cholestasis of pregnancy
- liver diseases in pregnancy
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Affiliation(s)
- Anil Arora
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil C. Anand
- Kalinga Institute of Medical Sciences, KIIT University, Bubaneswar, India
| | - Pankaj Puri
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subrat K. Acharya
- Kalinga Institute of Medical Sciences, KIIT University, Bubaneswar, India
| | - Kiran Aggarwal
- Department of Obstetrics and Gynecology, LHMC & Associated Hospitals, New Delhi, India
| | - Neelam Aggarwal
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Yogesh K. Chawla
- Kalinga Institute of Medical Sciences, KIIT University, Bubaneswar, India
| | - Vinod K. Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Bhabadev Goswami
- Department of Gastroenterology, Guwahati Medical College, Assam, India
| | - Kanwal Gujral
- Institute of Obstetrics and Gynecology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anoop Gupta
- Delhi IVF and Fertility Research Centre, New Delhi, India
| | - Ankur Jindal
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Premashish Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Patparganj, New Delhi
| | - Krishna Kumari
- Max Cure Suyosha Woman & Child Hospital, Hyderabad, India
| | - Kaushal Madan
- Max Smart Super Speciality Hospital, Saket, New Delhi, India
| | | | | | - Gaurav Pandey
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Uma Pandey
- Dept of Obstetrics & Gynecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ratna D. Puri
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Ramesh R. Rai
- Department of Gastroenterology, NIMS Medical College and Hospital, Jaipur, India
| | - Padaki N. Rao
- Department of Hepatology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Shiv K. Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Aparna Sharma
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Praveen Sharma
- Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Koticherry T. Shenoy
- Sree Gokulam Medical College and Research Foundation, Venjaramoodu, Thiruvananthapuram, India
| | - Karam R. Singh
- Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, India
| | | | - Vanita Suri
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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