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CHAPTER 58: Hepatic, Biliary, and Pancreatic Disorders

Disorders of the liver, gallbladder, and pancreas together constitute 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 intriguing and challenging.

HEPATIC DISORDERS

Liver diseases complicating pregnancy are placed into three general categories. The first includes those specific to pregnancy and resolve either spontaneously or following delivery. Hyperemesis gravidarum, intrahepatic cholestasis, acute fatty liver, and HELLP syndrome—which is characterized by hemolysis, elevated liver enzyme levels, and low platelet counts, are examples. The second category involves acute hepatic disorders that are coincidental to pregnancy, such as acute viral hepatitis. Last are chronic liver diseases that predate pregnancy, such as chronic viral or autoimmune hepatitis, cirrhosis, or esophageal varices.

Laboratory testing can aid differentiation of these disorders. Hepatic dysfunction from hyperemesis gravidarum may manifest as mildly elevated serum bilirubin and transaminase levels (Chap. 57, p. 1014). Others listed in Table 58-1 can show more marked findings. One example, severe preeclampsia syndrome, discussed in Chapter 40 (p. 689), can be further complicated by the HELLP syndrome, which can rarely cause liver failure (Casey, 2020).

TABLE 58-1Clinical Findings with Liver Diseases in Pregnancy
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TABLE 58-1Clinical Findings with Liver Diseases in Pregnancy
Diagnosis Onset Symptoms AST (U/L) Bili (mg%) Cr (mg%) Hematological Comments
Hyperemesis gravidarum Early N&V <300 1–4 NL or elevated (prerenal) NL Common, infant vitamin K deficiency, Wernicke encephalopathy, Boerhaave syndrome
ICP Late Pruritus ± jaundice <200 1–5 NL NL Common (0.5–2%), bile acids (>10 μmol/L), normal hepatic function
AFLP Late N&V (70%), HTN/preeclampsia, RUQ pain 145–565 2–8 >0.9 Thrombocytopenia, coagulopathy ± DIC, nucleated red cells, hemolysis, echinocytosis Low glucose, cholesterol <220 mg/dL, fibrinogen <300 mg/dL
HELLP Late Preeclampsia, RUQ pain 75–250 (initial) 1–2 <1.0 Thrombocytopenia, mild hemolysis Common (7–10% of preeclampsia), normal hepatic function
Hepatitis
 Viral Variable, chronic, episodic Jaundice, RUQ pain, fatigue 400–5000 20 NL Coagulopathy if cirrhotic, thrombocytopenia Common (1–3%), serological tests for hepatitis A, B, C, E
Autoimmune Variable, chronic, episodic Jaundice, RUQ pain, fatigue 100–1000 3–10 NL Coagulopathy if cirrhotic, thrombocytopenia Uncommon, ANA+, anti-LKM1, anti–smooth muscle
NAFLD Variable, chronic, episodic Obese, diabetes, ± RUQ pain NL to slightly elevated NL NL NL Common (6–8%), sonographic findings, MR imaging/CT findings, ± metabolic syndrome, NASH, cirrhosis

AFLP = acute fatty liver of pregnancy; ANA = antinuclear antibodies; AST = aspartate transaminase; Bili = bilirubin; BP = blood pressure; Cr = creatinine; CT = computed tomography; DIC = disseminated intravascular coagulation; HELLP = hemolysis, elevated liver enzymes, low platelets; HTN = hypertension; ICP = intrahepatic cholestasis of pregnancy; LKM1 = liver, kidney microsome 1; MR = magnetic resonance; NAFLD = nonalcoholic fatty liver disease; NASH = nonalcoholic steatohepatitis; NL = normal; N&V = nausea and vomiting; RUQ = right upper quadrant.

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