Updated Advice on Managing Liver Disease During Pregnancy

Rowen K. Zetterman, MD


September 15, 2017

In This Article

Liver Disease Associated With Pregnancy

Hyperemesis gravidarum. This condition occurs in approximately 1 of every 2000 pregnancies in the United States[4] and is one of the causes of hospitalization during pregnancy.[6] It usually begins in the first trimester, with protracted vomiting, dehydration, ketonuria, and weight loss.[7] The etiology is unclear and may be due to genetic or hormonal causes.[8]Depression that occurs before pregnancy does not appear to be a cause,[9] although postpartum depression can follow hyperemesis gravidarum.[10] No single best pharmacologic therapy has been defined.[11] Hyperemesis gravidarum does not influence long-term, all-cause mortality of the mother.[12]

ACG recommendation: "The treatment of hyperemesis gravidarum is supportive and may require hospitalization."[1]

Intrahepatic cholestasis. This condition occurs in the second or third trimester in 1 of every 1000 pregnancies in the United States.[4] Cholestasis and itching with elevated circulating bile acid levels (often > 10 µmol/L) develop in the mother and then typically resolve after delivery.[13] Intrahepatic cholestasis may be due to genetic disorders of defective canalicular transporters in the liver.[14] Maternal mortality is limited, but fetal distress, anoxia, meconium staining of amniotic fluid, and death can occur.[15] Use of an intrahepatic cholestasis management protocol that recommends infant delivery between 36 and 37 weeks when maternal levels of total bile acids are > 40 µmol/L results in improved fetal outcomes.[16]

ACG recommendations: "Because of increased risk of fetal complications...early delivery at 37 weeks is recommended."

"Ursodeoxycholic acid should be given at 10-15 mg/kg to women with intrahepatic cholestasis of pregnancy for symptomatic improvement."[1]

Preeclampsia/eclampsia. These conditions develop in approximately 1 in 250 pregnancies[4] in the second or third trimester, as defined by hypertension, proteinuria, and edema. Aminotransferase levels may increase and are typically modest.[4]

ACG recommendation: "After 36 weeks, women with severe preeclampsia should be delivered promptly to limit maternal and fetal complications."[1]

HELLP syndrome. This syndrome typically occurs in the third trimester in 1 of 435 pregnancies[4] and is often part of the spectrum of preeclampsia and eclampsia. Liver test values can be more significantly elevated than with preeclampsia alone,[4] and hemolysis, thrombocytopenia, and disseminated intravascular coagulation may occur.[17] Intrahepatic bleeding and hepatic rupture can develop with HELLP syndrome.[18]

ACG recommendation: HELLP syndrome "should be managed by prompt delivery, especially after 34 weeks' gestation."[1]

Acute fatty liver of pregnancy (AFLP). An uncommon disease, AFLP occurs in all ethnicities and develops in the late second or third trimester in 1 of every 12,000-15,000 pregnancies.[19] Patients may have concurrent preeclampsia or HELLP syndrome.[20] Pregnancy-related factors for AFLP include multigravid pregnancy, male-gender fetus, coexisting preeclampsia or HELLP syndrome, and a prior episode of AFLP.

ACG recommendations: "Women with AFLP should be delivered promptly; expectant management is not appropriate."

"The offspring of mothers affected by AFLP should be monitored carefully for...hypoketotic hypoglycemia and fatty liver."

"All women with AFLP and their children should have molecular testing for long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD)."[1]


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