medical management of jaundice in pregnancy -...
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MEDICAL MANAGEMENT OF JAUNDICE IN PREGNANCY
Dr. Md. Faizul Islam Chowdhury Associate Professor of Medicine
Medicine Unit – Yellow Dhaka Medical College & Hospital
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•Mind constricts (No relaxation, full of anxiety & fear)
•Heart dilates (Cardiomyopathy)
•Kidney porous (Proteinuria)
•Blood toxic (Toxaemia)
•Body bloaty (Oedema)
•Liver fatty (Acute fatty liver - Jaundice)
This is the pregnancy
Now our topic of discussion is
Jaundice in pregnancy
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This jaundice in pregnancy is described by two way –
A. Jaundice caused by pregnancy (unique to pregnancy)
B. Jaundice can occur in pregnancy (intercurrent illness)
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Causes of jaundice during pregnancy Jaundice unique to pregnancy Intercurrent illness
Intrahepatic cholestasis
Acute fatty liver
Severe pre eclampsia & eclampsia
HELLP syndrome
Severe hyperemesis gravidarum
Endotoxic shock
Viral hepatitis
Drug induced – INH, phenothiazines
Cholelithiasis
Haemolytic jaundice – incompatible blood transfusion
Auto immune hepatitis
CLD
Malaria
Hepatic neoplasm
Pancreatitis
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Why this is concern?
Jaundice High risk condition
Pregnancy Vulnerable situation
Risky + Vulnerable Red alert situation
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Why in pregnancy jaundice occurs?
Humoral change?
Placental hormones?
Auto immune mechanism?
Uterine stretching ?
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We are swimming in the sea of ‘enigma’
We are searching in the dark
with a beam of light
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Intra hepatic cholestasis of pregnancy (ICP/IHCP) Syn : Obstetric hepatosis
Icterus graviderum
What is ICP? Reversible 3rd trimester Resolve after delivery
Incidence – 0.5 – 1.8% of pregnancy
Etiology – Unknown - Dominance inheritance - Prevalence in certain population i.e., Chile - Family clusters - Circulating hormones in pregnancy - OCP
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Intra hepatic cholestasis of pregnancy (ICP/IHCP) – Cont’d
o Pathology:
Impairment of the movement of the microvilli in biliary canaliculi
Stasis of biliary flow
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Pathogenesis
Pre existing covert defect of bile transport
Circulating hormones
OCP in last trimester
Overt defect of bile transport
Cholestasis
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•First - pruritus – 80%;
begins with palm & sole
•Then - Jaundice – 20%; after 2 weeks of pruritus
Clinical feature
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Pruritus & Jaundice First jaundice, then pruritus – Acute hepatitis
Jaundice & pruritus simultaneously – Obstructive jaundice
First pruritus then jaundice –
i. Jaundice 2 weeks after pruritus – ICP
ii. Jaundice months after pruritus – PBC
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Investigations
• Bilirubin – elevated not more than 5 mg/dl
• Transaminase – 2-10 folds
• Alkaline phosphatase – 4 folds
• Bile salt
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Treatment Strategy –
Reducing symptoms in the mother
To provide an adequate obstetric care
To prevent fetal distress or sudden fetal death
Treatment design –
General care of the mother – Adequate rest
Low fat diet
Parenteral supplementation of vitamin K
Specific treatment – Diphenhydramin
Ursodeoxycholic acid (UDCA) 300 mg twice a day
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Treatment (Cont’d)
Other emerging drugs: Dexamethasone
Phenobarbital
S-Adenosylmethionine
Care to the fetus:
Close fetal monitoring
Nonstress testing
Search for meconium- if suspected fetal distress
Elective delivery at 37 weeks
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Outcome
No increase in maternal mortality
May be associated with – Prematurity
Foetal distress
Perinatal death
Resolves after delivery
Recur in the subsequent pregnancies
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Acute Fatty Liver of pregnancy
Architecture intact
Lobules swollen
Fatty infiltration of hepatocytes
Ballooning of hepatocytes
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Acute fatty liver of pregnancy (AFLP) (Cont’d)
First identified by Sheehan in 1940
Earlier terminology:
Acute yellow atrophy of pregnancy
Acute obstetric fatty metamorphosis of liver
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Acute fatty liver of pregnancy (AFLP) (Cont’d)
Etiology: Not known precisely
Genetic relation
Biochemical Relation : Associated with Glu474Gln mutation in the long-chain 3-hydroxy acyl-coenzyme A dehydrogenase (LCHAD).
(LCHAD is a fatty acid ß oxidation enzyme)
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Patogenesis
Mutation of the LCHAD
Mutant LCHAD is ineffective
No ß oxidation of fatty acid
Accumulation of fat in liver
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Incidence: Rare, 0.01% pregnancies (1 in 10,000)
Risk factors: Age: Mean 26 (16-39)
Primipara (67%)
Onset week of pregnancy: 28-38 (33%)
Male baby (60%)
Twin pregnancies
Pre eclampsia
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Clinical features
• 80% Vomiting
• 52% Abdominal pain
• 93% Jaundice
• 87% Encephalopathy
• 80% Polydipsia
• 60% Pruritus
• 47% Ascites
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Laboratory findings
Transaminase level increased 1-5 folds
Alkaline phosphatase increased 2-8 times
WBC > 15,000
Platelets < 1,00,000
Hypoglycemia
Decreased clotting factors
S.creatinine raised
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Histopathology (liver biopsy is not indicated for diagnosis):
In contrast with viral hepatitis & other common causes of fulminant hepatic failure, necrosis of hepatocytes is always minor
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Complications
Cerebral oedema
Renal failure (60%)
Hypoglycemia (53%)
Infections (45%)
GI hemorrhage (35%)
Coagulopathy (30%)
Fetal death
Severe PPH
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Management:
Delivery & supportive care
Outcome:
Maternal & fetal mortality approximately 20%
Normal liver functions return soon after delivery
Usually does not recur in subsequent pregnancies
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HELLP
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RBC
Breaks
Hepatocytes
Cracks
Platelets
Wrecks
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RBC in HELLP Syndrome
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Liver in HELLP Syndrome
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HELLP syndrome (Cont’d)
1st diagnosed by Weinstein in 1982
Evolution of the syndrome:
In 19th century – very unusual varieties of severe pre eclampsia with complicated progress
Today – HELLP syndrome (Association of characteristic hepatic & Haematologic disorder)
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1. Increase in volume?
2. Fetal decidual cell?
3. Vasospasm?
4. Deficient vascular repair?
5. Idiopathic?
Possible etiology
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Pathogenesis
Above causal agents Vasculo-endothelial disorder Platelet Aggregation/Consumption Fibrin Activation/Consumption Selective organic ischemia/Insufficiency Variable manifestation
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Diagnosis
Mid – II trimester
1st days postpartum
Antepartum diagnosis is made in 70% between 27 & 37 weeks of gestation
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Criteria for establishing the diagnosis
Haemolysis –
Abnormal peripheral blood smear
Elevated bilirubin > 1.2 mg/dl
Elevated liver enzymes –
SGOT > 72 IU/L
LDH > 600 IU/L
Low platelets –
Platelet count < 100 X 103 / mm3
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Hypertensive woman
+
epigastric & / or
right hypochondrial pain
+
Nausea, vomiting
+
Positive investigation
Right diagnosis of HELLP
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Classification of the HELLP syndrome
A. On the basis of the platelet count
B. On the basis of expression
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A. On the basis of the platelet count
Class 1 – Platelet count < 50,000 / mm3
Class 2 – Platelet count between 50,000 / mm3 to 1,00,000/ mm3
Class 3 – Platelet count between 1,00,000 / mm3 to 1,50,000/ mm3
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B. On the basis of expression
Complete HELLP –
Microangiopathic haemolytic anaemia in woman with severe pre eclampsia
LDH ≥ 600 IU/L
SGOT ≥ 70 IU/L
Thrombocytopenia < 1,00,000/ mm3
Partial HELLP –
One or two of the above
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Differential diagnosis of the HELLP syndrome
Thrombotic microangiopathies
Fibrinogen consumption disorders
Connective tissue disorders
Primary renal disease
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Risk factors for maternal morbidity
Clinical Epigastric pain
Nausea
Vomiting
Eclampsia
Severe hypertension
Abruptio placenta
Laboratory Platelets < 50000
LDH > 1400 IU/L
CPK > 200 IU/L
ALT > 100 IU/L
AST > 150 IU/L
Creatinine > 1.0
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Management
It needs multi disciplinary team – Obstetrician
Internist
Neonatologist
Management strategy – A. Management before labor & delivery
B. Management of labor & delivery
C. Management after labor & delivery
D. Advice on future pregnancy
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Management (Cont’d)
A. Management before labor & delivery –
1. Anticipate the diagnosis
2. Evaluate maternal condition –
Control of hypertension
Water & electrolyte balance
Prophylaxis of convulsion with MgSO4
Hemotherapy
Be alert of multi organ failure
3. Evaluate fetal condition
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Management (Cont’d)
B. Management of labor & delivery –
By obstetrician
C. Management after labor & delivery –
Intensive post partum treatment of the patient
Optimize perinatal care
D. Advice on future pregnancy
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Incidence
IHCP 0.5 – 1.8%
Acute fatty liver 0.01%
HELLP syndrome 4 – 12%
Acute Hepatitis 3 – 20%
Cholelithiasis 6 – 7%
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Outcome
Condition Maternal Mortality Mother Risk
Perinatal Mortality Foetal Risk
IHCP No increased risk 1 – 3.5% perinatal mortality
Acute fatty liver 18-20% maternal mortality
20-23%
HELLP 2% 33%
Pre eclampsia + AFL
Upto 85% Increased
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Acute viral hepatitis
Commonest jaundice
Hepatitis A, B, C, D & E
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Incidence
Developed countries
0.1%
Developing countries
3 – 20%
Acute hepatitis B 2 per 1000 pregnancies
Acute hepatitis C 1 per 1000 pregnancies
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Clinical feature
• Fever
• Anorexia
• Nausea
• Vomiting
• Yellow discoloration
• Right upper quadrant tenderness
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Laboratory findings
• ↑ Serum transaminase (200 - 2000 u/l)
• ↑ Plasma bilirubin
• Specific viral markers
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Treatment
Symptomatic & supportive:
• Adequate rest
• Nutrition- Diet rich in carbohydrate and
adequate protein
• Drugs- Neomycin, lactulose
• Avoid- sedatives, narcotics etc
• Prevention of complications
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Treatment (cont’d)
Immunization of the newborn:
Any potential for transmission of HBV at
delivery is an indication for passive and active
immunization of the newborn
No analogous treatment is available for
hepatitis C
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CHOLELITHIASIS & CHOLEDOCHOLITHIASIS IN PREGNANCY
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Cholelithiasis in pregnancy (cont’d)
Incidence:
May affect 6-7% of pregnant women
Risk factors:
Multiparity
Previous gallbladder disease
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Mechanism
Altered composition of bile
Slowing of gall bladder emptying
↑ Risk of gall stone
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Clinical feature
Symptoms similar to nonpregnant women
Abdominal pain –
Right upper quadrant / Epigastric region
Peaking at 12 – 24 hours
Radiate towards the back
Murphy's sign less common in pregnancy
Jaundice in 5% occasions
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Laboratory findings
Similar to non-pregnant women
USG- shows the stones in gall bladder or in ducts
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Management
Obstructive jaundice requires surgical intervention
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Outcome
Uncomplicated cholecystectomy
5% fetal loss
With bile duct exploration especially with pancreatitis
15 % maternal and 60% fetal mortality
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Autoimmune hepatitis
Can present with an acute attack
Serum bilirubin increase is dependant upon type of disease
Can be treated with azathioprine during pregnancy
Usually, a favorable outcome in terms of mother and baby
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Chronic liver disease in pregnancy
Increased risk of fetal loss
In PBC ursodeoxycholic acid can be safely continued
Cholestasis may worsen during pregnancy with PBC
Infants of patients with marked hyperbilirubinaemia during pregnancy may require exchange transfusion at birth
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Conclusion
Pregnancy –
The milestone of creation, thing is divine
Sometimes complicates behind
Patient should alert
Doctor must vigilant
Then comes to a nice end
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