Pregnancy is an exciting time filled with joy. Any abnormality such as the finding of liver test abnormalities during this time creates significant anxiety for both the pregnant woman and the expectant father. This anxiety is made worse by the simple fact that liver disease in pregnancy is poorly understood.
The good news is that most liver test abnormalities seen in pregnancy spontaneously resolve with no effect on either the mother or newborn child/children. The cause is usually unknown and tends to not recur with subsequent pregnancies. Despite this reassuring fact, a physician must evaluate liver test abnormalities found during pregnancy as significant liver disease can occur during this period that could adversely affect the mother and/or the child.
The most common causes of abnormal liver tests in pregnancy are not specific to pregnancy and are mostly due to viral infections such as hepatitis A, medication use, the use of complementary or alternative medications and herbs and fatty liver. There are, however, several important conditions specific for pregnancy that need to be recognized, as they are associated with significant risk.
Nausea and vomiting are quite common during the first trimester of pregnancy. So common, in fact, that morning sickness is thought to be one of the first signs of pregnancy. Most morning sickness is easily managed or goes away on its own. Occasionally, the nausea and vomiting will become protracted and severe requiring hospitalization for intravenous fluids. At this stage, morning sickness has evolved into a condition called hyperemesis gravidarum. Abnormalities in liver tests are common in this condition.
The development of hyperemesis gravidarum is associated with the first pregnancy, young age, smoking and obesity. The cause is unknown. If severe and the woman has difficulty maintaining her weight while pregnant, the fetus is at increased risk of intrauterine growth retardation. Hyperemesis gravidarum however, is not associated with liver disease.
Intrahepatic cholestasis of pregnancy is a condition unique to both pregnancy and oral contraceptive use and tends to occur in otherwise healthy women. This condition occurs in the third trimester of pregnancy and is marked by the development of severe itching.
Liver test abnormalities are common and many expectant mothers develop jaundice. The cause is unknown, although hormonal changes are felt to play a role in its development. It occurs more commonly among people of Latin American or Scandinavian descent. If mild, the itching is treatable with bile-acid resin binders such as cholestyramine. Ursodeoxycholic acid and phenobarbital have been successfully used to treat itching.
The only certain therapy, however, is delivery. With delivery, itching usually resolves within days and liver test abnormalities usually normalize within several weeks. This is a benign but frequently recurrent condition for the mother. Pregnant women who develop this need are at risk for the development of primary biliary cholangitis in the future. Intrahepatic cholestasis, however, is not benign for the fetus, as it is associated with an increased rate of fetal distress, premature births and stillbirths.
Two other conditions that are unique to pregnancy are worthy of mention. The HEELP syndrome (hemolytic anemia, elevated liver enzymes and low platelets) and acute fatty liver of pregnancy are conditions that occur in the third trimester. The causes for these disorders are unknown but a growing body of research suggests that acute fatty liver of pregnancy may be an inherited disorder.
Once diagnosed, these conditions need to be treated immediately with delivery as both conditions can rapidly progress to coma and maternal death. Within two weeks of delivery, symptoms generally resolve and the event is self-limited. If delivery goes well, there are no long-term sequelae associated with either condition. Both conditions, however, are associated with an increased risk of maternal death, fetal intrauterine growth retardation and fetal death.
David Bernstein, MD, is chief of gastroenterology, hepatology and nutrition at North Shore University Hospital and Long Island Jewish Medical Center.
