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Liv.52® – Unparalleled in liver care

Editorial

Liver disorders during pregnancy have potentially serious consequences for both maternal and fetal health. It is thereby extremely important to detect early signs and symptoms of liver dysfunction and to distinguish these from the anticipated benign hepatic changes of pregnancy.

The “Research Update” section of this issue discusses about the various liver disorders unique to pregnancy. The “Clinical Review” section features a clinical trial report evaluating the safety and efficacy of Liv.52 DS in the management of liver disorders during pregnancy.

In the “Expert comments” section, Dr Anil Baburao Pandit gives an insight into the prevalence and causes of jaundice and management of liver disorders during pregnancy. He also emphasizes on the efficacy of Liv.52 DS in the management of jaundice in pregnancy. The issue also features an article on Capparis spinosa, a hepatoprotective herb and one of the key ingredients of Liv.52 formulation.

Do write to us with your valuable feedbacks and suggestions at publications@himalayahealthcare.com.

Happy reading!– Editor

Table 1. Causes and Trimester of Liver Disease in PregnancyDisease category Specific disease Trimester of pregnancy

Pregnancy-related liver disease Hyperemesis gravidarum 1

Intrahepatic cholestasis of pregnancy

2–3

Preeclampsia 3, late 2

HELLP syndrome 3, late 2, postpartum

Acute fatty liver of pregnancy 3

Liver disease coincidental with pregnancy

Acute viral hepatitis 1–3

Budd-Chiari syndrome 1–3, postpartum

Gallstones 1–3

Drug-induced hepatitis 1–3

Chronic liver disease Chronic viral hepatitis 1–3

Autoimmune hepatitis 1–3

Liver cirrhosis 1–3

Wilson’s disease 1–3

IntroductionDuring pregnancy, the liver’s synthetic and metabolic functions are

affected by the increased serum estrogen and progesterone levels. Pregnancy is associated with many normal physiologic changes, which can mimic chronic liver disease. An increase in serum aminotransferase, bilirubin, or serum bile acid concentrations during pregnancy is always pathologic and should prompt further evaluation.

There are liver disorders unique to pregnancy, diseases occurring coincidentally, and preexisting chronic liver diseases. The pregnancy-related liver disorders have characteristic clinical features and timing of onset, whereas diseases unassociated with pregnancy may occur at any time (Table 1). While specific diseases are typically confined to a particular trimester, exceptions exist.

Correct diagnosis is critical because prompt therapy markedly improves the outcome of pregnancy. The diagnostic algorithm should include the following questions:

1. Are there any symptoms of underlying chronic liver diseases?

2. Are there any features of biliary disease?

3. Is there any evidence of acute viral hepatitis?

4. Is there any history of drug, herbal medication, and alcohol consumption and travel?

5. Does clinical presentation fit one of the liver diseases unique to pregnancy?

Analyzing the pattern of serum liver tests abnormalities is also helpful in making the diagnosis.

Hyperemesis GravidarumHyperemesis gravidarum (HG) is characterized by intractable nausea

and vomiting usually resolving by week 16 to 18 of gestation. Mild nausea with or without vomiting occurs in 50% to 90% of all pregnancies. The prevalence of HG varies from as low as 3 cases per 1000 pregnancies to as high as 1 per 100.

EtiologyHyperemesis has been attributed to a number of factors, but the

etiology remains uncertain. Psychologic, hormonal, and genetic factors,

abnormal gastric motility, specific nutrient deficiencies, alterations in lipid levels, changes in the autonomic nervous system may be involved in the pathogenesis of HG.

Clinical featuresHG has its onset in early pregnancy and resolves by 16 to 18 weeks of

gestation. However, symptoms continue until the third trimester in 15% to 20% of patients and until delivery in 5%. Symptoms range from mild to severe. Patients may present with weight loss exceeding 5% of their body weight, dehydration, ketosis, and electrolyte derangements, such as hypokalemia and metabolic alkalosis. Abnormal liver enzyme values occur in approximately 50% of patients who are hospitalized with HG. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) values can rise to 200 U/L.

Differential diagnosisHG is generally a diagnosis of exclusion. Other conditions unrelated

to pregnancy that can cause persistent nausea and vomiting include gastrointestinal disorders (gastroenteritis, hepatitis, pancreatitis, cholelithiasis), genitourinary tract disorders, metabolic (eg, diabetes, porphyria) and neurologic diseases (eg, migraine, tumor, vestibular lesions), drug toxicity, and psychological problems.

Intrahepatic Cholestasis of PregnancyIntrahepatic cholestasis of pregnancy (ICP) is the most common liver

disorder unique to pregnancy. In many areas of the world, ICP is a rare disease occurring at a rate of 1 in 1000 to 10,000 pregnancies.

Etiology and pathogenesisThe pathogenesis of ICP can be related to abnormalities in the

metabolism and disposition of sex hormones and/or bile acids determined by a genetic predisposition and environmental factors.

Clinical featuresICP is characterized by pruritus starting in the second or third trimester

of pregnancy and disappearing after delivery. It is often generalized but predominates on the palms and the soles of the feet, and is worse at night. Physical examination may show excoriations due to scratching. Jaundice occurs in 10% to 20% of cases, typically within 4 weeks of the onset of itching.

Serum total bile acid concentrations increase in ICP and may be the first or only laboratory abnormality. The concentration of serum cholic acid increases more than concentration of chenodeoxycholic acid, resulting in a marked elevation of the cholic/chenodeoxycholic acid ratio compared to pregnant women without ICP. Serum aminotransferase levels are elevated and may reach values greater than 1000 U/L, making distinction from viral hepatitis important.

Differential diagnosisThe cardinal feature of ICP (pruritus) helps to distinguish it from other

types of pregnancy-related liver disease that can share similar laboratory features (such as early HELLP syndrome or preeclampsia). The main differential diagnoses of pruritus of ICP without icterus are skin diseases, allergic reactions, and abdominal striae.

PreeclampsiaHypertensive disorders complicate 12% to 22% of pregnancies.

Preeclampsia occurs in approximately 3% to 14% of all pregnancies worldwide. Preeclampsia refers to the new onset of hypertension and proteinuria after 20 weeks of gestation in a previously normotensive woman. The etiology of this condition is unknown, but it seems that uteroplacental ischemia plays a major role.

All of the clinical features of preeclampsia can be explained as maternal responses to generalized endothelial dysfunction. Disturbed endothelial control of vascular tone causes hypertension, increased vascular permeability results in edema and proteinuria, and abnormal endothelial expression of procoagulants leads to coagulopathy.

• C l i n i c a l r e v i e w

• D r u g a l e r t

• N e w s w i s e

• E x p e r t c o m m e n t s

• H e r b f a c t s

• N e w s f l a s h

• L a u g h l i n e s

• L i v - w i s e

Vol. 6 • No. 3 • Jan–Mar 2012

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Liver diseases during pregnancy

Liver Diseases Unique to PregnancyKondrackienė J, Kupčinskas L

Medicina (Kaunas). 2008;44(5):337-345.

Algorithm of Abnormal Liver Tests

Hepatocellular liver test patern Cholestatic liver test pattern

Hepatitis serology Autoantibodies

Drug, alcohol, travel history

Ultrasound Drug, alchohol history

If the result of all tests are negative, suspect liver disease unique to pregnancy

Livline • Vol. 6 • No. 3 • Jan–Mar 2012

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C l i n i c a l r e v i e w

D r u g a l e r t

Liver Disorders During Pregnancy and Their ManagementMitra AK, et al.

The Antiseptic. 2008;105(4):193-196.

IntroductionDuring pregnancy, the human body undergoes several

changes in the process of its adaptation to the growing fetus. Although these changes are physiological, there is potential for morbidity and mortality to both mother and fetus. Liver is the site of many important metabolic and synthetic functions of the body. In normal pregnancy, the liver is not palpable. Owing to hemodilution, biochemical tests may reveal mild increase in liver function tests. Abnormal liver tests occur in 3% to 5% of pregnancies, with many potential causes, including coincidental liver disease (most commonly viral hepatitis or gallstones) and underlying chronic liver disease.

Liver dysfunction can appear at any point of pregnancy, which causes great anxiety to the patient, her family, and sometimes her medical attendants. A number of these diseases have been identified which are responsible for morbidity and mortality. Some of the liver disorders include viral hepatitis, AFLP (acute fatty liver of pregnancy), autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, gallstone disease, and drug-induced hepatitis.

ManagementLiver disease makes a normal pregnancy a high-risk

pregnancy. Extreme vigilance is needed to detect early signs and symptoms of liver dysfunction and distinguish these from the anticipated benign hepatic changes of pregnancy. Prompt management can save the life of the mother and the baby. Management of liver disease in pregnancy requires a concerted effort between the primary care physician, liver specialist, and obstetrician.

This study evaluated the efficacy and safety of Liv.52 in the management of liver disorders in pregnancy. The study

was conducted way back in 1974 to 1975 in 84 cases of liver disorder in pregnancy to evaluate the efficacy and safety of Liv.52 in the treatment of jaundice in pregnancy. This study is believed to be the first of its kind during that period as it involved management of pregnant women with jaundice.

In this study population of 84 patients, there were 9 pregnant women who were down with severe viral hepatitis. A total of 21 of 84 patients had undergone liver biopsy, after their written informed consent. Histopathological examinations of these patients with viral hepatitis had indicated extensive periportal round cell infiltration, fibrosis, and scaring. All these patients recovered completely after 6 weeks of treatment except one patient (19 years, second trimester of pregnancy).

Liv.52 did not produce any adverse effects in any of the patients who underwent Liv.52 drug therapy. Drug therapy with Liv.52 brought down the earlier reported mortality from 26.7% to 1.1% in patients with jaundice during pregnancy. However, a larger trial will be needed to confirm these findings. Liv.52 is a well-studied herbal formulation in various diseases, and thereby could be very useful in the management of liver diseases in pregnancy.

ConclusionLiver holds a very important position in the metabolic

system of the body. Its active participation in metabolism of carbohydrates, proteins, and fats including detoxification of noxious substances gives it a unique position in controlling the metabolic pathways of the body. In spite of tremendous strides in modern medicines, very few drugs are known to protect the liver from damage. Liv 52 holds a great promise in this regard and is known as the safest and effective medication.

Double-blind Clinical Trial of HD-03/ES in the Management of Chronic Hepatitis B

Mahto AK, Unnikrishnan N.Int J Clin Pract. 2010;21(5):247-251.

Methyldopa-induced Acute Reactive Hepatitis in Pregnancy, Drug-metab-olizing Capacity of the LiverOrv Hetil. 2010;151(11):457-461.

Alpha-methyldopa is a regularly used

antihypertensive drug during pregnancy. Although

methyldopa is the first drug of choice since decades,

it decreases the sympathoadrenal system. The reactive

hepatitis is not so frequent as the known serious side

effects of alpha-methyldopa. In nonpregnant women,

the estimated rate of manifest hepatotoxicity is 2.5%

to 10%. In this case, gestation hypertension developed

at the 21st week of gestation of a 35-year-old pregnant

woman. Oral methyldopa, a central alpha adrenergic

blocker therapy was introduced. On the 23rd week of

gestation, acute hepatitis developed. During differential

diagnosis of hepatitis, the etiology of methyldopa

was taken into account. Viral and autoimmune

origin was rolled out. No fetal aberration was found

during ultrasound examination. The function of drug

metabolizing function from blood was measured by

CYP phenotyping (CYP gene expression analysis).

CYP3A4 enzyme plays a primary role in the metabolism

of nifedipine. Antihypertensive therapy was changed

from methyldopa to nifedipine. Nifedipine dosage was

based on the value of CYP3A4 gene expression. With

the reduced nifedipine therapy (30 mg daily), blood

pressure was successfully under control. The diagnosis

of alpha-methyldopa-induced hepatitis was based on

anamnesis, clinical picture, and the results of chemical

and radiological examination and confirmed by the

level of drug-metabolizing capacity. The gestation

hepatotoxicity of alpha-methyldopa was reported

first in 1969 by Elkington Smith, who suggested the

monitoring of serum aminotransferase during alpha-

methyldopa therapy in pregnancy in their case report.

This case report confirms the monitoring of serum

aminotransferase level, which is important while

treating a pregnant woman with alpha-methyldopa.

Background In vitro studies indicate that HD-03/ES has surface antigen

suppression and hepatitis B virus (HBV) elimination activities. Acute and sub-acute toxicity studies have shown that HD-03/ES is devoid of significant toxicity following acute and repeated administration in rats. This study was undertaken to evaluate the safety and efficacy of the formulation HD-03/ES capsules in the management of patients with chronic hepatitis B infection.

Materials and MethodsDouble-blind, randomized, placebo-controlled clinical

study was carried out in 50 patients with chronic hepatitis B. The patients were divided into two groups: drug and placebo. The first group received HD-03/ES capsules at a dosage of 2 tablets two times a day for 24 weeks and the second group received placebo. The patients were subjected to biochemical investigations to assess the levels of HBsAg, HBeAg, and HBV DNA at baseline and 24 weeks after therapy. Liver function tests, including assessment of serum protein and total bilirubin levels, and ALT and aspartate aminotransferase (AST) activities were performed every month during the treatment period. The primary end point of the study was HBsAg clearance and secondary end points included decrease in HBV DNA levels and ALT normalization.

ResultsThere was a significant improvement in chief clinical signs

and symptoms such as abdominal pain, poor appetite, and jaundice in patients treated with HD-03/ES. Biochemical investigations showed that 41.75% patients who received HD-

03/ES therapy had undetectable HBsAg levels when compared to only 5% patients who received placebo (P<.001). HBeAg loss occurred more frequently during treatment with HD-03/ES, and 5 of the 9 patients who were positive for HBeAg initially were HBeAg negative at the end of the therapy. HBV DNA levels became undetectable in 6 patients treated with HD-03/ES therapy as compared to just 1 patient in the placebo

Table 1. Effect of HD-03/ES and Placebo Therapy on Weight and Jaundice

Time(week)

Weight (kg) Mean ± SD Jaundice

HD-03/ESn = 25

Placebon = 25

HD-03/ES PlaceboYes No Yes No

0 49.0 ± 10.0 47.0 ± 16.0 21 4 22 34 49.2 ± 8.1 46.1 ± 9.8 16 9 21 48 49.3 ± 8.1 46.2 ± 9.6 13 12 21 412 49.7 ± 7.9 45.9 ± 8.6 5 20 21 416 49.8 ± 9.4 46.1 ± 7.3 4 21 20 524 49.9 ± 7.7 46.6 ± 7.8 2 22 15 5

Table 2. Effect of HD-03/ES Therapy on Liver Function TestsTime (weeks)

Liver function test

0 16 24HD/03/ES

n = 25Placebon = 25

HD/03/ES Placebo HD/03/ES Placebo

ALT (U/L) 208.9 ± 28.6

231.8± 112.1

66.8 ± 12.3*

161.8 ± 32.4

63.4± 13.6*

172.4 ± 63.0

AST (U/L) 128.3 ± 34.1

117.1 ± 28.1

73.6 ± 13.1

87.1 ± 42.3

65.1 ± 11.2*

85.5 ± 26.1

Protein total (g/dL) 7.0 ± 0.2 6.9 ± 0.5 7.2 ± 0.2 6.9 ± 0.6 7.4 ± 0.1* 6.9 ± 0.7

Protein fraction globulin (g/dL) 3.6 ± 0.1 3.5 ± 0.1 3.9 ± 0.1* 3.7 ± 0.1 4.0 ± 0.2* 3.7 ± 0.2

Bilirubin (total) (mg/dL) 4.2 ± 1.3 3.4 ± 1.7 2.5 ± 0.3 2.8 ± 1.9 1.1 ± 0.2* 2.5 ± 1.3

ALT normalization

(%)- - 56.0 12 70.8 15

* P<.05 as compared to 0 weeks.

Table 3. Biochemical and Serological Response of HD-03/ES Group as Compared to Placebo Group

Variable hd-03/ES Placebo ALT normalization (%)

16 weeks 56 (14/25) 12 (3/25)24 weeks 70.8 (17/24) 15 (3/20)

HBsAg loss Positive Negative Positive Negative0 weeks 25 0 25 0

16 weeks 17 8 24 124 weeks 14 10*** 19 1

HBeAg loss Positive Negative Positive Negative0 weeks 9 16 5 20

16 weeks 5 20* 4 2124 weeks 4 20* 4 16HBV loss Positive Negative Positive Negative0 weeks 13 12 14 11

24 weeks 7 17* 13 7*P<.05 as compared to 0 weeks. ***P<.01 as compared to 0 weeks.

group (P<.05). It was also noted that alanine aminotransferase levels were normalized and the normalization was more significant in those who cleared their HBsAg (Tables 1–3). Adverse effects were mild and never warranted withdrawal of the drug.

ConclusionThese findings indicate that HD-03/ES is safe and effective

in the outpatient management of chronic hepatitis B.

Livline • Vol. 6 • No. 3 • Jan–Mar 2012

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N e w s w i s e

E x p e r t c o m m e n t s

Interview with Dr Anil Baburao Pandit, MD, DGO, FICOG

Liver Disorders in Pregnancy

Dr Anil Baburao PanditConsulting Room & Swaroop Sonography Clinic “Saraswati”, Near Hotel Monark Satara - 415001

H e r b f a c t s

Influencing Factors of Mother–Infant Vertical Transmission of Hepatitis B VirusZhang WL, et al.

Zhongguo Dang Dai Er Ke Za Zhi. 2011;13(8):644-646.

The aim of this study was to investigate factors influencing mother–infant vertical transmission of hepatitis B virus (HBV). A total of 635 pregnant women with chronic hepatitis B or chronic asymptomatic HBV carriers were enrolled. The rate of HBV infection was compared between the infants born from the pregnant women of different HBV-DNA load, different ways of delivery, and different liver functions at birth and 3 months after birth. The newborn infants were routinely injected with hepatitis B immunoglobulin (200 IU) and hepatitis B vaccine (10 μg) within 12 hours of birth. The newborns presenting HBV infection within 24 hours of birth by serum test were re-injected with hepatitis B immunoglobulin (200 IU), 14 days after birth. The rate of HBV infection in infants with maternal HBV-DNA load >105 copies/mL was higher than in those with maternal HBV-DNA load ≤105 copies/mL at birth (14.4% vs 4.1%; P<.01) and 3 months after birth (4.7% vs 0%; P<.01). The rate of HBV infection at 3 months was lower than at birth in both groups. The rate of HBV infection in infants born by natural labor was higher than in those born by caesarean section at birth (P<.05). However, by 3 months after birth, the rate of HBV infection between the two groups was similar. It might thus be an effective way to reduce the rate of HBV infection in infants by decreasing maternal HBV-DNA load. With the administration of hepatitis B immunoglobulin and hepatitis B vaccine, the delivery way and the liver function of pregnant women may not to be factors influencing mother–infant HBV vertical transmission.

Maternal Hepatitis B and Hepatitis C Carrier Status and Perinatal OutcomesConnell LE, et al.

Liver Int. 2011;31(8):1163-1170.

The aim of this study was to examine the association between maternal hepatitis B and C mono- and co-infections with singleton pregnancy outcomes in the state of Florida. The researchers analyzed all Florida births from 1998 to 2007 using birth certificate records linked to hospital discharge data. The main outcomes of interest were selected pregnancy outcomes including preterm birth, low birth weight (LBW), small for gestational age (SGA), fetal distress, neonatal jaundice, and congenital anomaly.

The study sample consisted of 1,670,369 records. Human immunodeficiency virus co-infection and all forms of substance abuse were more frequent in mothers with hepatitis B and C infection. After using multivariable modeling to adjust for important socio-demographical variables and obstetric complications, women with hepatitis C infection were more likely to have infants born preterm (OR, 1.40; 95% CI, 1.15–1.72), with LBW (OR, 1.39; 95% CI, 1.11–1.74), and congenital anomaly (OR, 1.55; 95% CI, 1.14–2.11). In addition, women with hepatitis B infection were less likely to have infants born SGA (OR, 0.79; 95% CI, 0.66–0.95). These findings provide further understanding of the association between maternal hepatitis B or C carrier status and perinatal outcomes. Infants born to women with hepatitis C infection appear to be at risk for poor birth outcomes, including preterm birth, LBW, and congenital anomaly.

Characteristics of Ascites in Patients with Pregnancy-specific Liver DiseasesDevarbhavi H, et al.

Clin Gastroenterol Hepatol. 2011.

The characteristic of ascites in patients with pregnancy-specific liver disease (PsLD), which comprise acute fatty liver of pregnancy, hemolysis, increased levels of liver enzymes, low platelet syndrome, and preeclampsia-associated liver dysfunction are unknown.

The researchers evaluated the cellular and biochemical characteristics, and model for end-stage liver disease (MELD) scores, in patients with PsLD. A total of 46 consecutive patients with PsLD were investigated for the presence of ascites. The study assessed cellular and biochemical characteristics of the ascites fluid from these patients.

Ascites was observed in 35 of 46 patients with PsLD (76%). In 25 patients tested (71.4%), the ascites fluid had low levels of albumin (<0.2 g/dL) and protein (<1 g/dL) and high serum-ascites albumin gradients (SAAG), indicating portal hypertension. Spontaneous bacterial peritonitis (SBP) was observed in 48% of patients tested and was not associated with mortality. Patients with ascites had significantly low serum levels of protein and albumin (P<.001).

MELD scores did not differ between patients with or without ascites (32 vs 27; P=.1). Ascites occurs in 76% of women with PsLD, is transient, and has characteristics of portal hypertension based on a high SAAG. Almost half of patients with PsLD develop SBP, which does not affect survival.

A New Antioxidant Compound from Capparis spinosaYang T, et al.

Pharm Biol. 2010;48(5):589-594.

An activity-directed fractionation and purification process was used to isolate 1,1-diphenyl-2-picrylhydrazyl radical (DPPH) scavenging components from fruits of Capparis spinosa L. (Capparaeae). Ethyl acetate and aqueous fractions showed greater DPPH scavenging a c t i v i t i e s compared to the petroleum ether fractions. The ethyl acetate fraction was subjected to purification using column chromatography. A new antioxidant cappariside (4-hydroxy-5-methylfuran-3-carboxylic acid, 1), together with seven known organic acids (2-8) for the first time from plants of genus Capparis and four known organic acids (9-12) were isolated from C spinosa. The structures were elucidated by extensive analysis of 1D- and 2D-NMR spectroscopic. In addition, compounds 1, 2, 4, 5, 9, 10, and 12 indicated strong scavenging capacity for DPPH radicals with a SC(50) value of 0.204 ± 0.002, 0.007 ± 0.0, 0.011 ± 0.0, 0.044 ± 0.0016, 0.032 ± 0.0, 0.090 ± 0.001, and 0.350 ± 0.017 mM, respectively.

Capparis spinosa

How frequently do you see cases of jaundice during pregnancy? What are the common causes of jaundice during pregnancy?

In tropical countries like India, liver diseases during pregnancy are associated with high risk of morbidity and mortality. According to a 2001 report, jaundice is responsible for 5% to 20% of maternal deaths in the developing countries of Asia. Morbidity is more likely in the presence of a preexisting liver disease such as autoimmune hepatitis or when a new onset liver disease occurs during pregnancy as in viral hepatitis.

Viral hepatitis is the most common cause of jaundice during pregnancy. The incidence of hepatitis in pregnancy varies widely across the world, with around 0.1% in developed countries and 3% to 20% or higher in developing countries. Certain causes of jaundice that are unique to pregnancy include cholestasis of pregnancy, preeclampsia, acute fatty liver of pregnancy.

Why are pregnant women prone to liver disorders?During pregnancy, the synthetic and metabolic functions of

liver are affected by increased serum estrogen and progesterone levels. Although these changes are physiological, there is potential for morbidity and mortality to both mother and fetus. Probably, there is a decline in immunity.

Abnormal liver tests are observed in 3% to 5% of pregnancies, with many potential causes, including coincidental liver disease (most commonly viral hepatitis or gallstones) and underlying chronic liver disease.

How do you manage liver disorders during pregnancy?Liver disorders could make normal pregnancy a high-

risk pregnancy. Thereby extreme vigilance is needed to detect early signs and symptoms of liver dysfunction and to distinguish these from the anticipated benign hepatic changes of pregnancy. An increase in serum aminotransferase, bilirubin, or serum bile acid concentrations during pregnancy is always pathologic and requires evaluation since the underlying liver disease could be severe and result in an increased risk to the mother and fetus. Drug therapy is often required, and clinicians need to be familiar with which drugs are safe and which can be dangerous during pregnancy. Early diagnosis of liver disorders and prompt delivery with supportive therapy help in improving maternal and perinatal outcome.

What is your opinion about use of Liv.52 in the management of liver disorders during pregnancy?

Liv.52, a polyherbal formulation from The Himalaya Drug Company, is a well-known hepatoprotective drug, useful in the treatment of various liver dysfunctions/disorders including viral hepatitis, alcoholic liver disease, anorexia, and drug-induced hepatitis. Several studies have proven its safety and efficacy in the management of jaundice during pregnancy. I regularly prescribe Liv.52 to my patients with hepatic disorders and have seen good results, as it definitely improves appetite and gives sense of well being. It is a very useful drug in jaundice during pregnancy.

Capparis spinosa is used in Liv.52®

owing to its hepatoprotective, antioxidant, antimicrobial, and

anti-inflammatory properties.

Livline • Vol. 6 • No. 3 • Jan–Mar 2012

4

N e w s f l a s h

Edited and Published byDr Pralhad S Patki, MD

The Himalaya Drug Company, Bangalore

Printed atSri Sudhindra Offset Process

Bangalore

E-mailpublications@himalayahealthcare.com

Websitewww.himalayahealthcare.com

EDITORIAL TEAM

Editor in chiefDr Pralhad S Patki

Managing EditorDr Jayashree B Keshav

Editorial AssistantsPooja Sinha

Shruthi VB

Shahina KR

Rashmi Raj

Layout ArtistsDayananda Rao S

Santosh G

I think and think for months and years. Ninety-nine times, the conclusion is false. The hundredth time I am right.

– Albert Einstein

…contd from page 1 (Research update)

Liv-

wis

e

L a u g h l i n e sAs a senior citizen was

driving down the freeway, his cell phone rang.

Answering, he heard his wife’s voice urgently warning him, “Herman, I just heard on the news that there’s a car going the wrong way on Route 280. Please be careful!”

“It’s not just one car,” said Herman, “It’s hundreds of them!”

• • •

A lawyer, an engineer, and a mathematician were called in for a test. The engineer went in first and was asked, “What is 2+2?” The engineer thought awhile and finally answered, “4.” Then the mathematician was called in and was asked the same question. With little thought he replied, “4.0.” Then the lawyer was called in, and was asked the

same question. The lawyer answered even quicker than the mathematician, “What do you want it to be?”

• • •

A woman walked into the kitchen to find her husband stalking around with a fly swatter.

“What are you doing?” She asked.

“Hunting flies,” He responded.

“Oh! Killed any?” She asked.

“Yup, 3 males, 2 females”, he replied.

Intrigued, she asked, “How can you tell?”

He responded, “3 were on a beer can, 2 were on the phone.”

• • •

HELLP SyndromeHELLP syndrome occurs in approximately 1 per 1000 pregnancies.

The majority of cases are diagnosed between 28 and 36 weeks of gestation. The disease presents prior to delivery in 70%, postpartum in 30% of cases, usually within 48 hours, but occasionally as long as 7 days after delivery.

Clinical featuresThe clinical presentation of HELLP syndrome varies. Although

some patients have no symptoms, most complain of abdominal pain and tenderness. The pain is located in the midepigastrium, right upper quadrant, or below the sternum. Many patients also have nausea, vomiting, and malaise. Hypertension and proteinuria are present in approximately 85% of cases, pulmonary edema in 6%, ascites in 8%, and acute renal failure, usually occurring in the setting of DIC (disseminated intravascular coagulation), in 20%.

Differential diagnosisThe differential diagnosis includes AFLP; or, because of similar

symptoms or laboratory findings, gastroenteritis; hepatitis; appendicitis; gallbladder disease; idiopathic thrombocytopenic purpura; hemolytic-uremic syndrome; or thrombotic thrombocytopenic purpura.

Acute Fatty Liver of PregnancyThe prevalence of acute fatty liver of pregnancy (AFLP) is estimated

to be 1 per 16,000 cases to 1 per 7000. AFLP occurs in the second half of pregnancy, usually close to term. However, some patients may present and be diagnosed after delivery.

EtiologyRecently, an association between AFLP and one of the inherited

defects in mitochondrial beta-oxidation of fatty acids—long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency—was suggested. This enzyme is one of the four enzymes, which break down long-chain fatty acids in the liver.

Clinical featuresAFLP may present with malaise, fatigue, anorexia, nausea, vomiting,

headache, abdominal pain, and jaundice. Within 1 to 2 weeks of onset

of symptoms, the disease may rapidly worsen. Patients then develop acute liver failure, including hepatic encephalopathy, ascites, edema, and renal insufficiency.

Differential diagnosisThe differential diagnosis includes acute viral hepatitis, especially

hepatitis E in endemic areas, or herpes simplex; drug-induced hepatitis; HELLP syndrome; biliary tract disorders.

SummaryAn increase in serum aminotransferase, bilirubin, or serum bile

acid concentrations during pregnancy is always pathologic and requires evaluation since the underlying liver disease may be severe and result in an increased risk to the mother and fetus. Although liver diseases unique to pregnancy are uncommon, they should always be suspected because of potential for acute liver failure. Gestational age is the best guide to differential diagnosis of pregnancy-related liver disease.

Acute Viral Hepatitis During Pregnancy

The course of most viral hepatitis infections (hepatitis A, B, C, and D) is unaffected by pregnancy; however, a more severe course of viral hepatitis in pregnancy has been observed in patients with hepatitis E. Notwithstanding, opinions differ over the maternal and fetal outcome of pregnancy associated with viral hepatitis.

While some studies report that acute viral hepatitis carries a high risk for both mother and fetus, other studies conclude that nonfulminant viral hepatitis does not influence the course of pregnancy or fetal well-being.

Rate of transmission of the virus during pregnancy depends on the virus. For instance, intra-utero transmission of hepatitis A virus is very rare, but perinatal transmission could occur. Conversely, 60% of pregnant women who acquire acute hepatitis B virus (HBV) infection at or near delivery will transmit the HBV virus to their offspring. Mother to child transmission of hepatitis E virus infection was established between 33.3% and 50%.

Breast feeding is not contraindicated in women infected with the hepatitis A, E, or C. However, for acute hepatitis B, with appropriate immunoprophylaxis, breast-feeding poses no additional risk for the transmission of HBV.

Finally, whether live or inactivated vaccines are used, vaccination of pregnant women should be considered on the basis of risks and benefits associated with them.

Source: Sookoian S. Ann Hepatol. 2006;5(3):231-236.