24. Liver Disease in Pregnant Women

Summary

Any pregnant woman who becomes unwell during any stage of pregnancy following the clinical history should be examined for evidence of liver disease, particularly checks for evidence of liver failure. Physical examination should include evaluations of hydration status, mental status, and search for skin manifestations of liver disease, for example bruising, spider nevi (palmarerythemia may be present in all pregnant women). Even if there are no findings, all should have liver biochemistry and liver function evaluated in addition to hematologic and renal function testing. A full medical and surgical history is needed and the specific trimester elucidated.

The history (including trimester) and physical examination, taking into account the results of screening blood tests, is required to narrow down the differential diagnosis. If there are any signs of liver failure, transfer to an intensive care unit is preferable. Diagnostic tests for all types of viral hepatitis should be sent, including a vaginal swab for herpes simplex. Ultrasound may contribute towards the diagnosis of fatty liver and Budd–Chiarisyndrome. Close monitoring of the complete blood count and INR are required in those with “presumed” pregnancy-associated toxemia. Curiously, during pregnancy cholestasis although associated with pruritus has a liver biochemical pattern more in keeping with a “hepatitis”; serum bile acid levels clinch the diagnosis. Intense pruritus due to cholestasis of any cause may be very difficult to control with standard oral therapies and may require plasmapheresis. All patients with signs of liver failure should be assessed by a liver transplant service.