COMMENTARY

Updated Advice on Managing Liver Disease During Pregnancy

Rowen K. Zetterman, MD

Disclosures

September 15, 2017

In This Article

New Guidelines, New Diseases to Consider

A recent guideline from the American College of Gastroenterology (ACG)[1] on the evaluation and management of liver disease occurring during pregnancy prompted me to reconsider a previous article of mine, Liver Disease in Pregnancy. In that article, I discussed only liver injury that occurs related to pregnancy. However, this new guideline includes other liver diseases, such as liver masses, biliary tract disease, and viral infections, that can be present during pregnancy. It seems appropriate to provide an update that shares this additional information, with direct quotes from the ACG's recent guideline throughout.

Evaluation of the Liver During Pregnancy

Importantly, as noted, when liver problems or abnormal liver test results are observed during pregnancy, a careful evaluation should always be undertaken.

ACG recommendation: A pregnant patient with abnormal liver tests "should undergo standard work-up as with any non-pregnant individual."[1]

During pregnancy, liver blood flow remains normal as maternal intravascular volume increases. The additional blood volume causes an apparent reduction in levels of hematocrit, blood urea nitrogen, creatinine, and albumin, owing to dilution.[2] Aminotransferase levels and bilirubin are unaffected by pregnancy, although maternal alkaline phosphatase levels may increase by up to three times normal from placental production.[3]

Liver disease or abnormal liver tests occur in 0.77% of pregnant women in the United States.[4] Aminotransferase elevation and signs of cholestasis occur, depending on the cause. The highest aminotransferase levels develop with acute fatty liver of pregnancy and HELLP (hemolysis, elevated values on liver tests, low platelet count) syndrome. Frank clinical jaundice is uncommon in pregnancy-related liver disease.

Ultrasound is safe for evaluation of the liver during pregnancy and is the modality of choice for imaging.[1] MRI can be used, but should be done without contrast. Gadolinium during MRI can cross the placenta and increase gadolinium contact with the fetus through excretion by fetal kidneys into the amniotic fluid. CT later in pregnancy can be considered when used with a minimized radiation protocol and limitation of contrast. Radiation of the fetus carries a concern of teratogenicity, with the biggest risks of exposure occurring at 8-15 weeks of gestation.[1] Administration of iodine contrast agents to the mother has also been associated with neonatal hypothyroidism.[5]

ACG recommendations: "Ultrasound is safe and the preferred imaging modality..." of the liver during pregnancy.

"Magnetic resonance imaging (MRI) without gadolinium can be used in the second and third trimester" of pregnancy.

"CT... may be used judiciously with minimized radiation protocols (2-5 rads)" during pregnancy.[1]

Gastrointestinal symptoms may require upper endoscopy or endoscopic retrograde cholangiopancreatography (ERCP) to be done in the pregnant patient. Endoscopy is considered safe during pregnancy, although sedation agents other than benzodiazepines should be used.[1] Liver biopsy is rarely required for diagnosis during pregnancy but can be performed when needed.

ACG recommendations: "Endoscopy is safe in pregnancy but should be deferred until the second trimester if possible."

"Meperidine and propofol can be used for endoscopic sedation."[1]

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