liver disease in pregnancy - mucosal immunology · general considerations bibleclass 23.09.2015,...

Liver Disease in Pregnancy

Bibleclass 23.09.2015

Felix Brunner

General Considerations

Bibleclass 23.09.2015, Brunner 2

Intrahepatic

Cholestasis of

Pregnancy

Pre-existing Liver

Cirrhosis

Bile Stone

Disease

Intrahepatic

Cholestasis of

Pregnancy

Pre-existing Liver

Cirrhosis

Bile Stone

Disease

Acute Fatty Liver

of Pregnancy

Intrahepatic

Cholestasis of

Pregnancy

Pre-existing Liver

Cirrhosis

Bile Stone

Disease

Acute Fatty Liver

of Pregnancy

Hepatitis B

Physiological Changes in

Pregnancy

Cardiovascular Endocrinological

Biliary

Lab Parameter

Pregnancy

Cardiovascular

• Heart Rate,

Cardiac output ⬆• Blood pressure,

vascular

resistance ⬇• 50% blood

volume

Endocrinological

Biliary

Lab Parameter

Pregnancy

Cardiovascular

• Heart Rate,

vascular

volume

Endocrinological

Biliary

Lab Parameter

• Alk. Phosph⬆• Albumin ⬇

Pregnancy

Cardiovascular

• Heart Rate,

vascular

volume

Endocrinological

• Hyperestrogenic

Spider Nävi

Palmar

erythema

Biliary

Lab Parameter

Pregnancy

Cardiovascular

• Heart Rate,

vascular

volume

Endocrinological

• Hyperestrogenic

Spider Nävi

Palmar

erythema

Biliary

• Gallbladder

Motility ⬇

Lab Parameter

Overview

• Hyperemesis Gravidarum

• Intrahepatic Cholestasis of

Pregnancy

• Pre-Eclampsia & Eclampsia

• HELLP-Syndrom

• Acute Fatty Liver in Pregnancy

• HBV Transmission

4Bibleclass 29.04.2015, Brunner

Hyperemesis Gravidarum

Trimester: 1-2

Symptoms: Intractable Vomitus

Ketosis

Trimester: 1-2

Ketosis

5% Weight loss

Trimester: 1-2

Ketosis

5% Weight loss

Epidemiology: 0.3-2% of all Pregnancies

Mechanism: Mixed (Motility, Hormonal, ANS)

Risk Factors: ⬆ BMI

Psychiatric Disorders,

Diabetes mellitus

Multiple Pregnancies

Diabetes mellitus

Positive Family History

Diabetes mellitus

Lab: Aminotransferases ≤ 20xULN

Complications:

Mother: Dehydration, AKI, Weight ⬇Wernicke Encephalopathy

Foetus: Low Birth Weight

Preterm Delivery

Complications:

Preterm Delivery

Therapy: Rehydration

Complications:

Preterm Delivery

Antiemetics

Complications:

Preterm Delivery

Antiemetics

Vitamin Supp. (e.g. B1!!)

Intrahepatic Cholestasis of

Pregnancy

Trimester: 2nd Half of Pregnancy

Pregnancy

Symptoms: Pruritus (particularly Soles & Palms)

Diarrhoea

Pregnancy

Diarrhoea

Jaundice

Pregnancy

Diarrhoea

Jaundice

Epidemiology: 0.1-1.5% all Pregnancies

Pregnancy

Diarrhoea

Jaundice

Epidemiology: 0.1-1.5% all Pregnancies

(Scandinavia & South America ⬆)

ICP - Pathogenesis

Joshi, Lancet 2010

• 15% Mutation

MDR3 gene

(10 identified)

• Female

Hormones

Inhibit Bile Salt

Export Pumps

Risk Factors: Intrahepatic Cholestasis due to

Contraceptive Drugs,

Bile Acids > 10 µmol/L

Complications:

Mother: Risk of Biliary &

Autoimmune Disease in the

Future

Foetus: Anoxia, Prematurity, Stillbirth,

Perinatal Death

Complications:

Future

Perinatal Death

Therapy: Ursodeoxycholicacid

Complications:

Future

Perinatal Death

10-15mg/kg

Complications:

Future

Perinatal Death

10-15mg/kg

Early Delivery Week (36)-38

Pre-Eclampsia & Eclampsia

Trimester: 2nd Half of Pregancy

Definition: Pre-Eclampsia = AHT +

Proteinuria

Eclampsia = Pre-Eclampsia

+ Seizures

Proteinuria

Eclampsia = Pre-Eclampsia

+ Seizures

Epidemiology: 5-10% all pregnancies

Mechanism: Placenta Ischemia

➡ Endothelial Dysfunction

& Coagulation Activation

Risk Factors: Age <16 or >45 years

Primiparity

Pre-existing AHT

Primiparity

Pre-existing AHT

pos. Family History

Occurrence previous Pregnancy

Primiparity

Pre-existing AHT

pos. Family History

Occurrence previous Pregnancy

Complications:

Mother: Hypertensive Crises

Renal Dysfunction

Hepatic Rupture or InfarctionSeizures

Increased Morbidity & Mortality

Complications:

Mother: Hypertensive Crises

Renal Dysfunction

Hepatic Rupture or InfarctionSeizures

Increased Morbidity & Mortality

Therapy: Early Delivery, Magnesiumsulfate

Definition: Hemolysis

Elevated Liver Enzymes

Low Platelets

Epidemiology: 0.6 % all Pregnancies

Low Platelets

Epidemiology: 0.6 % all Pregnancies

5-10% Pre-Eclampsia

Mechanism: Not Clear

Severe Form of Pre-Eclampsia?

Risk Factors: Advanced Maternal Age

Multiparity

Caucasian Ethnicity

Multiparity

Caucasian Ethnicity

Lab: Hemolysis, Platelets ⬇

Multiparity

Caucasian Ethnicity

Lab: Hemolysis, Platelets ⬇

Aminotransferases & Bilirubin ⬆

Complications:

Mother: Hepatic Encephalopathy

Renal Failure

Hepatic Hematoma & Rupture

Hepatic Infarction

Child: Prematurity ➡ 6-70% mortality

Therapy: Early delivery (≥ week 34)

Antihypertensive Therapy

(Labetalolol, Hydralazin,

Nifedipin)

Antihypertensive Therapy

(Labetalolol, Hydralazin,

Nifedipin)

OLT in case of Liver Failure

Acute Fatty Liver of Pregnancy

Trimester: 3rd.

Symptoms: Vomiting, Jaundice,

Hypoglycemia,

Trimester: 3rd.

Hypoglycemia,

Lactacidosis,

Trimester: 3rd.

Hypoglycemia,

Lactacidosis,

Hyperammonaemia

Trimester: 3rd.

Hypoglycemia,

Lactacidosis,

Hyperammonaemia

Epidemiology: 5/100’000 pregnancies

Trimester: 3rd.

Hypoglycemia,

Lactacidosis,

Hyperammonaemia

Epidemiology: 5/100’000 pregnancies

Mechanism:

• Mitochondrial

Cytopathy

• The Fetus has a defect

Fatty acid β oxidation

• Deficient long-chain 3-

hydoxyacyl coenzyme A

dehydrogenase

Mother

Complications:

Mother: Risk factor for development

of biliary & autoimmune

disease in the future

Foetus: Anoxia, prematurity, stillbirth,

perinatal death

Complications:

perinatal death

Complications:

perinatal death

10-15mg/kg

Complications:

perinatal death

10-15mg/kg

Early delivery week (36)-38

Acute Fatty Liver of PregnancySwansea Diagnostic

Criteria Risk Factors:

• Twin pregnancy

• Nulliparity

• Inverse Relation

between BMI & AFLP

Complications:

Mother: Hepatic Encephalopathy

Liver Failure, Liver Rupture

Renal Failure

Maternal Mortality 1-20%

Child: Features associated

with defect fatty acid oxidation:

Hypoglycaemia, Hepatic failure,

MyopathyBibleclass 23.09.2015, Brunner 24

HBV Transmission

Background:

• Switzerland:

0.5% of Pregnant Women

HBs-Antigene positive

• Mother-to-Child-Transmission:- HBe-Ag positive: 70-90%

- HBe-Ag negative: 10-40%

- Acute Hepatitis B in Pregnancy: 40-60%

HBV Transmission

Background:

• Postnatal Hepatitis B Immunoglobulin

& HBV Vaccine reduces Transmission to 5-10%

• Predictive for Immunoprophylaxis Failure

HBe-Antigen positive

HBV DNA > 200‘000 IU/ml

HBV Transmission

Bibleclass 23.09.2015, Brunner 29Bleich, J Clin Gastr 2014

liver disease in pregnancy - mucosal immunology · general considerations bibleclass 23.09.2015,...

Documents

liver disease in pregnancy: diagnosis and treatment ·...

liver 3 kiss 2018 [kompatibilis üzemmód] · 2018. 3....

pregnancy and vascular liver diseases€¦ · coagulation...

cholestasis of pregnancy –where are we?...intrahepatic...

hÍgado graso · acute fatty liver is an exclusive disease...

chronic hypertension complicating pregnancy€¦ · of...

acute fatty liver of pregnancy acute pancreatitis in a...

viral hepatitis and pregnancy -...

hepatitis and pregnancy - gfmer.ch · pdf fileliver disease...

liver disease in pregnancy - university of louisville

dr david rowbotham - gp cme - 1505 sigma... · overview...

association of hypoproteinemia in preeclampsia with...

approach to elevated liver enzymes in pregnancy -...

hepatitis in pregnancy. summary of physiological changes in...

liver disease in pregnancy - mucosal immunology · liver...

fatty liver and pregnancy

haematological aspects of systemic disease. overview...

pregnancy and the liver - american college of...

acute fatty liver of...

management of liver diseases in pregnancy moderator-prof....