COMMENTARY

Liver Disease in Pregnancy

Rowen K. Zetterman, MD

Disclosures

April 08, 2013

In This Article

Hyperemesis Gravidarum

Hyperemesis during pregnancy is defined by protracted vomiting, which can result in dehydration, ketosis, or > 5% weight loss.[7] The condition occurs in < 2% of women during pregnancy.[8] Factors associated with hyperemesis include increased body mass index, multiparity, diabetes mellitus, and psychiatric disorders.[9] Hyperthyroidism may also develop in some patients during pregnancy, resolving with delivery.[10]

Hyperemesis gravidarum typically begins during the fourth week of pregnancy and resolves by week 20,[11] although in some women the symptoms continue throughout pregnancy. Other causes of vomiting should be excluded, such as viral hepatitis, gastroenteritis, small bowel obstruction, and acute cholecystitis. Aminotransferase levels are mildly elevated in up to 25% of patients but can be 20 times normal values. Azotemia, hypokalemia, hypophosphatemia, and hyponatremia can also develop, and jaundice is occasionally observed. Abnormal liver tests return to normal with resolution of vomiting. After vomiting has resolved, persistent abnormalities should raise suspicion for underlying liver disease. A liver biopsy is not needed in these patients. Histology, if obtained, would show fatty changes and intrahepatic cholestasis.[12]

Treatment includes avoidance of foods that trigger nausea, antiemetics such as promethazine or ondansetron, and occasionally hospitalization for intravenous fluids, nutritional support, and vitamin supplementation. Wernicke encephalopathy has been observed in these patients, and thiamine supplementation should be considered. Treatment with corticosteroids is not indicated.[13] Hyperemesis may recur in future pregnancies.

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