Liver Disease in Pregnancy

Rowen K. Zetterman, MD


April 08, 2013

In This Article

Intrahepatic Hemorrhage or Infarction

These conditions can develop, albeit rarely, in preeclampsia or HELLP syndrome, typically occurring in the late third trimester or postpartum interval in 1 per 45,000-225,000 pregnancies, with a maternal mortality of up to 50%.[38] Associated factors include multiparity, advanced maternal age, simultaneous preeclampsia, and antiphospholipid syndrome.[19,39] Intrahepatic hemorrhage and/or rupture typically occur during the third trimester of pregnancy[40] but have been reported up to 6 weeks postpartum. Patients with preeclampsia or HELLP syndrome should be monitored closely following pregnancy.

Symptoms and signs of hepatic hematoma can occur before significant laboratory test changes occur; they include right upper quadrant pain, nausea, and vomiting. Because these are also the symptoms of preeclampsia and HELLP syndrome, delay in diagnosis may result until the patient develops hepatic rupture and shock, which usually develop within 48 hours of symptom onset. Fever, ileus, and shoulder pain should raise suspicion for intrahepatic hemorrhage or intra-abdominal bleeding. Shoulder pain in a supine patient that improves with sitting can be an indicator of intra-abdominal blood irritating the diaphragm. Intravascular volume loss with azotemia, hypotension, shock, and acute renal failure can result.

The differential diagnosis of intrahepatic infarction or hemorrhage includes acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and ruptured hepatic adenoma, hepatocellular carcinoma, or hemangioma. Laboratory findings include anemia, thrombocytopenia, leukocytosis, marked aminotransferase elevation, and azotemia. If hepatic hematoma or rupture is considered, CT or MRI of the liver can be helpful.[41] Changes are typically found in the right lobe.

Treatment should include urgent delivery if gestation is > 34 weeks or if there is fetal distress or signs of severe maternal bleeding.[42] Patients with intrahepatic hematoma or infarction can be observed and transfused as needed. These patients are at risk for intrahepatic infection. Patients with hepatic rupture should be considered for hepatic angiography; if clinically unstable, selective hepatic artery embolization or surgical exploration should be performed. Surgical treatment includes hepatic artery ligation, packing of the liver, or liver resection.[40] Liver transplantation has been used for this condition.