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CHAPTER 55: Hepatic, Biliary, and Pancreatic Disorders

Pregnancy is comparatively seldom complicated by jaundice. Notwithstanding the fact that in most cases the jaundice disappears without treatment, too favorable a prognosis should not be ventured, for the reason that now and again the condition may represent the initial symptom of acute yellow atrophy of the liver.

—J. Whitridge Williams (1903)

INTRODUCTION

Even though Williams only mentions acute hepatic fatty metamorphosis, in practice, disorders of the liver, gallbladder, and pancreas together comprise a formidable list of complications that may arise in pregnancy. Some stem from preexisting conditions and some are unique to gestation. The relationships of several of these with pregnancy can be fascinating, intriguing, and challenging.

HEPATIC DISORDERS

Customarily, liver diseases complicating pregnancy are placed into three general categories. The first includes those specifically related to pregnancy that resolve either spontaneously or following delivery. Examples are intrahepatic cholestasis and acute fatty liver, both discussed in the next sections. Also, hepatic dysfunction from hyperemesis gravidarum may involve the liver. Mild hyperbilirubinemia with elevated serum transaminase levels is seen in up to half of affected women requiring hospitalization. However, these levels seldom exceed 200 U/L (Table 55-1). Liver biopsy may show minimal fatty changes. Hyperemesis gravidarum is discussed in detail in Chapter 54 (Upper Gastrointestinal Tract Disorders). Another in this first category is hepatocellular damage with preeclampsia—the HELLP syndrome—which is characterized by hemolysis, elevated serum liver enzyme levels, and low platelet counts. These changes are discussed in detail in Chapter 40 (Liver).

TABLE 55-1Clinical and Laboratory Findings with Acute Liver Diseases in Pregnancy
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TABLE 55-1 Clinical and Laboratory Findings with Acute Liver Diseases in Pregnancy
Hepatic Renal Hematological and Coagulation
Disorder Onset in Pregnancy Clinical Findings AST (U/L) Bili (mg/dL) Cr (mg/dL) Hct Plat Fib DD PT Hemolysis
Hyperemesis Early Severe N&V NL–300 NL–4 ↑ ↑↑ NL NL NL NL No
Cholestasis Late Pruritus, jaundice NL–200 1–5 NL NL NL NL NL NL No
Fatty liver Late Moderate N&V,
± HTN, liver failure		 200–800 4–10 ↑↑↑ ↑↑↑ ↓↓ ↓↓↓ ↑ ↑↑ ↑↑↑
Preeclampsia Mid to late HA, HTN NL–300 1–4 ↑ ↑ ↓↓ NL ↑ NL ↑–↑↑
Hepatitis Variable Jaundice 2000+ 5–20 NL ↑ ↓ NL NL ↑ No

↑ = increased levels; ↓ = decreased levels; AST = aspartate transaminase; Bili = bilirubin; Cr = creatinine; DD = d-dimers; Fib = fibrinogen; HA = headache; Hct = hematocrit; HTN = hypertension; N&V = nausea and vomiting; NL = normal; Plat = platelets; PT = prothrombin time.

The second category involves acute hepatic disorders that are coincidental to pregnancy, such as acute viral hepatitis. The third category includes chronic liver diseases that predate pregnancy, such as chronic hepatitis, cirrhosis, or esophageal varices.

Importantly, several normal pregnancy-induced physiological changes induce appreciable ...

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