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Early liver disease detection during pregnancy key for improved outcomes
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PHILADELPHIA — Early detection of liver-related complications and hepatic diseases in patients who are pregnant leads to reduced risks and improved outcomes for both mother and child, according to a presentation at the American College of Gastroenterology Annual Meeting.
“The first thing is recognition. Recognition is most important because early recognition allows us to take better care of our patients,” Nancy S. Reau, MD, FACG, from the Rush University Medical Center in Chicago, said during her presentation. “Liver diseases can be unique to pregnancy, but there are a lot of things that can happen to a woman with [pre-existing] liver disease who becomes pregnant, so you need to manage both directions.”
According to Reau, it is common in pregnant patients for albumin and hemoglobin levels to decrease and for alkaline phosphatase and alpha-fetoprotein to increase. In contrast, liver transaminase and bilirubin levels typically remain steady and changes in these levels should be investigated.
“We approach the liver through pattern recognition — is this a hepatocellular or a cholestatic process?” she said. “In a pregnant woman, you should go through the same sort of decisional tree as any other individual who presents with abnormal liver enzymes.”
Ultrasound should be the first line in liver imaging when investigating abnormal liver enzymes in a pregnant patient, Reau said. Magnetic resonance imaging should be performed without gadolinium if possible. If computed tomography is required, it should be performed with minimal radiation.
A “trimester-based approach” can help prognosis, Reau explained. Liver complications such as acute viral hepatitis, drug-induced liver injury and liver masses can present during any of the three trimesters, whereas intrahepatic cholestasis of pregnancy and pre-eclampsia present in the second or third trimester. Acute fatty liver of pregnancy is seen in the third trimester.
Cholelithiasis is the “most common cause for liver tests in pregnant women,” Reau said, and added that surgical prevention prior to delivery is preferred. Budd-Chiari Syndrome is also common, according to one study, and the recommended treatment is heparin.
The recommended therapy for hyperemesis, gravidarum, includes monitoring for metabolic alkalosis or acidosis, thiamine replacement, and gut rest followed by low fat-high carb diet.
Intrahepatic cholestasis can be misleading because bilirubin and gamma-glutamyl transferase levels can appear normal. Primary presentation is pruritis and management should include weekly bile acid testing and treatment with ursodeoxycholic acid.
“Acute fatty liver in pregnancy is the most frightening and important to recognize liver-related pregnancy outcome,” Reau said. “It is rare, but the symptoms can be nondescript. Although our outcomes now are excellent, before we did rapid recognition in supportive care almost all of these mothers and children died.”
Acute fatty liver in pregnancy symptoms include nausea, vomiting, abdominal discomfort, and up to 50% of pregnant patients may develop pre-eclampsia, which can rapidly lead to liver failure. According to Reau, management includes prompt delivery, maternal support which could include plasma exchange after delivery, and monitoring the child for long-chain L-3 hydroxyacyl-CoA dehydrogenase deficiency.
Regarding hepatitis B, assessment of HBV e-antigen positivity and maternal HBV DNA can determine the risk for mother-to-child transmission and should be monitored through all three trimesters. In patients whose HBV DNA is higher than 10 log IU/mL in the second and third trimester, patients should begin treatment with tenofovir disoproxil. In all cases, infants should receive HBV immune globulin and vaccine at birth.
While there are no currently known interventions to reduce mother-to-child hepatitis C transmission, Reau stated that the new all-oral direct-acting antivirals nearly ensure that both mother and child can be cured post-partum.
“In conclusion, pregnancy-induced liver disease is uncommon, but prompt recognition is imperative for appropriate management. Pre-existing liver disease typically has minimal impact on pregnancy,” Reau said. “Additionally, viral hepatitis should be screened for to prevent transmission and allow follow-up in the child.” – Talitha Bennett
Reference : Reau N. Liver Disorders in Pregnancy. Presented at: American College of Gastroenterology Annual Scientific Meeting; Oct. 5-10, 2018; Philadelphia.
Disclosure: Reau reports no relevant financial disclosures.