What is liver disease in pregnancy?
Pregnant women can suffer from pre-existing liver disease. They can develop new liver diseases that non-pregnant people also develop, but there are a handful of liver problems that strike pregnant women in particular. Notably, these conditions include hyperemesis gravidarum (HG), hemolysis and elevated liver enzymes and low platelets (HELLP) syndrome, acute fatty liver of pregnancy (AFLP), and intrahepatic cholestasis of pregnancy (ICP).
ICP also is known as cholestasis of pregnancy, jaundice of pregnancy, obstetric cholestasis, and prurigo gravidarum occurring during the late second trimester or any time during the third trimester. The condition features an abnormally high flow of bile (a substance produced by the liver that is needed for digestion) due to high levels of the hormone estrogen.
HELLP is a pregnancy complication that can occur as a further complication of another pregnancy condition, preeclampsia, but the relationship between HELLP and preeclampsia is not totally understood. Preeclampsia features high blood pressure but also dysfunction of organs, particularly the kidney, but it also can be the liver. Thus, preeclampsia and HELLP can overlap, plus HELLP can develop in women who do not have preeclampsia. On the other hand, preeclampsia and HELLP tend to strike mothers-to-be of different age groups, so many researchers consider HELLP and preeclampsia to be separate conditions.
AFLP, which can occur during the third trimester (usually between 28-40 weeks gestation, especially weeks 35-36), or in a mother soon after delivering a baby, features high concentrations of fat in the mothers liver. Normally, fat comprises about 5 percent of the livers content, but in AFLP, the liver consists of 13 – 19 percent fat, and this may be due to problems in the rearrangement and breakdown of molecules called fatty acids coming from the fetus.
How common is liver disease during pregnancy?
Liver disease develops in about 3 percent of pregnancies.
How is liver disease during pregnancy diagnosed?
The physical exam, plus the history of your illness, can offer important clues, particularly the timing of the onset of complications. HELLP and AFLP, for instance, are third trimester complications that also can begin after delivery. In contrast, HG typically begins during the first trimester, and ICP can occur from the late second trimester onward. Liver disease can produce pain in the right upper part of your abdomen, headache, yellowing of the skin and white part of your eyes, nausea, vomiting, changes in the color of your urine, itching, and various other effects. Tests to help make a diagnosis include a liver panel, a complete blood count (CBC), a peripheral blood smear, and abdominal imagining using ultrasonography or computed tomography (CT). Physicians try to avoid performing a liver biopsy through a needle, but sometimes a biopsy is necessary.
Does liver disease cause problems during pregnancy?
Along with symptoms such as nausea, vomiting, abdominal pain, fatigue, headache, and lack of appetite, AFLP can lead to low blood sugar, severely altered states of consciousness, and coma. Heartbeat irregularities can happen, as well as bleeding in the gastrointestinal tract and throughout the body. Patients can develop whats called diabetes insipidus, which means that their blood is getting too diluted, and they are urinating excessively. They also can develop whats called metabolic acidosis, which means that the pH inside their bodies is too low, a condition that disrupts body chemistry. Multiple organs can be disrupted, including the kidneys, brain, liver, and pancreas. This can lead to kidney failure and/or liver failure, even to the point that the only way to save the patient is with a liver transplant.
HELLP syndrome can develop into very severe complications. One such complication is eclampsia in which, on top of the problems of platelets and organ trouble, the woman suffers seizures. The blood clotting problem connected with platelets can deteriorate into what is called disseminated intravascular coagulation (DIC), plus the kidneys can stop functioning, fluid can accumulate in the lungs and abdomen, clots can block blood vessels in the brain and liver, the retina of the eyes can detach, and there can be bleeding in the brain.
Women suffering from HG can develop deficiencies of nutrients such as vitamin B1 (thiamine). This, in turn, can lead to a severe brain condition called Wernicke encephalopathy, featuring tiredness and confusion, dampened reflexes, problems with movement, including the movement of the eyes. In very extreme cases, Wernicke encephalopathy can be fatal, if recognized early thiamine deficiency is easily curable. HG also can lead to deficiencies of fat-soluble vitamins, such as vitamin K, which is important for blood clotting so that a deficiency can lead to bleeding during pregnancy and severe bleeding during labor and delivery. The vomiting may lead to a particular type of acid-base disturbance called metabolic alkalosis, which causes or exacerbates one specific electrolyte disturbance called hypokalemia, low potassium. This can lead to muscle damage, kidney problems, and problems with the rhythm of the heart, which also can be fatal. Excessive vomiting and wrenching furthermore can damage the esophagus, badly enough to cause bleeding and entry of air into tissues and the chest cavity.
A woman with ICP may experience flu-like symptoms, such as nausea and vomiting, as well as abdominal pain and anorexia (lack of appetite). Urine may darken, and a deficiency of vitamin K may develop due to problems absorbing it. If this happens, it can lead to bleeding problems. If the duct that carries bile from the liver becomes obstructed, the woman can develop severe pain and require surgery, but this is very rare.
Does liver disease during pregnancy cause problems for the baby?
Because of the decreased pH in the mothers body in AFLP, the acid-base balance in the fetus can be disrupted as well, putting the life of the fetus at risk, until the fetus is delivered. HELLP can cause intrauterine growth restriction, where the fetus does not grow as quickly and as completely as she needs to grow, plus the condition can lead to preterm delivery, which itself is connected with numerous complications for the newborn. HELLP and possibly also HG can cause whats called abruptio placentae, when the placenta detaches from the uterus too early, thereby totally cutting off circulation to the fetus while also causing severe uterine bleeding. Newborns of mothers with HELLP can suffer from neonatal thrombocytopenia (low platelet count resulting in severe bleeding), and respiratory distress syndrome.
HG is associated with increased rates of preterm birth and low birth weight, both of which can lead to physical and mental problems for the
baby. Infants born to mothers with HG also may be prone to psychiatric conditions.
What to consider about taking medications when you are pregnant or breastfeeding:
- The risks to yourself and your baby if you do not treat the liver disease
- The risks and benefits of each medication you use when you are pregnant
- The risks and benefits of each medication you use when you are breastfeeding
What should I know about using medication to treat liver disease during pregnancy?
ICP is treated effectively with ursodeoxycholic acid (UDCA), which is safe both for the mother and her fetus. The first medication that often is given is a combination of two drugs called doxylamine succinate (an antihistamine) and pyridoxine HCl (vitamin B6), which together are known as diclegis. The treatment is safe for the baby, but its main use is not for HG, but for nausea and vomiting of pregnancy, in which it is reported effective in 70-80 percent of cases. First-line drugs specifically for HG include ondansetron and metoclopramide, while second choice drugs offered to patients who do not improve with one of the other drugs include promethazine, clonidine, and mirtazapine. Corticosteroid medications also have been used in patients with HG, but controversy surrounds whether or not they are effective. With AFLP and HELLP, the baby needs to be delivered early, so medications consist of corticosteroids, particularly betamethasone, to accelerate the development of the fetal lungs. Steroids also help the mother with the effects of HELLP. Women with HELLP also need magnesium sulfate to prevent seizures; this is not harmful to the fetus. The mother also can be given any of a handful of pregnancy-safe blood pressure drugs. The latter must be done with extreme caution, since lowering blood pressure too much can reduce circulation through the placenta, which can harm the fetus.
Who should NOT stop taking medication for liver disease during pregnancy?
In many cases, particularly with AFLP and HELLP, medications are vital to keeping the mothers condition stable, so they must not be withheld.
What should I know about choosing a medication for my liver disease during pregnancy?
It is important to stay in communication with your health care provider as the release of new studies over time can change the outlook on the role of specific medications during pregnancy.
You may find Pregistrys expert reports about the medications to treat this condition here. Additional information can also be found in the sources listed below.
What should I know about taking a medication for liver disease when I am breastfeeding?
Generally, HG resolves by the midpoint of pregnancy, so you will not need anti-HG medications by the time that you are breastfeeding. HELLP usually resolves after delivery, although, to prevent seizures, you may need magnesium sulfate, which is not harmful to a nursing infant. Usually, ICP also resolves following delivery, so if you are taking UDCA, youll be able to stop the treatment. UDCA is not approved for use during breastfeeding but is thought to be safe if you are still using it while nursing.
Because AFLP can develop at the end of pregnancy, or even after delivery, a new mother can be undergoing treatment for AFLP when she has a newborn who must eat. Since this is a critical situation, when care is usually given in an ICU setting, its unlikely that she will be in a condition to breastfeed.
What alternative therapies besides medications can I use to treat liver disease during pregnancy?
With a lot of these pregnancy liver complications, delivery of the baby as early as possible, generally around 37 weeks gestation, is a major component of treatment. Typically, delivery is by cesarean section.
What can I do for myself and my baby when I have liver disease during pregnancy?
Cooperate with your physicians. These are serious complications, but if recognized early and managed efficiently, they are frequently survivable, both for mother and child.
Resources for acute liver disease in pregnancy:
For more information about liver disease during and after pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446]) or contact the following organizations: