Liver diseases

coincidental with but

not induced by
pregnancy
Liver diseases coincidental with but
not induced by pregnancy
 Acute viral hepatitis
 Gallstone disease
 Alcohol-related diseases
 Budd-Chiari syndrome
 Viral Hepatitis
 Incidence in India: 30-50%
 Incidence at JLNH:37.9% of cases of jaundice
in pregnancy (22/58 cases of jaundice in
pregnancy)
 Viral hepatitis is inflammation of liver due to
viral infection.
 It may present as
 Acute infection
 Chronic infection
 Causative agent: hepatotropic
viruses A,B,C,D,E.

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Symptoms:
 Prodromal Stage: precedes jaundice by 1-2
weeks – anicteric phase
-anorexia
-nausea
-vomiting
-malaise
-myalgia
-low grade fever

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Symptoms:

 Icteric phase:phase of clinical jaundice.

-constitutional symptoms disappear
 Post-icteric phase (Recovery phase):jaundice
starts receding.Duration of post-icteric phase
is 2-12 weeks.

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Investigations

 Serum bilirubin:5-20 mg/dl

>20 mg/dl (severe disease)
 ALT : 400-4000 IU/L
 AST : 400-4000 IU/L
 Sr.Alkaline phosphatase : Normal or mildly
elevated
 Prothrombin time : prolonged

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 Management
As the disease is self limiting
limiting,treatment is mainly supportive.
-ANC care remains the same as in normal
pregnancy
-adequate rest
-hydration
-nutrition
-antiemetics
-Pregnancy need not be terminated.
-Breast feeding can be continued.

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 Risk factors for parenteral
infection
 IV drug abusers
 History of STDs
 Multiple sexual partners
 Patients on haemodialysis,and who have
received blood and blood products
 Health care workers
 Organ Transplantation
 Homosexuals
 Infants born to HBsAg or HCV Ab positive
mothers
 Tatooing/body piercing

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Serological interpretation

Acute Chronic Recovered Vaccination

HBsAg Anti-HBe IgG anti HBs IgG anti HBs

HBeAg HBeAg

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 Clinical Features
A B C D E
Non- Double Single
Causative Delta RNA
enveloped stranded stranded
agent virus virus
RNA virus DNA virus RNA virus
Incubation
15-45 30-180 15-160 Years 50-70
period (Days)
Mode of Feco-oral
Feco-oral Parenteral
transmission

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 Diagnosis

A B C D E
HBs Ag, HBe HCV PCR HEV
IgM to HAV
Ag, Anti HBe Ag, Recombinant immuno IgM Anti HDV specific
Marker (IgG indicates
Anti HBc Ag, blot assay HDV Ag antibody
past infection)
DNA load Antibody to HCV (Elisa)

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 Complications

(i)Obstetric complications (ii) Fetal complications

Spontaneous miscarriages Low birth weight

Preterm labour
Intrapartem haemorrhage
Postpartem haemorrhage

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 Management of HBV infection
 Management is mainly supportive
 High calorie diet
 Bed rest and vitamins
 Hospitalisation is required only if there is
marked anorexia or vomiting,for
administration of IV fluids.
 There is no recommended anti-viral therepy
for acute viral hepatitis
 Acute viral infection is not an indication for
termination of pregnancy.
 The mode of delivery does not appear to have
a significant effect on outcome.
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 Specific Management of Hepatitis B
 Pregnant woman who is seronegative
should have HB immune globulin (HBIG),0.06
ml/kg IM,soon after exposure.
 A second dose after 1 month.
 Then she should be given recombinant DNA vaccine
IM 0.5 ml,3 doses at 0,1 and 6 months.
 All infants born to HBsAg positive mothers should
receive HBIG 0.5 ml IM within 12 hrs of birth,and
simultaneous vaccination in contralateral limb with
0.5 ml vaccine at doses 0,1 and 6 months.
 Health care personnel should use double
gloves,barrier gowns,eye glasses,protective
boots,safe disposal of sharps and vaccination of
health care workers. 14
 Post-exposure prophylaxis of susceptible
pregnant women
1. Exposure to persons who have acute hepatitis B
 Administer a dose of Hepatitis B immune globulin
(HBIG) 0.06 ml/kg IM for immediate protection,
and a dose of HBV vaccine 0.5 ml in ihe
contralateral arm.
 A second dose of HBIG should also be given 1
month later.

2. Exposure to persons with chronic HBV infection

 Active post-exposure prophylaxis with Hepatitis B
vaccine alone is recommended for contacts of
persons with chronic HBV infection.
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MANAGEMENT OF VIRAL HEPATITIS
 Rest:Patient should be put to bed rest,if
necessary hospitalise.

 Isolation:Patient should be kept in

isolation.Blood samples should be collected with
gloved hand.Disposable syringes should be
used.

 Nutrition:Diet rich in carbohydrate and

adequate protein should be prescribed.
If the patient cannot tolerate oral feeding,Total
Parenteral Nutrition may be given intravenously

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MANAGEMENT OF VIRAL HEPATITIS

 Drugs:Hepatotoxic drugs should be

avoided.
 There is no place for termination of
pregnancy.
 Haemorrhagic complications are
managed by giving fresh frozen plasma.

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 Complications of Viral Hepatitis

Maternal Complications

Due to jaundice Obstetric Complications

 Hepatic encephalopathy Abortion

 Renal dysfunction PPH

 Coagulopathy Preterm labour
 DIC

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Complications of Viral Hepatitis

Foetal Complications

 Intra uterine foetal death(22.72%)

 Foetal distress(4.54%)
 Growth Retardation
 Low birth weight

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 Herpes Simplex Virus

 Mortality:43%
 Common in:Immunocompromised
 It mimics acute fatty liver of pregnancy
 Vertical transmission:30-50%
(if primary episode occurs at delivery)
On examination:oral herpetic lesions
herpetic lesions on vulva/cx

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Investigations

 Serum transaminase level:high

 Serum marker:IgM antibody to HSV
 Liver biopsy shows:
extensive hepatocellular necrosis
intranuclear herpetic inclusions

Treatment
Acyclovir-400 mg three times a day for 5-7
days
Ganciclovir 21
 Cytomegalovirus

 Aymptomatic in pregnant women

 Risk of transmission is high if acute infection
occurs in first 22 weeks.
 Prognosis is favourable

Management
Termination of pregnancy-because of serious
potential risks to the infected foetus.

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 Gallstone Disease
 Incidence:10-12% in third trimester
sludge in 26.2%
gall stones in 5.2%
 Pathogenesis:
During pregnancy,bile becomes more lithogenic
because:
Estrogen changes biliary lipids
-decreases bile acids and phospholipids
which solubilize cholesterol
-decreases bile flow (cholestasis)
Progesterone decreases gall bladder
contractility
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Symptoms
 Most gall stones disappear spontaneously
without causing symptoms

Management
Conservative
Surgical:laparoscopic surgery in 1st trimester
sphincterotomy/cholecystectomy in 2nd
trimester (when organogenesis is
complete and the size of uterus does not
interfere with surgery)

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 Alcohol Related Disease
 Women are two to four times more likely than
men to develop alcoholic liver disease for the
same amount of alcohol ingested, and they
exhibit a tendency to disease progression
even with abstinence.
 Complications:
Miscarriage
Still births
Prematurity
Growth retardation
Foetal alcohol syndrome
 Alcohol abstinance throughout pregnancy
should be emphasized 25
 Budd Chiari Syndrome
 Manifests after delivery.
 Characterised by thrombosis of hepatic veins
and portal hypertension.
 Clinical manifestations:
Abdominal pain
Ascites
Hepatomegaly
 Management:
Anticoagulants
Diuretics
High albumin
Do angiography,put stent and remove t
thrombus. 26
Preexistent liver diseases

 Portal hypertension, cirrhosis, primary

biliary cirrhosis
 Autoimmune hepatitis
 Wilson disease
 Chronic infection with hepatitis B or
hepatitis C virus
 Alcoholic liver disease

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 Cirrhosis
 It is a slowly progressive disease in which
healthy liver tissue is replaced by scar tissue.

 It is rare for a patient of cirrhosis to

conceive,because:
-Cirrhosis leads to metabolic and hormonal
disturbances which leads to anovulation
and infertility.
-They may become infertile due to the
condition.

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Effects of Cirrhosis on pregnancy

1. Maternal problems
-Increased risk of life-threatening variceal
haemorrhage, especially during labour.
-Post-partem haemorrhage
-Hepatic decompensation
-Rupture of splenic artery aneurysm

2.Fetal problems
-Spontaneous abortion
-Premature births
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 Autoimmune Hepatitis
 It is common in younger age group.
 Symptom:amenorrhoea
 Complications:
- Exacerbation of disease after delivery.
- Premature births
- Foetal loss 33%
 Diagnosis is done by:
-antinuclear antibody
-antismooth muscle antibody
-antimicrosomal antibody

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Management

 Immunosuppressive therapy should be

continued during pregnancy
 Corticosteroids
 Azathioprine-It is safe in pregnancy at
dosage <100 mg/day.

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 Wilson’s Disease
 Wilson disease is an autosomal recessive
disorder in which copper accumulates in
tissues,characterized by:
Cirrhosis
Neurological abnormalities
Hematological dysfunction (less commonly)
Renal dysfunction.

 D-Penicillamine has been used during

pregnancy. However, the dosage should be
reduced to the minimum necessary dose,
which is 25% to 50% of the dose the patient
had been taking before the pregnancy,as
there is risk of hemolytic crises,hepatic
failure.It reduces copper absorption or
removes excess copper from the body. 32
 Wilson’s Disease

 Zinc is the agent of choice for Wilson

disease during pregnancy because of its
safety for the fetus. It should be
maintained throughout the pregnancy
at 50 mg three times a day.

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