Journal of Pregnancy and Child Health
Open Access

Liver diseases; Preeclampsia; HELLP syndrome; Acute fatty liver of pregnancy

Pregnancy-induced liver disorders represent a significant area of concern in obstetric care due to their potential impact on both maternal and fetal health [1]. The liver's role in metabolic processes, detoxification, and hormone regulation makes it vulnerable to various conditions that can arise or be exacerbated during pregnancy [2]. Understanding the spectrum of liver diseases in pregnancy—from common benign conditions to critical complications—is crucial for effective management and improving patient outcomes [3].

Pathophysiology

Bile acid accumulation: ICP is characterized by impaired bile flow, leading to the accumulation of bile acids in the liver. This condition arises due to altered hepatocyte function and defective transport of bile acids across the hepatocyte membrane [4]. The accumulation of bile acids in the maternal bloodstream results in pruritus and, potentially, adverse fetal outcomes.

Hormonal influence: Pregnancy hormones, particularly estrogen and progesterone, are thought to play a role in ICP. Estrogen can affect the synthesis and secretion of bile acids, while progesterone can alter bile flow and the expression of bile acid transporters [5].

Genetic factors: Genetic predisposition may also contribute, as certain genetic mutations affect bile acid metabolism and transport.

Benign liver conditions

Intrahepatic cholestasis of pregnancy (icp)

ICP is the most common pregnancy-specific liver disorder, characterized by impaired bile flow leading to elevated serum bile acids. Key aspects include:

Clinical presentation: It typically presents in the third trimester with pruritus, often affecting the palms and soles, without associated rash. Serum bile acid levels are elevated [6].

Diagnosis: Diagnosis is based on clinical symptoms and laboratory tests showing elevated bile acids and liver enzymes.

Management: Treatment involves managing symptoms with antihistamines and ursodeoxycholic acid to reduce bile acid levels. Induction of labor is often recommended at 37-38 weeks to minimize risks to the fetus.

Benign liver tumors

Benign liver tumors such as hepatic hemangiomas and focal nodular hyperplasia (FNH) are relatively common findings during pregnancy.

Hepatic hemangiomas: These are vascular liver tumors often discovered incidentally. They typically require no treatment unless they grow significantly or cause symptoms.

Focal nodular hyperplasia: Usually asymptomatic and does not require intervention unless complications arise.

Severe liver conditions

Preeclampsia and hellp syndrome

Preeclampsia is a hypertensive disorder of pregnancy that can progress to HELLP syndrome (Hemolysis, Elevated Liver Enzymes, and Low Platelets), a severe complication.

Clinical presentation: Symptoms include severe hypertension, proteinuria, upper abdominal pain, and signs of liver dysfunction. HELLP syndrome can lead to elevated liver enzymes, liver rupture, and significant maternal and fetal risks.

Diagnosis: Diagnosis is based on clinical criteria and laboratory findings of elevated liver enzymes, low platelets, and hemolysis.

Management: Immediate delivery is the definitive treatment. Supportive care includes managing hypertension, fluid balance, and monitoring for complications such as liver rupture.

Imaging during pregnancy

Imaging during pregnancy is a crucial aspect of prenatal care that helps in diagnosing and managing maternal and fetal conditions [7]. However, it is essential to consider both the benefits and potential risks of imaging modalities to ensure the safety of both the mother and the developing fetus [8]. Here's an overview of commonly used imaging techniques during pregnancy, their indications, and considerations:

Ultrasound

Safety: Ultrasound is considered the safest imaging modality during pregnancy as it uses high-frequency sound waves rather than ionizing radiation.

Types: Includes transabdominal ultrasound (TAUS) and transvaginal ultrasound (TVUS).

Indications

Routine screening: Performed during the first trimester (to confirm pregnancy and estimate due date) and second trimester (to assess fetal growth, anatomy, and placental location).

Diagnostic purposes: Evaluates abnormal findings from routine screenings, such as suspected fetal anomalies or placental issues.

Guidance: Assists in guiding procedures such as amniocentesis or fetal blood sampling.

Considerations

Limitations: Ultrasound may not detect all fetal anomalies and can sometimes provide ambiguous results.

Frequency: Routine use is generally safe, but unnecessary or excessive scanning should be avoided to prevent undue anxiety and unnecessary medical interventions.

Magnetic resonance imaging (MRI)

Safety: MRI does not use ionizing radiation but strong magnetic fields. It is generally considered safe for the fetus, especially after the first trimester.

Types: Includes pelvic MRI, fetal MRI, and maternal MRI.

Indications

Complex cases: Used when ultrasound results are inconclusive or when there is a need for detailed imaging of complex fetal anomalies, the placenta, or maternal pelvic structures.

Evaluation: Assesses fetal brain development, suspected placental abnormalities, or maternal pelvic pathologies.

Considerations

Timing: MRI is usually performed when other imaging modalities are inadequate or in cases of suspected complex issues.

Contrast agents: If contrast agents are used, gadolinium-based contrast, which is generally avoided during pregnancy, should be used cautiously and only when absolutely necessary.

Computed tomography (CT)

Safety: CT involves ionizing radiation, which poses potential risks to the developing fetus. It is generally avoided during pregnancy unless absolutely necessary.

Types: Includes abdominal, pelvic, and chest CT scans.

Indications

Emergency situations: Used in urgent situations where rapid and detailed imaging is needed, such as in cases of trauma or suspected severe maternal pathology that cannot be adequately assessed by other means [9].

Evaluation: Helps diagnose conditions such as appendicitis or pulmonary embolism when ultrasound results are inconclusive.

Considerations

Radiation exposure: The radiation dose is minimized, and protective measures (e.g., lead shielding) are employed. The risk to the fetus is assessed against the potential benefits of the information gained [10].

Alternatives: Whenever possible, alternative imaging methods like ultrasound or MRI are preferred to avoid radiation exposure.

X-ray

Safety: X-ray imaging uses ionizing radiation, which can potentially harm the developing fetus. It is generally avoided during pregnancy unless absolutely necessary.

Types: Includes plain X-rays of the abdomen, pelvis, and chest.

Indications

Emergency situations: Used in cases of severe trauma, where immediate assessment is critical, or when other imaging modalities are unavailable.

Evaluation: Helps diagnose conditions such as fractures or certain infections.

Considerations

Radiation exposure: Minimizing radiation exposure to the fetus is crucial. Protective measures like lead shielding are employed, and the area of exposure is kept as limited as possible.

Alternatives: Whenever feasible, alternative imaging methods like ultrasound or MRI are preferred to avoid ionizing radiation.

Nuclear medicine

Safety: Nuclear medicine involves the use of radioactive materials. It is typically avoided during pregnancy due to potential risks of radiation exposure to the fetus.

Acute liver failure (ALF) in pregnancy

Acute liver failure in pregnancy is a rare but critical condition with high maternal and fetal morbidity and mortality.

Etiology: Causes may include viral hepatitis, acetaminophen overdose, or acute 

fatty liver of pregnancy (AFLP). AFLP is characterized by microvesicular steatosis and typically presents in the third trimester.

Clinical presentation: Symptoms include jaundice, coagulopathy, encephalopathy, and rapid deterioration of liver function.

Management: Management involves supportive care, treating the underlying cause, and often requires urgent delivery. Liver transplantation may be necessary in severe cases.

Acute fatty liver of pregnancy (AFLP)

AFLP is a rare, serious condition that often presents in the third trimester and involves the accumulation of fat in liver cells.

Clinical presentation: Symptoms include nausea, vomiting, abdominal pain, jaundice, and elevated liver enzymes. AFLP can lead to acute liver failure if untreated.

Conclusion

Pregnancy-related liver diseases span a broad spectrum from benign conditions to severe, life-threatening complications. Early diagnosis, effective management, and a multidisciplinary approach are key to improving maternal and fetal outcomes. Continued research and clinical advancements are essential to further enhance understanding and treatment of these complex conditions, ultimately ensuring safer pregnancies and healthier outcomes for both mothers and their children.

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