Acute fatty liver

• Incidence ~ 1:10,000 pregnancies
• Associated with obesity and multiple pregnancy
• More common with male fetuses (3x) and in primigravidae
• Associated with 10-20% maternal mortality and 20-30% perinatal mortality
• Typically presents in the third trimester with malaise, anorexia, nausea and vomiting and epigastric pain and profound hypoglycaemia

• Hypertension and proteinuria may be present and the woman may be jaundiced. 

The woman may develop fulminant hepatic failure with encephalopathy. 

There is also an association with diabetes insipidus
• Ultrasound scan shows fatty infiltration of the liver although it may be normal
• Liver biopsy is the gold standard for diagnosis though rarely needed

• Main differential diagnosis is HELLP syndrome

Obstetric cholestasis

- Associated with increased maternal serum bilirubin, cholesterol and triglyceride concentrations 

- Alkaline phosphatese, gamma-GT, AST and ALT concentrations are also increased 

Obstetric cholestasis

• Associated with :

1. meconium stained liquor, 
2. IUD, 
3. intra-partum fetal distress and 
4. pre-term delivery

• Diagnosis based on raised serum bile acids. 
Conjugated bilirubin and liver enzymes are also raised.

• IOL is recommended at 37-38 weeks gestation

Acute fatty liver in pregnancy

• Typically presents in the third trimester with malaise, anorexia, nausea and vomiting and epigastric pain


• Ultrasound scan shows fatty infiltration of the liver although it may be normal


• MANAGEMENT -
• Multi-disciplinary care involving hepatologist and ITU physician


• Prompt delivery after correcting coagulopathy and hypoglycaemia.


• Liver failure and encephalopathy are recognised complications

Obstetric cholestasis

• Most common pregnancy-induced liver disorder, 
  second commonest cause of jaundice in pregnancy 

(viral hepatitis is the commonest cause worldwide))

• Anorexia, malaise, steatorrhoea, epigastric discomfort and dark urine may be present.

• Serum bile acid concentrations are markedly raised. 
  Conjugated bilirubin and liver enzymes are also raised.

• Ursodeoxycholic acid reverses biochemical abnormalities but no evidence that it alters fetal outcome. 
  Not licensed for use in pregnancy

Liver disease

• Worldwide, viral hepatitis is the commonest cause of liver disease in pregnancy
• HELLP syndrome may occur in women without hypertension or proteinuria. 
Usually, hypertension and / or proteinuria are not marked

Gilbert's syndrome

• Gilbert's syndrome presents as mild fluctuating jaundice which may only be apparent when the patient is tired, dehydrated or starved
• Associated with unconjugated hyperbilirubinaemia, but liver enzymes are normal
• Relatively common in Caucasians with prevalence of 1-2%

Ursodeoxycholic acid

- Ursodeoxycholic acid acts by altering the bile acid pool and reducing the proportion of hydrophobic and hepatotoxic bile acids. 

- Reduces serum bile acid concentration. 

- Not licensed for use in pregnancy

 - No evidence that ursodeoxycholic acid affects fetal outcome in obstetric cholestasis