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

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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