By R. Kyle Barnett, MD
Abnormal liver tests occur in approximately 3-5% of pregnant women. For some women, test results that would otherwise suggest liver or gallbladder dysfunction in a non-pregnant woman may, in fact, be normal in a pregnant woman. Abnormal test results should be evaluated by a specialist since some diseases, newly diagnosed in pregnancy, may require more immediate intervention for the expectant mother or unborn fetus.
Managing a pregnant woman with liver disease is a common medical scenario that involves unique challenges, since the mother AND fetus must be considered in any clinical treatment decisions. Pregnant patients who have had abnormal liver tests can expect to undergo some level of additional testing, to address initial testing results.
A standard workup, just as any non-pregnant individual with similar results would have, is the first step. Most liver test results remain the same during pregnancy, except for those produced by the placenta. Abnormalities seen with certain liver tests require further evaluation.
Ultrasound testing is safe and is the preferred imaging type in abnormal liver assessment that suggests gallbladder disease. MRI and CT scans may be used but only under certain conditions in later pregnancy.
Endoscopy may be necessary during pregnancy, but if possible, not until after the second trimester. Sedation with propofol is acceptable for pregnant patients.
Liver Diseases Unique to Pregnancy
Hyperemesis gravidarum (HG), is a condition which includes severe morning sickness, with symptoms which can include nausea, vomiting, jaundice, weight loss and dehydration which can affect liver function, urine output, blood pressure, cognition and heart rate. Treatment for HG may require hospitalization to ensure the pregnant woman receives fluids and nutrients necessary for her own health as well as that of the fetus, usually followed by bedrest.
Preeclampsia with liver involvement can progress to the level of Severe Preeclampsia, prompting delivery after 36 weeks to limit maternal and fetal complications.
HELLP syndrome, is an unusual set of symptoms that may be related to preeclampsia. It affects liver function, causes the breakdown of red blood cells and produces a low platelet count, which negatively affects blood clotting ability. Immediate delivery is recommended (especially after 34 weeks).
Other Condition That Can Occur
Gallbladder and Biliary System
If symptoms indicate, gall bladder removal is possible during pregnancy using laparoscopic surgical techniques.
Patients with liver masses should be treated prior to pregnancy when possible. Most conditions do not require routine imaging, but those with certain lesions should be monitored by ultrasound to track growth.
Current recommendations for pregnant women with chronic hepatitis B virus infection include vaccinating infants born to HBV-infected mothers and antiviral medication given during the third trimester to reduce transmission to the newborn. At present, chronically hepatitis B-infected women can still breastfeed, as no strong evidence indicates otherwise.
Women with risk factors for hepatitis C should be screened with blood tests, but screening is not indicated in women without risk factors. Invasive procedures, including an elective C-section, should be avoided if possible in women with chronic hepatitis C, to prevent transmission of hepatitis C to the fetus.
Women with acute hepatitis should be tested for common causes of acute liver injury including viral hepatitis and herpes hepatitis. Those with acute hepatitis suspected to be caused by herpes virus should be treated with antiviral medication.
Women suspected of cirrhosis should have an upper endoscopy to screen for esophageal varices in the second trimester. Those with large esophageal varices should be treated accordingly.
There are more liver conditions that could be present during pregnancy for certain at-risk patients. Pregnant women under a doctor’s care will be able to address any health concerns that could affect the mother or fetus.
Patients who know they have hepatitis or feel there is a risk of exposure, have liver conditions that require medical care or have hereditary factors that may indicate liver problems, should consult with their doctor prior to becoming pregnant to ensure the healthiest start for themselves and their baby.