Hyperemesis gravidarum

Intrahepatic cholestasis of pregnancy

HELLP +/– PET

Acute fatty liver of pregnancy

Timing

First trimester

Second/third trimester

Second trimester (>20 wks), third trimester, post partum

Third trimester

Signs and symptoms

Nausea/vomiting, dehydration (postural hypotension and tachycardia), weight loss >5%

Pruritus of the limbs and trunk (especially palms/soles), worsened at night, no rash

Epigastric pain, nausea/vomiting, headache, hypertension, other features of PET

Nausea/vomiting, abdominal pain, encephalopathy, general malaise, polydipsia, polyuria, jaundice

Liver enzymes and bilirubin

Increased AST/ALT (100s IU/L), slightly elevated bilirubin

Increased AST/ALT (<1000 IU/L), bilirubin (conjugated) usually normal but can be mildly elevated

Increased AST/ALT (100-1000s IU/L), slightly elevated bilirubin (unconjugated)

Increased AST/ALT (<500 IU/L), significantly increased bilirubin (conjugated)

Other investigations

Hyponatremia, hypokalemia, metabolic alkalosis, ketosis

Increased bile acid levels (>10 micromol/L)a

Hemolysis on smear, elevated LDH, thrombocytopenia, AKI

AKI, DIC, hypocalcemia, hypoglycemia, leukocytosis

Treatment

Supportive care with IV fluids, antiemetics, electrolyte replacement, PPI, +/– thiamine

– Ursodeoxycholic acid (10-15 mg/kg in 2-3 divided doses), antihistamines, topical creams

– Resolves after delivery

Delivery, hypertension management, magnesium for eclampsia prevention (if appropriate), +/– blood products

Delivery, supportive care, liver transplant (in rare cases)

Complications

Hyponatremia, Wernicke encephalopathy, other vitamin deficiencies

Preterm labor and stillbirth (increased risk if bile acids >100 micromol/L)

Subcapsular liver hematoma, liver rupture, placental abruption, eclampsia (if PET), pulmonary edema, maternal/fetal mortality

Liver failure, maternal/fetal mortality

Recurrence

High

High

– Low

– Increased risk of developing PET, preterm delivery, and fetal growth restriction

Rare if no fatty acid oxidation disorders

a The ULN depends on the laboratory and local practices.