Dr Amit Basnotra, Dr Richa Sharma
Liver and biliary tract disorders can affect the pregnant woman and her fetus and the most common presentation is Jaundice
It is customary to divide liver diseases into those specifically related to pregnancy, those coincidental to pregnancy, and those that are chronic and antedate pregnancy. Pregnancy may normally induce appreciable changes in some of the tests to assess liver function
What is Jaundice ?
Jaundice Or Icterus is the yellowish discolouration of the skin and mucosa and it is caused by the rising levels of bilirubin and it can be due to reasons related to liver and those which are non hepatic like in pregnancy
When Should You Seek Medical Care ?
You should seek urgent medical attention and care when you notice yellowish discolouration of eyes/skin or have dark coloured urine and abdominal swelling along with other sign symptoms like itching
Incidence-
Jaundice complicates about 1 in 2000 pregnancies
What Could be the Reasons of Jaundice In Pregnancy ?
Viral hepatitis is the most common cause and may account for up to 40% of cases.
Other conditions include hemolytic jaundice, recurrent intrahepatic cholestasis of pregnancy (up to 25%), and gallstones (6%).
Hyperemesis
Acute fatty liver
Hypertensive disease of pregnancy are responsible for less than 10% of cases.
Jaundice may also occur in association with treatment with drugs such as chlorpromazine and, rarely, in severe cases of excessive vomiting.
How to Detect it ?
From the clinical details with certain set of questionnaire can help to reach the timely diganosis
History with regard to recent travel abroad
Past and current medical or surgical illnesses
Side effects of certain drugs, substance abuse
Episode of blood product transfusion and any complications for the same
Besides one need to rule out any family history of jaundice or liver disease
We have to ask for the symptoms of pruritus, pain, nausea, vomiting, fever, and color and consistency of stools.
Gestational age and estimation of fetal weight and fetal movement and viability should be established.
Dermatological manifestations of liver disease can be in the form of-
Palmar erythema
Spider nevi are present in 60% of normal pregnant women
How to Assess the Severity Of Illness ?
Clinical assessment is need to categorise and plan the next step of management-
Degree of jaundice
Hydration status
Level of consciousness
Cardiovascular stability
Presence of flapping tremor
Evidence of ecchymoses, ascites, hepatic tenderness, and uterine and so on
Management Of A Jaundice Pregnant Patient-
Jaundice when happens in pregnancy carries a lots of underlying risks not only to the prospecrive mother but also to the in utero baby who has to yet come in the world.It carries a lot of worries and queries in mind of the patient, family and treating doctor too as sometimes the sequence of events may be unpredictable especially when detected late so right approach on time is very important seeking help of Gastroentrologist besides the Obstetrician so that things not missed and appropriate treatment can be given.
Patient may often need Hospitalization for investigation and monitoring during which they will be subjected to a battery of blood tests ,viral screening and even ultrasound both for the patient and for the foetal well being as here two lives on stake due to one reason and it definitely shifts the normal course of pregnancy to high risk zone
Joint management with a physician or surgeon would be useful to identify the etiology and carry out supportive therapy with maintenance of hydration, nutrition, correction of electrolyte disturbances, correction of coagulopathy, and control of blood glucose levels.
Intensive care with ventilatory support may be necessary in some cases depending on the etiology and severity of the disease. It may be necessary to expedite delivery even though the fetus may be premature.So all will be decided as per the clinical status of the mother and the viability status of the baby with team approach as at end aim is to have a SAFE MOTHER AND SAFE BABY !!
Conditions Which Can Present As Jaundice In Pregnancy –
Below are few coditions which can lead to Jaundice In Pregnancy-
1) Viral hepatitis-
This does not appear to occur more frequently in pregnancy than at other times, nor is it significantly different in its cause or management as far as the mother is concerned. Management of the patient is not influenced by pregnancy and treatment similar to that in the nonpregnant should be given.
Prematurity and stillbirths are more common if the disease occurs later in pregnancy. However, if jaundice occurs earlier, it appears to be less harmful. Neither hepatitis B nor hepatitis A virus causes congenital abnormalities, and so an infection during pregnancy is not an indication for termination. Jaundice due to gallstones is rare in pregnancy but, if it does occur, removal of the stone(s) would be indicated.
Liver diseases peculiar to pregnancy-
Hyperemesis gravidarum.
Hypertensive disease of pregnancy.
Its association with HELLP syndrome is well recognized
Treatment is by delivery of the fetus.
Intrahepatic cholestasis of pregnancy.
This presents with pruritus and jaundice.
It usually resolves within 48 hours of delivery and up to 45% of cases recur in subsequent pregnancies
There is a recognized fetal mortality associated with this condition, especially in late pregnancy
Fetal assessment in the form of frequent cardiotocographs (CTGs) and biophysical profiles is indicated, especially in late pregnancy. However, it is not clear that frequent antepartum testing can prevent the adverse outcomes in pregnancies complicated by intrahepatic cholestasis so the risk still contiues but definitely timley measures taken can help save two lives
Acute fatty liver and acute hepatic failure –
Rarely, in late pregnancy, a patient will develop vomiting, upper abdominal pain, and jaundice. This may quickly be followed by headaches, mental confusion, and death. The whole duration of the disease may be merely a few days.
The progress of the condition is so rapid that effective treatment may be almost impossible. Early delivery is indicated at the first appearance of jaundice if the diagnosis is not in doubt.
Conclusion-
Jaundice in Pregnancy is a condition which may be just a mild manifestation of altered physiology or may be a warning sign of an underlying grevious disease so crux is not to ignore and seek urgent help and medical care.Right approach and guidance both by doctor and self awareness by the patient and family members can help check impending serious outcomes.Multidisciplinary approach keeping safety of patient and the baby as priority should be the way.
(The authors are Senior Gastroentrologist and Senior IVF Consultant)
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