Monday, February 16, 2015

Elevated Liver Enzymes in Pregnancy

Let's discuss the approach to this common problem in pregnancy.

Helpful Hints in determining the etiology of elevated liver enzymes:
  • Use the gestational age to guide the diagnosis
  • Need to rule out viral/gallstone/cancer/autoimmune/drugs as the cause of elevated liver enymes at any time of the pregnancy.
  • Chronic hepatitis B or C poses a risk of transmission to the offspring
  • All of the below diagnoses can recur in subsequent pregnancy.
Liver tests affected by pregnancy (decrease, except ALP):
  • ALP (increased in the second and third trimester, due to the placenta)
  • Albumin and total protein (decreased from the first trimester due to hemodilution)
  • Bilirubin levels (slightly decreased from the first trimester)
  • GGT (slightly decreased in late pregnancy)
Liver tests not affected by pregnancy:
  • AST, ALT, PT, total bile acids, LDH
"Hi, can you please page GI to my cell phone?"

Differential Diagnosis
There are four main differential diagnoses to consider
  • Hyperemesis gravidarum - 1st trimester. 
    • Mild, often <200 alt="" often="">AST.
    • Admit to hospital if hypovolemic
    • Diclectin can be used for management for nausea
    • If persistent, make sure to rule out molar pregnancy
  • Cholestasis of pregnancy - 2nd Trimester. Common; 
    • Affected pregnancies are at increased risk for prematurity and stillbirth, and early delivery should be considered when possible. 
    • Pruritus starting in the hands and soles. NOT jaundiced but have high ALP
    • Enzymes are often very high with normal GGT. 
    • Measure bile acids  to help make the diagnosis (>10)
    • Often have history of pruritus during current and previous pregnancies. Likely to recur
    • Small risk to baby, none to the mom
    • Treatment
      • Deliver earlier
      • Ursodeoxycholic acid
      • Can also use hydroxizine, cholestyramine to help with symptoms
      • Vitamin K if INR is up
  • Acute fatty liver of pregnancy - Second half of pregnancy, usually 3rd trimester.
    • True hepatic dysfunction. ACUTE LIVER FAILURE Baby's free fat damages mom
    • Signs of pre-eclampsia and HELLP syndrome in 50% of patients.
    • Nausea/vomiting, pain, jaundice
    • Rare
    • Enzymes vary from 200-500. 
    • Uric acid, WBC, bilirubin, and INR elevated
    • Glucose and platelets are low
    • Must exclude HELLP (AFLP doesn't have hemolysis unless the patient also has DIC)
    • Screen mom and baby for LCHAD.
    • May recur in future pregnancies
    • Treatment
      • Deliver!
      • Glucose infusion 
      • Reversal of coagulopathy (FFP, cryoprecipitate, pRBC, platelets) PRN. 
      • Watch for pulmonary edema due to loss of proteins 
  • HELLP syndrome 
    • Hemolysis, Elevated Liver Enzymes, and Low Platelets
    • Present with neurological symptoms as well; abdominal pain, vision changes.
    • Microangiopathy Hemolytic Anemia
    • Elevated LDH, raised INR as well
    • AST > 70
    • Second half of pregnancy, usually 3rd trimester.
    • Management:
      • Prompt delivery!
      • Magnesium sulphate for seizure prevention
    • May recur in future pregnancies

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