Characteristics of pregnancy-related liver diseases - McMaster Textbook of Internal Medicine

Table 15.4-3. Characteristics of pregnancy-related liver diseases
	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	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.
AKI, acute kidney injury; ALT, alanine transaminase; AST, aspartate transaminase; DIC, disseminated intravascular coagulation; HELLP, hemolysis, elevated liver enzymes, low platelets; IV, intravenous; LDH, lactate dehydrogenase; PET, preeclamptic toxemia; PPI, proton pump inhibitor; ULN, upper limit of normal.