Hepatic, Biliary, and Pancreatic Disorders
BS. Nguyễn Hồng Anh
Disorers o the liver, gallblaer, an pancreas together constitute a ormiable list o complications that may arise in pregnancy. Some stem rom preexisting conitions, an some are
unique to gestation. Te relationships o several o these with
pregnancy can be intriguing an challenging.
HEPATIC DISORDERS
Liver iseases complicating pregnancy are place into three
general categories. Te rst inclues those specic to pregnancy an resolve either spontaneously or ollowing elivery.
Hyperemesis graviarum, intrahepatic cholestasis, acute atty
liver, an HELLP syndrome—which is characterize by hemolysis, elevate liver enzyme levels, an low platelet counts, are
examples. Te secon category involves acute hepatic isorers
that are coinciental to pregnancy, such as acute viral hepatitis.
Last are chronic liver iseases that preate pregnancy, such as
chronic viral or autoimmune hepatitis, cirrhosis, or esophageal
varices.
Laboratory testing can ai ierentiation o these isorers.
Hepatic ysunction rom hyperemesis graviarum may mani-
est as milly elevate serum bilirubin an transaminase levels
(Chap. 57, p. 1014). Others liste in Table 58-1 can show
more marke nings. One example, severe preeclampsia syn-
rome, iscusse in Chapter 40 (p. 689), can be urther com
plicate by the HELLP synrome, which can rarely cause liver
ailure (Casey, 2020).
Importantly, several normal pregnancy-inuce physiological changes inuce appreciable liver-relate clinical an laboratory maniestations (Chap. 4, p. 70 an Appenix, p. 1229).
Abnormalities such as increase serum alkaline phosphatase
levels, palmar erythema, an spier angiomas are common uring normal pregnancy. In aition, higher levels o estrogen,
progesterone, an other pregnancy hormones alter expression
o the cytochrome P450 system. For example, hepatic CYP1A2
expression eclines, but that o CYP2D6 an CYP3A4 rises.
Te latter pair possibly aects metabolism o commonly use
therapeutic agents in pregnancy (Dallmann, 2018; Ornoy,
2019). Cytochrome enzymes are also expresse in the placenta.
Te net eect is complex an likely inuence by gestational
age an organ o expression (Isoherranen, 2013). Despite these
unctional changes, no major hepatic histological changes are
inuce by normal pregnancy.
■ Acute Liver Failure in Pregnancy
Fortunately, liver ailure is uncommon uring pregnancy. O
the various causes, rug-inuce liver injury (DILI) is probably
the most requent non-pregnancy-relate etiology (Hoonagle,
2019). Acetaminophen toxicity is the most prevalent cause in
the Unite States (Lee, 2018). Other sources o liver ailure
inclue acute atty liver o pregnancy (AFLP), ulminant viral
hepatitis, environmental toxins, autoimmune hepatitis, shock
liver, an alternative meicines. In a highly selective stuy o
70 reerre women with a hepatic encephalopathy, hal were
cause by AFLP an hal were associate with HELLP syn-
rome (Casey, 2020).
Te treatment o acute liver ailure in pregnancy mirrors that
or nonpregnant iniviuals. Terapy targets the unerlying etiology, an a team o obstetricians, maternal-etal meicine an
critical care specialists, hepatologists, an transplant surgeons is
TABLE 58-1. Clinical Findings with Liver Diseases in Pregnancy
Diagnosis Onset Symptoms AST (U/L)
Bili
(mg%) Cr (mg%) Hematological Comments
Hyperemesis
gravidarum
Early N&V <300 1–4 NL or
elevated
(prerenal)
NL Common, infant
vitamin K
deficiency,
Wernicke
encephalopathy,
Boerhaave
syndrome
ICP Late Pruritus ±
jaundice
<200 1–5 NL NL Common (0.5–2%),
bile acids (>10
μmol/L), normal
hepatic function
AFLP Late N&V (70%), HTN/
preeclampsia,
RUQ pain
145–565 2–8 >0.9 Thrombocyto penia,
coagulopathy ±
DIC, nucleated
red cells,
hemolysis,
echinocytosis
Low glucose,
cholesterol
<220 mg/dL,
fibrinogen <300
mg/dL
HELLP Late Preeclampsia,
RUQ pain
75–250
(initial)
1–2 <1.0 Thrombocytopenia,
mild hemolysis
Common (7–10%
of preeclampsia),
normal hepatic
function
Hepatitis
Viral Variable,
chronic,
episodic
Jaundice, RUQ
pain, fatigue
400–5000 20 NL Coagulopathy
if cirrhotic,
thrombocyto penia
Common (1–3%),
serological tests
for hepatitis A,
B, C, E
Autoimmune Variable,
chronic,
episodic
Jaundice, RUQ
pain, fatigue
100–1000 3–10 NL Coagulopathy
if cirrhotic,
thrombocyto penia
Uncommon,
ANA+, antiLKM1, anti–
smooth muscle
NAFLD Variable,
chronic,
episodic
Obese,
diabetes, ±
RUQ pain
NL to
slightly
elevated
NL NL NL Common (6–8%),
sonographic
findings, MR
imaging/
CT findings,
± metabolic
syndrome, NASH,
cirrhosis
AFLP = acute fatty liver of pregnancy; ANA = antinuclear antibodies; AST = aspartate transaminase; Bili = bilirubin;
BP = blood pressure; Cr = creatinine; CT = computed tomography; DIC = disseminated intravascular coagulation;
HELLP = hemolysis, elevated liver enzymes, low platelets; HTN = hypertension; ICP = intrahepatic cholestasis of pregnancy;
LKM1 = liver, kidney microsome 1; MR = magnetic resonance; NAFLD = nonalcoholic fatty liver disease;
NASH = nonalcoholic steatohepatitis; NL = normal; N&V = nausea and vomiting; RUQ = right upper quadrant.
to investigate hepatic structure. For a pregnancy-relate etiology, elivery is unertaken. Because o comorbi coagulopathy,
vaginal elivery is preerable i it can be achieve expeitiously
an etal conition allows. Hepatotoxic agents are avoie, coagulopathy is correcte, an monitoring or cerebral eema an
increase intracranial pressure is necessary (Brown, 2018). Liver
transplantation is problematic uring pregnancy, but elivery
beore transplantation is consiere i necessary (Bacak, 2016).
assemble. Laboratory stuies initially inclue serum levels o
transaminases, bilirubin, amylase, lipase, electrolytes, creatinine,
albumin, brinogen, lactate, an total cholesterol; complete
bloo count; an coagulation stuies (Bacak, 2016). Etiologytargete testing is escribe ully in later sections but broaly
inclues viral an autoimmune serological assays an testing or
acetaminophen, iron, an copper toxicity. Compute tomography (C) an magnetic resonance (MR) imaging may be neee1032
Section 12
Medical and Surgical Complications
■ Intrahepatic Cholestasis of Pregnancy
Characterize by pruritus, jaunice, or both, this conition has
been calle recurrent jaunice o pregnancy, cholestatic hepatosis, an icterus graviarum. Intrahepatic cholestasis o pregnancy
(ICP) is more common in multietal pregnancy, an genetic
inuences are signicant (Sticova, 2018). Because o this, its
incience varies by population. In North America, the overall
incience approximates 1 case in 500 to 1000 pregnancies, but
its rate nears 5.6 percent among pregnant Latina women in
Los Angeles (Lee, 2006). Historically, inigenous women rom
Chile an Bolivia also have a relatively high incience o ICP.
For unknown reasons, this incience has ecrease since the
1970s an is now less than 2 percent (Reyes, 2016). In Sween,
China, an Israel, the incience varies rom 0.25 to 1.5 percent
(Luo, 2015).
Pathogenesis
Te cause o ICP is unclear, but changes in various sex steroi hormone levels are implicate. In one stuy, women
treate with vaginal progesterone or preterm labor prophylaxis showe a ourol increase in the ICP rate (Zipori, 2020).
Current research ocuses on the numerous mutations in the
many genes that control hepatocellular transport systems. One
example is mutations o the ABCB4 gene, which encoes multirug resistance protein 3 (MDR3) associate with progressive
amilial intrahepatic cholestasis. Another is error in the ABCB11
gene, which encoes a bile-salt export pump (Reichert, 2018).
Other potential gene proucts are the arnesoi X receptor
an transporting APase encoe by ATP8B1 (Abu-Hayyeh,
2016; Sticova, 2018). Te latter preisposes to rug-inuce
cholestasis. In this regar, we have encountere impressive cholestatic jaunice in gravias taking azathioprine ollowing renal
transplantation.
Following the inciting cause(s), bile acis are incompletely
cleare an accumulate in plasma. Hyperbilirubinemia results
rom retention o conjugate pigment, but total plasma concentrations rarely excee 4 to 5 mg/L. Alkaline phosphatase
levels are usually elevate even more than or normal pregnancy. Serum transaminase levels are normal to moerately
elevate but selom excee 200 U/L (see able 58-1). Liver
biopsy shows mil cholestasis with bile plugs in the hepatocytes an canaliculi o the centrilobular regions. Inammation
or necrosis is absent. Tese changes isappear ater elivery
but oten recur in subsequent pregnancies or with estrogencontaining contraceptives.
Clinical Presentation
Generalize pruritus that shows preilection or the palms an
soles usually evelops in late pregnancy or occasionally earlier.
Constitutional symptoms are absent, an skin changes are limite to excoriations rom scratching.
Serum transaminase an bile aci levels are measure in
women with suspecte ICP. As a threshol or comparison, total
serum bile aci levels typically remain <10 μmol/L throughout
normal pregnancy (Egan, 2012). Elevate total serum bile aci
or transaminase levels plus pruritus supports an ICP iagnosis. Biochemical tests may be abnormal at presentation or may
ollow initial pruritus ater several weeks. Moreover, a rise in
transaminase levels may precee an increase in serum bile aci
levels (Woo, 2018b). Approximately 10 percent o women
have concurrent jaunice.
With normal liver enzyme levels or with specic skin n-
ings, pruritus may instea reect other ermatological isorers
(Chap. 65, p. 1155). Sonography may be warrante to exclue
cholelithiasis an biliary obstruction (p. 1042). Moreover, acute
viral hepatitis is an unlikely iagnosis because o the usually low
serum transaminase levels seen with ICP. Conversely, unerlying chronic hepatitis C is associate with a signicantly greater
risk o eveloping ICP, which may be as much as 20-ol
higher (Marschall, 2013).
Management
Pruritus may be troublesome an is thought to result rom
elevate serum bile salt concentrations. Antihistamines an
topical emollients usually provie some relie. Cholestyramine
is reporte to be eective, but this compoun also lowers
absorption o at-soluble vitamins. Tis may lea to vitamin K
eciency an etal coagulopathy. Subsequent etal intracranial
hemorrhage an stillbirth have been reporte (Matos, 1997).
Currently, the most popular treatment is with ursoeoxycholic aci (Actigall), which relieves pruritus an reuces serum
levels o bile salts an liver enzymes (Bacq, 2012; Parízek,
2016). It is available as 300-mg capsules. Oral osing is 10 to
15 mg/kg maternal boy weight aily, which is ivie into
two or three oses (ran, 2016). In a large ranomize trial,
the maternal “itch score” was not signicantly lower with urso-
eoxycholic aci compare with placebo (Chappell, 2019).
From our experiences at Parklan Hospital, however, pruritus
typically improves ater 2 to 3 weeks o ursoeoxycholic aci
therapy (Yule, 2021). Such treatment has also been reporte
to lower risks or stillbirth an etal istress an is iscusse
subsequently.
Other escribe treatments inclue therapeutic plasma
exchange an riampin (Liu, 2018; Ovaia, 2018). A ranomize
trial comparing ursoeoxycholic aci an riampicin is unerway
(Australian New Zealan Clinical rials Registry, 2019).
Perinatal Outcomes
Early reports escribe excessive averse etal outcomes in
women with ICP. However, ata rom the past two ecaes
are ambiguous concerning increase perinatal mortality rates
an whether close etal surveillance is preventive. Sheiner an
coworkers (2006) escribe no ierences in perinatal outcomes in 376 aecte pregnancies compare with their overall obstetrical population. However, rates o labor inuction
an cesarean elivery in aecte women were signicantly
higher. In a stuy o 5477 women with ICP rom a atabase o
1.2 million births, neonates ha a lower 5-minute Apgar score,
but the stillbirth rate was not greater (Wikström Shemer, 2013).
Te latter rate was thought to reect a higher labor inuction
rate, which at the time o the stuy was recommene to avoi
stillbirth.
In some stuies, complications evelope more requently
in women with higher total bile aci levels (Di Mascio, 2019;
Herrera, 2018; Ovaia, 2019). Tese stuies escribe stillbirthsHepatic, Biliary, and Pancreatic Disorders 1033
CHAPTER 58
abnormalities o atty aci oxiation. Several mutations or the
mitochonrial triunctional protein enzyme complex that catalyzes the last oxiative steps in the pathway are implicate. Te
most common are the G1528C an E474Q missense mutations o the gene on chromosome 2 that coes or long-chain-
3-hyroxyacyl-CoA ehyrogenase (LCHAD) (Liu, 2017a).
Mutations or meium-chain acyl-CoA ehyrogenase (MCAD)
an or carnitine palmitoyltranserase 1 (CP1) eciency are
others. Tese are similar to mutations in chilren with Reye-like
synromes.
Sims an colleagues (1995) observe that some homozygous LCHAD-ecient chilren with Reye-like synromes ha
heterozygous mothers with AFLP. Tis was also seen in women
with a compoun heterozygous etus. Although some conclue
that only heterozygous LCHAD-ecient mothers are at risk or
ALFP when their etus is homozygous, this is not always true (Liu,
2017a). An association between atty aci β-oxiation enzyme
eects an severe preeclampsia, especially in women with HELLP
synrome, is also controversial (Chap. 40, p. 693). Most observations erive rom retrospective stuy o mothers with a chil
who later evelope Reye-like synrome. One case-control stuy
compare 50 mothers o chilren with a atty aci oxiation
eect an 1250 mothers o matche control inants (Browning,
2006). During their pregnancy, 12 percent o mothers with an
aecte chil evelope HELLP synrome an 4 percent evelope AFLP. Comparatively, only 0.9 percent o control women
evelope liver problems. Despite these nings, the clinical, biochemical, an histopathological nings are sufciently isparate
an support that severe preeclampsia, with or without HELLP
synrome, an AFLP are istinct synromes (American College
o Obstetricians an Gynecologists, 2012; Byrne, 2020).
Clinical Findings
AFLP almost always maniests in the last trimester an rarely
mipregnancy (Wong, 2020). From Parklan Hospital,
espite normal nings uring antenatal testing. One stuy o
693 Sweish women oun a greater perinatal mortality rate in
women with bile acis levels >40 μmol/L (Glantz, 2004). In
others, an increase stillbirth risk was note in women whose
serum bile aci levels were >100 μmol/L (Brouwers, 2015;
Chappell, 2019, Kawakita, 2015). Chappell an associates
(2019) also oun that ursoeoxycholic aci treatment i not
lower perinatal eath rates. Te use o antenatal etal testing
was not escribe. In a metaanalysis o 5557 women with ICP,
Ovaia an colleagues (2019) conclue that serum bile aci
levels >100 μmol/L were associate with stillbirth.
Other averse perinatal outcomes also have been escribe.
Brouwers an colleagues (2015) oun higher rates o spontaneous preterm birth (19 percent) an meconium-staine amnionic ui (48 percent), espite active management leaing to
earlier elivery. Novel associations o ICP with preeclampsia, gestational iabetes, an large or gestational age also are
reporte (Wikström Shemer, 2013).
In summary, management is irecte at early elivery to
mitigate the relatively uncommon incience o etal eath.
reatment with ursoeoxycholic aci oes not always improve
maternal symptoms or protect against stillbirth. It is problematic that antenatal testing oes not reliably orecast impening
etal eath. We o not routinely employ these or uncomplicate ICP. Te precise gestational age or labor inuction is
uncertain, but many authors recommen 37 weeks’ gestation
(Woo, 2018b). At Parklan Hospital, we routinely inuce
labor at 38 weeks i symptoms worsen or i serum bile aci
levels excee 40 μmol/L.
Fetal Effects of Bile Acids
As note, evience supports that maternal serum bile aci levels
>100 μmol/L contribute to etal eath an meconium passage. Fetal eath may be relate to the cariotoxicity o bile
acis, which causes cariac ysunction an presumably cariac
arrest. In an ex-vivo preparation o cariac myocytes, cholic
aci lowere beating rates in a ose-epenent ashion, while
elevating intracellular calcium concentration (Gao, 2014).
Prolongation o the etal cariac PR interval an successul
reversal with ursoeoxycholic aci has been escribe (Rorí-
guez, 2018; Strehlow, 2010). Last, Ozel an coworkers (2018)
emonstrate impaire global ventricular unction in etuses o
pregnancies complicate by ICP.
■ Acute Fatty Liver of Pregnancy
Te most requent cause o acute liver ailure uring pregnancy
is acute atty liver—also calle acute atty metamorphosis or acute
yellow atrophy. It is characterize by accumulation o microvesicular at that literally “crows out” normal hepatocytic unction (Fig. 58-1). Grossly, the liver is small, sot, yellow, an
greasy. In its worst orm, the incience approximates 1 case per
10,000 births (Nelson, 2013). AFLP recurring in subsequent
pregnancy is rare (Usta, 1994).
Etiopathogenesis
Although the unerlying cause remains unclear, many cases o
AFLP are associate with recessively inherite mitochonrial
FIGURE 58-1 Acute fatty liver of pregnancy. Cross section of the
liver from a woman who died as the result of pulmonary aspiration and respiratory failure. The liver has a greasy yellow appearance. Inset: Electron photomicrograph of a swollen hepatocyte
containing numerous microvesicular fat droplets (*). The nucleus
(N) remains centered within the cell in contrast to the case with
macrovesicular fat deposition. (Reproduced with permission from
Dr. Don Wheeler.)1034
Section 12
Medical and Surgical Complications
Nelson an colleagues (2013) escribe 51 women with
AFLP at a mean gestational age o 37 weeks (range 31.7 to
40.9 weeks). Approximately 41 percent were nulliparous an
20 percent were elivere at 34 weeks’ gestation or earlier.
Women with a multietal gestation account or 20 percent o
cases (Vigil-De Gracia, 2011).
AFLP has a broa spectrum o clinical eatures an severity, an symptoms usually avance over several ays. Persistent
nausea an vomiting are major complaints. Degrees o malaise, anorexia, epigastric pain, an progressive jaunice vary.
In almost all severe cases, acute liver injury causes prooun
enothelial cell activation, capillary leakage, an hemoconcentration; acute kiney injury; ascites; an sometimes pulmonary
permeability eema (Bernal, 2013). Hal o aecte women
have hypertension, proteinuria, an eema, alone or in combination. Notably, these signs also suggest preeclampsia.
As shown in Tables 58-1 an 58-2, egrees o moerate to
severe liver ysunction are maniest by hypobrinogenemia,
hypocholesterolemia, an prolonge clotting times. Serum
bilirubin levels usually are <10 mg/L, an serum transaminase levels are moestly elevate an usually <1000 U/L. An
AFLP iagnosis is arrive at by clinical an laboratory n-
ings. Biopsy is unnecessary. Te Swansea criteria propose by
Ch’ng an associates (2002) as a screening tool an preictor o
severity shows suitable sensitivity (Table 58-3) (Morton, 2018;
Wang, 2017).
Hemolysis can be severe an is thought to stem rom eects
o hypocholesterolemia on erythrocyte membranes (Cunningham, 1985). Laboratory evience inclues leukocytosis,
nucleate re cells, mil to moerate thrombocytopenia, an
increase serum levels o lactic aci ehyrogenase (LDH) or
ecrease haptoglobin levels. Te peripheral bloo smear emonstrates echinocytosis. However, the hematocrit is oten high
or within the normal range because o hemoconcentration.
TABLE 58-3. Swansea Criteria for AFLP Diagnosisa
Clinical features
Vomiting
Abdominal pain
Encephalopathy
Polydipsia/polyuria
Laboratory features
Bilirubin >0.8 mg/dL AKI or Cr >1.7 mg/dL
Glucose <72 mg/dL Ammonia >47 μmol/L
WBC >11,000/μL Coagulopathy or PT >14 s
AST or ALT >42U/L Urea >340 μmol/L
Ultrasound features
Ascites or echogenic liver
Histologic features
Microvesicular steatosis
aThe presence of six or more features without another
explanation for them supports a diagnosis of AFLP.
AFLP = acute fatty liver of pregnancy; AKI = acute kidney
injury; ALT = alanine transaminase; AST = aspartate transaminase; PT = protime; WBC = white blood cell count.
With severe hemoconcentration, uteroplacental perusion is
reuce an this, along with maternal aciosis, can cause etal
eath. Likewise, maternal an etal aciemia are associate with
a high incience o etal jeopary an a concorantly high cesarean elivery rate.
Te egree o clotting ysunction varies an can be
potentially lie threatening, especially i cesarean elivery is
unertaken. Coagulopathy is cause by iminishe hepatic
procoagulant synthesis, although some evience supports
TABLE 58-2. Comparison of Clinical Findings at the Time of Admission in
67 Women with Acute Fatty Liver of Pregnancy and 67 with
HELLP Syndrome
Factor AFLP HELLP p Value
Clinical findings (%)
Hypertension
Abdominal pain
Nausea/vomiting
62
34
63
94
46
19
<0.001
0.18
<0.001
Laboratory values
AST (u/L)
Creatinine (mg/dL)
Fibrinogen (mg/dL)
Bilirubin (mg/dL)
Platelets (per μL)
LDH (u/L)
Glucose (mg/dL)
278 [146, 564]
1.6 [1, 2]
200 [95, 298]
2.9 [1, 6]
163,000 [121, 205]
464 [361, 749]
88 [68, 102]
135 [77, 250]
0.6 [1, 1]
455 [367, 519]
0.6 [0, 1]
115,000 [78, 150]
552 [439, 759]
98 [83, 114]
<0.001
<0.001
<0.001
<0.001
<0.001
0.19
0.011
AFLP = acute fatty liver of pregnancy; AST = aspartate transaminase;
HELLP = hemolysis, elevated liver enzymes, and low platelets; LDH = lactic
acid dehydrogenase.
Data from Byrne, 2020; Nelson, 2020.Hepatic, Biliary, and Pancreatic Disorders 1035
CHAPTER 58
increase consumption rom isseminate intravascular coagulopathy. As shown in able 58-2, hypobrinogenemia can be
prooun. O 51 women care or at Parklan Hospital, almost
one thir ha a plasma brinogen level nair below 100 mg/
L (Nelson, 2014). Elevate levels o serum d-imers or brinsplit proucts also inicate an element o consumptive coagulopathy (Lisman, 2017). Although usually moest, occasionally
thrombocytopenia is marke. Among the women rom Parklan Hospital, 20 percent ha platelet counts <100,000/μL,
an 10 percent ha platelet counts <50,000/μL (Byrne, 2020).
Because liver ysunction an kiney injury are central to
AFLP, Byrne an colleagues (2020) have propose the acronym FaCC to ierentiate AFLP rom HELLP synrome
using levels o commonly available laboratory analytes: brinogen (<300 mg/L) an cholesterol (<220 mg/L), creatinine
(>0.9 mg/L), an total bilirubin (>1 mg/L). o emphasize, the clinical eatures an sequelae o AFLP are attribute
to liver ysunction, whereas in HELLP synrome the procoagulant prouction an unction o the liver appears relatively
preserve.
AFLP typically continues to worsen ater iagnosis. Hypoglycemia is common, an hepatic encephalopathy, severe
coagulopathy, an some egree o renal ailure each evelop in
approximately hal o women. Delivery ortunately arrests liver
unction eterioration, but recovery may require substantial
supportive care.
Various liver imaging techniques can help conrm the
iagnosis, but none is particularly reliable (Liu, 2017a). In a
prospective evaluation o the Swansea criteria, only a quarter
o women with AFLP ha classic sonographic nings that
inclue maternal ascites or an echogenic hepatic appearance (Knight, 2008). Although Châtel an coworkers (2016)
escribe greater liver at etecte by MR imaging, this has not
been our experience.
We have encountere several women with an unerevelope orm o AFLP. Clinical involvement is relatively minor
an laboratory aberrations—usually only hemolysis an a
ecrease plasma brinogen level—heral the synrome. Tus,
the spectrum o liver involvement can inclue unnotice miler
cases, nings that are instea attribute to preeclampsia, or
a severe orm isplaying overt hepatic ailure an associate
encephalopathy.
Management
Intensive supportive measures an soun obstetrical care are
essential. Delivery o the etus is necessary in the treatment o
AFLP, an signicant procrastination increases maternal an
etal risks. We preer a trial o labor inuction with close etal
surveillance. Although some recommen cesarean elivery to
hasten hepatic healing, this raises maternal bleeing complication risks when coagulopathy is severe. Nonetheless, cesarean elivery is common ue to etal intolerance o labor, an
rates approach 90 percent. In some cases, the etus has alreay
ie when AFLP is iagnose, an the elivery route is less
problematic. o correct coagulopathy, transusions with whole
bloo or packe re cells, along with resh-rozen plasma, cryoprecipitate, an platelets, are usually necessary or surgery or
vaginal laceration repair (Chap. 44, p. 772).
Hepatic unction usually returns to normal within a week
postpartum, but in the interim, intensive meical support may
be require. wo associate conitions can be seen uring this
time. Perhaps a ourth o women have evience or transient
diabetes insipidus. Tis presumably stems rom elevate vasopressinase concentrations cause by iminishe hepatic pro-
uction o its inactivating enzyme. Secon, acute pancreatitis
evelops in approximately 20 percent.
With supportive care, recovery usually is complete. Maternal eaths are cause by liver ailure, sepsis, hemorrhage, aspiration, renal ailure, pancreatitis, an gastrointestinal bleeing.
wo women ie in the series rom Parklan Hospital. One
ha associate encephalopathy an aspirate beore intubation uring transer to our care. Te other was a woman
with prooun liver ailure an nonresponsive hypotension
(Nelson, 2013). Other treatment measures have inclue plasma
exchange an liver transplantation (Ringers, 2016; Wu, 2018).
Maternal and Perinatal Outcomes
Maternal mortality rates with AFLP approache 75 percent
in the past, but the contemporaneous outlook is much better.
From his review, Sibai (2007) cites an average mortality rate
o 7 percent. He also cite a 70-percent preterm elivery rate
an a 15-percent perinatal mortality rate, which in the past was
nearly 90 percent. During the past our ecaes at Parklan
Hospital, the maternal an perinatal mortality rates have been
4 percent an 12 percent, respectively (Byrne, 2020).
■ Viral Hepatitis
Most viral hepatitis synromes are asymptomatic, an acute
symptomatic inections are becoming less common in the
Unite States. Tere are at least ve istinct types o viruses
causing hepatitis: A (HAV), B (HBV), D (HDV) cause by
the hepatitis B–associate elta agent, C (HCV), an E (HEV).
Te clinical presentation o acute inection is similar in all, an
although the viruses themselves probably are not hepatotoxic,
the immunological response to them causes hepatocellular
necrosis (Dienstag, 2018a,b). Several other viral agents can
inect the liver, an two examples are cytomegalovirus an herpes simplex virus (Calix, 2020; McCormack, 2019).
Acute inections are most oten subclinical an anicteric.
When they are clinically apparent, nausea an vomiting, hea-
ache, an malaise may precee jaunice by 1 to 2 weeks. By the
time jaunice evelops, symptoms usually are improving. Lowgrae ever is more common with hepatitis A. Serum transaminase levels vary, an their peaks o not correspon with isease
severity. Peak levels that range rom 400 to 4000 U/L are usually reache by the time jaunice evelops (see able 58-1).
Serum bilirubin values typically continue to rise, an peak at 5
to 20 mg/L, espite alling serum transaminase levels.
Severe eatures shoul prompt hospitalization. Tese inclue
persistent nausea an vomiting, prolonge prothrombin time,
low serum albumin level, hypoglycemia, high serum bilirubin
level, or central nervous system symptoms. In most cases, clinical an biochemical recovery is complete within 1 to 2 months
in all cases o hepatitis A, in most cases o hepatitis B, but in
only a small proportion o those cause by hepatitis C.1036
Section 12
Medical and Surgical Complications
Patient’s eces, secretions, bepans, an other articles in contact
with the intestinal tract shoul be hanle with glove-protecte
hans. In hospitals, extra precautions, such as ouble gloving uring elivery an surgical proceures, are recommene. Due to
signicant exposure o health-care personnel to hepatitis B, the
Centers or Disease Control an Prevention (CDC) recommen
active an passive vaccination, as escribe later (p. 1037) (Schillie, 2018). For hepatitis C, although irect antiviral regimens have
been evelope, there is no vaccine. Guielines instea recommen postexposure serosurveillance only.
Acute hepatitis has a case-atality rate o 0.1 percent. For those
requiring hospitalization, it may reach 1 percent. Most atalities
are ue to ulminant hepatic necrosis, which in later pregnancy
may resemble AFLP. In these cases, hepatic encephalopathy is the
usual presentation, an the mortality rate is 80 percent. Approximately hal o patients with ulminant isease have hepatitis B
inection, an co-inection with the elta agent is common.
Chronic hepatitis is more prevalent than acute inection. Te
CDC (2019) estimates that almost 3.5 million persons in the
Unite States are living with chronic viral hepatitis. Although
most are asymptomatic, approximately 20 percent evelop cirrhosis within 10 to 20 years (Dienstag, 2018a). When present,
symptoms are nonspecic an usually inclue atigue. In some
patients, cirrhosis with liver ailure or bleeing varices may be
the initial ning. Also, asymptomatic chronic viral hepatitis
remains the leaing cause o liver cancer an the most requent
reason or liver transplantation.
Chronic viral hepatitis is usually iagnose serologically
(Table 58-4). With persistently abnormal biochemical tests,
liver biopsy usually iscloses active inammation, continuing
necrosis, an brosis that may lea to cirrhosis. Chronic hepatitis is classie by cause; grae, ene by histological activity;
an stage, which is the egree o progression (Dienstag, 2018a).
Most young women with chronic viral hepatitis either are
asymptomatic or have only mil liver isease. For asymptomatic women, pregnancies are usually uncomplicate. With symptomatic chronic active hepatitis, pregnancy outcome epens
primarily on isease severity, an especially on the presence o
portal hypertension (p. 1040). Te ew women whom we have
manage have one well, but their long-term prognosis is poor.
Accoringly, they shoul be counsele regaring possible liver
transplantation as well as contraceptive an sterilization options.
Hepatitis A
Vaccination has reuce the incience o hepatitis A by 95
percent. In 2019, the rate was 6 cases per 100,000 iniviuals
in the Unite States (Centers or Disease Control an Prevention, 2021). HAV is an RNA picornavirus an is transmitte
by the ecal–oral route an usually by contaminate oo or
water ingestion. Te incubation perio approximates 4 weeks.
Iniviuals she virus in their eces, an uring the relatively
brie perio o viremia, their bloo also is inectious. Signs an
symptoms are oten nonspecic an usually mil, although
jaunice evelops in most patients. Symptoms usually last less
than 2 months, but 10 to 15 percent o patients may remain
symptomatic or relapse or up to 6 months (Dienstag, 2018b).
Early serological testing ienties immunoglobulin M (IgM)
anti-HAV antiboy, which may persist or several months.
During convalescence, IgG antiboy preominates, an it provies subsequent immunity. Hepatitis A lacks a chronic stage.
Vaccination uring chilhoo with inactivate hepatitis
viral vaccine is more than 90-percent eective. Te American
College o Obstetricians an Gynecologists (2018) an the
Avisory Committee on Immunization Practices recommens
HAV vaccination or high-risk aults (Freeman, 2020). Tis
inclues pregnant women at risk (Nelson, 2020). Caniates
are persons with chronic liver isease, human immunoe-
ciency virus (HIV) inection, homelessness, or illegal rug use.
Tose working in group acilities with at-risk persons, con-
ucting research with HAV, or traveling to or aopting rom
enemic areas also are inclue. High-risk countries are liste
in the CDC (2020b) “Yellow Book”—Health Inormation or
International ravel.
For an unvaccinate gravia who is recently expose by
close personal or sexual contact with a person with hepatitis
A, passive immunization is provie by a 0.1-mL/kg ose o
immune globulin. Concurrently, the rst ose o the hepatitis
A vaccine series is given in a separate arm (Nelson, 2020).
Pregnancy and Hepatitis A. Management o hepatitis A in
pregnancy inclues a balance iet an iminishe physical
activity. Women with mil illness may be manage as outpatients. In evelope countries, the eects o hepatitis A on
pregnancy outcomes are not ramatic (American College o
Obstetricians an Gynecologists, 2012, 2018). However, in
resource-poor countries, both perinatal an maternal mortality rates are substantively higher. HAV is not teratogenic,
an transmission to the etus is negligible. Te risk o preterm
birth may be higher, an neonatal cholestasis has been reporte
(Urganci, 2003). Although HAV RNA has been isolate in
breast milk, no cases o neonatal hepatitis A have been reporte
seconary to breasteeing (Daui, 2012).
Hepatitis B
Tis inection stems rom a ouble-strane DNA virus that
is oun worlwie. HBV is enemic in Arica, Central an
TABLE 58-4. Laboratory Features of Chronic Hepatitis
Disorders Tests Autoantibodies
Hepatitis B HBsAg, IgG anti-HBc,
HBeAg, HBV DNA
Uncommon
Hepatitis C Anti-HCV, HCV RNA Anti-LKM1
Hepatitis D Anti-HDV, HDV RNA,
HBsAg, IgG anti-HBc
Anti-LKM3
Autoimmune ANA, anti-LKM1, anti-SLA,
hyperglobulinemia
ANA, anti-LKM1,
anti-SLA
Cryptogenic All negative None
HBc = hepatitis core; HBeAg = hepatitis B e antigen;
HBsAg = hepatitis B surface antigen; LKM = liver, kidney
microsome; SLA = soluble liver antigen.
Modified with permission from Jameson JL, Fauci AS,
Kasper DL, et al: Harrison’s Principles of Internal Medicine,
20th ed. New York, NY: McGraw Hill; 2018.Hepatic, Biliary, and Pancreatic Disorders 1037
CHAPTER 58
Southeast Asia, China, Eastern Europe, the Mile East, an
certain areas o South America. In all these, inection prevalence reaches 5 to 20 percent. An estimate 1.6 million people
in the Unite States have chronic hepatitis B (Lim, 2020).
HBV is carcinogenic, an chronic inection is a known risk or
hepatocellular carcinoma. For others, cirrhosis can be a longterm sequela.
HBV is transmitte by exposure to bloo or other boy
uis rom inecte iniviuals. In enemic countries, vertical
transmission, that is rom mother to etus or newborn, accounts
or at least 35 to 50 percent o chronic HBV inections. In
low-prevalence countries such as the Unite States, which has
a prevalence below 2 percent, the more requent transmission
moe is sexual contact or share contaminate neeles.
Acute hepatitis B evelops ater an incubation perio that
ranges rom 40 to 150 ays (Schillie, 2018). At least hal o
acute inections are asymptomatic. Symptoms completely
resolve within 3 to 4 months in most. However, acute hepatitis
B accounts or hal o ulminant hepatitis cases.
Figure 58-2 etails the sequence o the various HBV antigens an antiboies in acute inection. Te rst serological
marker is hepatitis B surace antigen (HBsAg), which oten
precees the rise in transaminase levels. As HBsAg isappears, antiboies to the surace antigen evelop (anti-HBs),
an this marks complete isease resolution. Hepatitis B core
antigen (HBcAg) is an intracellular antigen an not etectable in serum. However, antiboies against this core antigen
(anti-HBc) are etectable an oun within weeks o HBsAg
appearance. Te hepatitis B e antigen (HBeAg) is present uring times o high viral replication an oten correlates with
etectable HBV DNA. Ater acute hepatitis, at least 90 percent o aults recover completely, an the remainer are consiere to have chronic hepatitis B.
0 4 8 12
HBeAg
HBsAg
IgM Anti-HBc
IgG Anti-HBc
Anti-HBs
Anti-HBe
ALT
Jaundice
16 20 24 28 32
Weeks after exposure
36 52 100
FIGURE 58-2 Sequence of various antigens and antibodies in
acute hepatitis B. ALT = alanine transaminase; anti-HBc = antibody
to hepatitis B core antigen; anti-HBe = antibody to hepatitis B e
antigen; anti-HBs = antibody to hepatitis B surface antigen; HBeAg =
hepatitis B e antigen; HBsAg = hepatitis B surface antigen. (Redrawn
from Dienstag JL: Acute viral hepatitis. In Jameson JL, Fauci AS,
Kasper DL, et al (eds): Harrison’s Principles of Internal Medicine,
20th ed. New York, NY: McGraw Hill; 2018b, p 2347.)
Chronic HBV inection is oten asymptomatic but may cause
persistent anorexia, weight loss, atigue, an hepatosplenomegaly.
Extrahepatic maniestations inclue arthritis, generalize vasculitis, glomerulonephritis, pericaritis, myocaritis, transverse
myelitis, an peripheral neuropathy. One risk actor or chronic
isease is age at acquisition. Pertinent to the obstetrician, this
risk excees 90 percent in newborns. Te risk is 50 percent in
young chilren an is less than 10 percent in immunocompetent aults (Schillie, 2018). An immunocompromise state such
as with HIV inection, organ transplantation, or chemotherapy
creates vulnerability.
Tose with chronic HBV inection have serum test results
that show HBsAg persistence. Tese inecte persons may be
asymptomatic carriers or may have chronic liver isease with or
without cirrhosis or hepatocellular cancer. Te presence o HPV
DNA in serum tests is a marker o HBV replication. Tose with
high HBV replication, which is reecte in high HBV DNA
levels with or without HBeAg, have the greatest likelihoo o
eveloping cirrhosis an hepatocellular carcinoma.
Pregnancy and Hepatitis B. Te US Preventive Services
ask Force (2019) recommens that all pregnant women be
screene or HBV. Tis practice ienties asymptomatic cases
an later allows neonatal intervention. At the rst prenatal care
visit, a serologic HBsAg level is obtaine, an this is repeate
in high-risk women again at the time o elivery. All states
require cases o HBV inection to be reporte, an 26 manate
that pregnant women be screene (Culp, 2016). HBV inection oes not cause excessive rates o maternal morbiity or
mortality (Stewart, 2013). In one regional stuy in the Unite
States, 14 percent o women with HBV inection ha a worsening o isease, sometimes terme a fare, either antepartum
or in the 6 months postpartum (Kushner, 2018). A review o
ata rom the National Inpatient Sample reporte a moest
rise in preterm birth rates in HBV-positive mothers but no
eect on etal-growth restriction or preeclampsia rates (Re-
ick, 2011). Others have shown similar results (Cui, 2017;
Liu, 2017b).
ransplacental HBV inection is uncommon, an owers
an associates (2001) reporte that viral DNA is rarely oun
in amnionic ui or cor bloo. Te highest HBV DNA levels
are oun in women who transmitte the virus to their etuses
(Dunkelberg, 2014; Society or Maternal-Fetal Meicine, 2016).
o curb vertical transmission, newborns o seropositive
mothers are given hepatitis B immune globulin (HBIG) plus
the rst o a three-ose hepatitis B recombinant vaccine series
very soon ater birth. In the absence o HBV immunoprophylaxis, 10 to 20 percent o women positive or HBsAg transmit
viral inection to their inant. Tis rate rises to almost 90 percent i the mother is HBsAg an HBeAg positive. Aministration o immunoprophylaxis an hepatitis B vaccine shortly
ater birth has lowere transmission ramatically an prevente
approximately 90 percent o inections (Smith, 2012). But,
women with high HBV viral loas—106 to 108 copies/mL—or
those who are HBeAg positive still have at least a 10-percent
vertical transmission rate, regarless o immunoprophylaxis
(Rogan, 2019; Yi, 2016). Hill an colleagues (2002) reporte1038
Section 12
Medical and Surgical Complications
HCV screening or all aults at least once in a lietime, an
more regularly or those with risk actors (Schillie 2020). Tese
are injection rug use, hemoialysis, or exposure to bloo-
contaminate items. Te CDC also recommene prenatal
HCV screening or all women regarless o risk actors. Te
US Preventive Services ask Force (2020) has publishe similar
recommenations.
Chronic hepatitis C is iagnose by ientication o
anti-HCV antiboies etecte with a serum immunoassay.
Acute HCV inection is usually asymptomatic or yiels mil
symptoms. Only 10 to 15 percent o patients evelop jaun-
ice. Te incubation perio ranges rom 15 to 160 ays,
with a mean o 7 weeks. ransaminase levels are elevate
episoically uring the acute inection. HCV RNA testing
conrms clinical suspicion o active or acute HCV inection.
RNA levels may be oun even beore rises in transaminase
an anti-HCV levels. Anti-HCV antiboy is not etecte
or an average o 15 weeks an in some cases up to 1 year
(Dienstag, 2018b).
Nearly 80 to 90 percent o patients with acute HCV will
be chronically inecte. Although most remain asymptomatic,
approximately 20 to 30 percent progress to cirrhosis within 20
to 30 years. ransaminase an HCV RNA values uctuate over
time. Liver biopsy reveals chronic isease an brosis in up to
50 percent, however, these nings are oten mil. Overall, the
long-term prognosis or most patients is goo.
Pregnancy and Hepatitis C. As expecte, most pregnant
women iagnose with HCV have chronic isease. Aggregate
reports have chronicle moestly greater etal risks o low birthweight, neonatal intensive-care amission, preterm elivery, an
mechanical ventilation (Rossi, 2020; Society or Maternal-Fetal
Meicine, 2017). In some women, these averse outcomes may
have been inuence by concurrent high-risk behaviors associate with HCV inection.
Te primary averse perinatal outcome is vertical transmission o HCV inection to the etus-neonate. Tis is higher in
mothers with viremia (Inol, 2014). Airoli an Berghella
(2006) cite a rate o 1 to 3 percent in HCV-positive, RNAnegative women compare with 4 to 6 percent in those who
were RNA-positive. In a report rom Dublin, the vertical transmission rate in 545 women with HCV inection was 7 percent
in RNA-positive women compare with none in those who
were RNA-negative (McMenamin, 2008). Some have oun
an even higher risk when the mother is co-inecte with HIV
(Snijewin, 2015; ovo, 2016). Approximately two thirs o
prenatal transmission cases occur peripartum. HCV genotype,
invasive prenatal proceures, breasteeing, an elivery moe
are not associate with vertical transmission. Tat sai, invasive
proceures such as scalp-electroe etal heart rate monitoring
are avoie. HCV inection is not a contrainication to breast-
eeing (Post, 2017).
No license vaccine is available or HCV prevention. In
2011, the rst irect-acting antiviral rugs against HCV
became available. Since then, secon-generation prototypes
with ewer averse eects have been evelope an are given as
combinations to nonpregnant iniviuals. Tey are currently
that the 2.4-percent transmission rate was not increase with
breasteeing i neonatal vaccination was complete. Although
virus is present in breast milk, the incience o transmission is
not iminishe by ormula eeing (Shi, 2011). Te American
Acaemy o Peiatrics an the American College o Obstetricians an Gynecologists (2018) o not consier maternal HBV
inection a contrainication to breasteeing.
As a secon transmission-prevention practice, the CDC an
numerous societies now recommen antiviral therapy to ecrease
viral levels in gravias whose viral loa excees 106 to 108 copies/
mL (Schillie, 2018). Newer rugs inclue tenoovir, an aenosine nucleosie analogue, an telbivuine, a thymiine analogue.
enoovir is the rst-line agent uring pregnancy, an no ose
ajustments are necessary (Cressey, 2018). Tese antiviral meications appear sae in pregnancy an are not associate with
greater rates o congenital malormations or averse obstetrical
outcomes (Sylvester-Armstrong, 2019). Follow-up o chilren at
age 6 to 7 years oun no relate problems (Wen, 2020).
Regaring efcacy, one ranomize trial in Tailan showe
that tenoovir compare with placebo beginning at 28 weeks’ gestation i not reuce the low rate o vertical transmission i both
active an passive immunoprophylaxis were given at birth to the
neonate (Jourain, 2018). In another similar ranomize trial,
vertical transmission rates were signicantly lowere (Pan, 2016).
For high-risk mothers who are seronegative, HBV vaccine
can be given uring pregnancy. Caniates are persons with
chronic liver isease, iabetes, HIV or HCV inection, injection rug use, occupational exposure risk, househol contacts,
or long-term travel to enemic areas. Tose requiring ialysis,
living in a long-term-care or correctional acility, or engaging
in sex with multiple or HBV-inecte partners also are inclue
(Schillie, 2018).
Vaccine efcacy is similar to that or nonpregnant aults,
an overall seroconversion rates approach 95 percent ater three
oses (Stewart, 2013). Te traitional vaccination scheule o
0, 1, an 6 months may be ifcult to complete uring pregnancy, an compliance rates ecline postpartum. Shefel an
coworkers (2006) reporte that an accelerate three-ose regimen—given initially an at 1 an 4 months—resulte in seroconversion rates o 56, 77, an 90 percent, respectively. Tis
regimen was usually easily complete uring prenatal care.
Hepatitis D
Also calle delta hepatitis, this is a eective RNA virus that is a
hybri particle with an HBsAg coat an a elta core. Te HDV
must co-inect with HBV either simultaneously or seconarily,
an transmission is similar to HBV.
Hepatitis C
Tis inection stems rom a single-strane RNA virus. ransmission is via bloo an other boy uis, although sexual
transmission is inefcient. In the Unite States, ault prevalence o HCV was reporte to be 2 to 5 cases per 1000 births
(Prasa, 2020; Rossi, 2020). Up to a thir o anti-HCV positive persons have no ientiable risk actors (Dienstag, 2018b).
Until recently, screening or HCV was encourage only or
high-risk iniviuals. But in 2020, the CDC recommeneHepatic, Biliary, and Pancreatic Disorders 1039
CHAPTER 58
not recommene or use in pregnancy except in clinical trials
(Society or Maternal-Fetal Meicine, 2017). Te combination
o leipasvir plus soosbuvir shows efcacy an reassuring saety
ata in early clinical trials.
Hepatitis E
Tis inection stems rom a water-borne RNA virus, which usually is enterically transmitte by contaminate water supplies.
Hepatitis E is oun worlwie, but the Centers or Disease
Control (2020a) lists Mexico, Asia, an Arica as enemic
areas. In these regions, seroprevalence rates vary by age an
geography, but overall rates o 10 percent have been reporte.
In Mexico, Durango State has the highest rate—37 percent
(Fierro, 2016).
Hepatitis E is the most common cause o acute hepatitis
worlwie but rarely causes liver ailure in the Unite States
(Fontana, 2016). Epiemic outbreaks in thir-worl countries
result in substantial morbiity an mortality rates. Pregnant
women have a greater case-atality rate than nonpregnant iniviuals (Li, 2020). In a metaanalysis o nearly 4000 women
rom Asia an Arica, maternal an etal case-atality rates were
21 an 34 percent, respectively (Jin, 2016a). Fulminant hepatitis, although rare, is more common in gravias an contributes
to the increase mortality rates.
A recombinant HEV vaccine has been evelope an
license in China (Zaman, 2020). It is >95 percent eective or
12 months ater vaccination. Long-term efcacy is 87 percent,
an protective titers are maintaine or up to 4.5 years (Zhang,
2015). Preliminary ata rom inavertently vaccinate pregnant
women show no averse maternal or etal events (Wu, 2012).
■ Autoimmune Hepatitis
Tis generally progressive chronic hepatitis is more common
in women an western countries. Autoimmune hepatitis requently coexists with other types o autoimmune isease, particularly autoimmune thyroi isease an Sjögren synrome.
It is characterize by multiple autoimmune antiboies such as
antinuclear (ANA), anti-smooth muscle, an anti-liver, kiney
microsome 1 (LKM1) antiboies (see able 58-1). Rates o
subsequent cirrhosis vary worlwie. Te less common type 2
autoimmune hepatitis has an even higher prevalence in emales
an typically a more aggressive presentation. Te incience
peaks in chilhoo an aolescence.
Symptoms are typical o acute an chronic hepatitis, but a
ourth o patients may be asymptomatic. reatment employs
corticosterois, alone or combine with azathioprine (Dienstag, 2018a). Failure to respon to these two agents is more
requent in those with type 2 isease. Nearly all women with
type 2 isease require long-term intensive therapy. In some
patients with progressive isease an cirrhosis, hepatocellular
carcinoma evelops.
In general, autoimmune hepatitis—especially when severe—
increases the risk o averse pregnancy outcomes. Westbrook
an coworkers (2012) reporte the outcomes o 81 pregnancies in 53 women. A thir ha a are, an these were more
common in those not taking meication an those with active
isease in the year beore conception. Women with cirrhosis
ha more maternal an etal complications. From a Sweish
national atabase o 171 births, the requencies o preterm
birth, low birthweight, an iabetes were elevate, but not
those o preeclampsia or cesarean elivery (Stokkelan, 2016).
Another stuy reporte elivery beore 38 weeks’ gestation in
25 percent o cases an evelopment o a postpartum are in a
thir (Danielsson Borssén, 2016). However, averse outcomes
were not greater in women with cirrhosis. Given the important
role o procoagulant prouction, surveillance o coagulation
inices is avise to minimize obstetrical hemorrhage complications. Also, the usual vaccines, along with pneumococcal vaccine, shoul be given (Furer, 2020).
■ Iron and Copper Overload
Chronic hepatitis an cirrhosis can result rom iron an copper
overloa. Iron overloa may stem rom a primary cause, such as
hereitary hemochromatosis, or rom seconary complications
o erythrocyte isorers (Chap. 56 p. 1052). Many gene mutations unerlying hereitary hemochromatosis involve hepciin
an result in ysregulate iron transport. Some o these mutations are more common in certain populations rom northern
Europe (Pietrangelo, 2016; Salgia, 2015). Cariomyopathy,
iabetes, joint isease, an skin changes can coexist with liver
isease. Diagnosis is mae by ientiying an HFE gene mutation an elevate serum erritin an transerrin saturation levels. An abnormal HFE gene alone is not iagnostic because the
mutation has low penetrance. Pregnancy outcomes are riven
by the egree o liver ysunction, although higher iron levels
may aect birthweight (Dorak, 2009).
A orm o neonatal hemochromatosis that oes not aect
the mother is now thought to be alloimmune an is calle
gestational alloimmune liver disease (Anastasio, 2016; Ibrahim, 2020). With this, maternal autoantiboies cross to the
etus an meiate ysunction o iron homeostasis, although
the antigenic target o these alloantiboies remains unclear. It
is associate with signicant neonatal morbiity an mortality an requently recurs in subsequent pregnancies. In these
cases, antepartum treatment with intravenous immunoglobulin
(IVIG) may improve outcomes (Felman, 2013; Roumiantsev,
2015).
Wilson disease is cause by copper overloa leaing to
chronic hepatitis an cirrhosis. Autosomal recessive mutations
o the ATP7B gene unerlie this isorer. Tis gene coes or
the P-type APase involve in copper transport to ceruloplasmin an bile (Banman, 2015). Tis systemic conition can
also maniest with cariomyopathy, renal isease, neuropsychiatric symptoms, an certain enocrine abnormalities. Serum
ceruloplasmin, slit-lamp examination, an 24-hour urinary
copper excretion are use to ientiy this isease. A KayserFleischer ring surrouning the iris is highly specic, but a suspecte iagnosis generally requires subsequent genetic analysis
conrmation.
With Wilson isease, inertility may be present, but pregnancy outcomes among aecte women are inuence by isease severity (Malik, 2013). In one multicenter stuy o 282
pregnancies, the miscarriage rate was 26 percent, an 6 percent
o the women ha worsening liver isease (Peienberger, 2018).1040
Section 12
Medical and Surgical Complications
Birth eects were not increase with chelation treatment.
Maternal an neonatal outcomes were goo. Te American
College o Gastroenterology states that ew ata guie which o
the various chelating agents is best (ran, 2016). Tese inclue
penicillamine, zinc, an trientine, an any theoretical risks are
outweighe by the risks o iscontinuing therapy. Te latter
inclue not only hepatic ecompensation, but also injury to
the placenta an etal liver. Accoringly, the American College
o Gastroenterology recommens that pregnant women shoul
continue their chelation therapy, although a ose reuction o
25 to 50 percent shoul be consiere to promote woun healing in the event o a surgical elivery.
■ Nonalcoholic Fatty Liver Disease
Tis is the most common chronic liver isease in the Unite
States. Unsurprisingly, because it is requently comorbi with
obesity, it is emonstrable in 25 percent o American aults
(Abelmalek, 2018). Nonalcoholic atty liver isease (NAFLD)
is a macrovesicular atty liver conition that resembles alcohol-inuce liver injury but is seen without ethanol abuse. Its
most severe orm—nonalcoholic steatohepatitis (NASH)—is an
increasingly recognize conition that may occasionally progress to hepatic cirrhosis. Currently, this is the thir most common inication or liver transplantation in the Unite States
(Diehl, 2017).
Obesity, type 2 iabetes, an hyperlipiemia—syndrome X
—requently coexist with NAFLD (Chap. 51, p. 904). Te current hypothesis suggests that these conitions may interact with
other unknown etiological agents to cause multiple insults that
lea to hepatic injury (Buzzetti, 2016). In one stuy o inivi-
uals with type 2 iabetes an normal liver enzyme levels, hal
ha NAFLD, an those with NAFLD showe greater insulin
resistance (Portillo-Sanchex, 2015). In a stuy o obese aolescents unergoing bariatric surgery an intraoperative core
liver biopsy, more than a thir ha atty liver without hepatitis.
An aitional 20 percent ha borerline or enite NASH
(Xanthakos, 2015).
Liver amage ollows a progressive continuum rom NAFLD
to NASH an then to hepatic brosis that may progress to cirrhosis (Goh, 2016). Te isease is usually asymptomatic, an it
is a requent explanation or elevate serum transaminase levels oun uring routine screening. When other liver isease is
exclue, NAFLD is the cause o elevate asymptomatic transaminase levels in up to 90 percent o cases. Currently, weight
loss along with control o iabetes an yslipiemia is the only
recommene treatment.
Pregnancy
During the past ecae, we have encountere an increasing
number o obese an iabetic gravias with atty liver inltration. Tese women appear to have no greater rates o averse
outcomes relative to liver involvement compare with pregnant
women o similar weight. However, some emerging ata inicate
potential concerns. In one patient registry, risks o gestational
iabetes, preeclampsia, preterm birth, an low-birthweight
newborns were two- to threeol higher than in unaecte
women (Hagström, 2016). Yarrington an colleagues (2016)
reporte a high rate o gestational iabetes among nonobese
women who ha elevate alanine transaminase levels in the rst
trimester. Somewhat relate, in another stuy, almost a ourth
o women with prior gestational iabetes ha NAFLD (Foghsgaar, 2017). Last, some evience suggests that the etus o an
aecte mother is at increase risk or NAFLD in aulthoo
(Baker, 2018).
■ Cirrhosis
Irreversible chronic liver injury with extensive brosis an
regenerative noules is the nal common pathway or several
isorers. Laënnec cirrhosis rom chronic alcohol exposure is the
most requent cause in the general population. However, in
young women, most cases are cause by postnecrotic cirrhosis
rom chronic hepatitis B or C. As iscusse, many cases o cryptogenic cirrhosis are now known to be cause by NAFLD (Ge,
2016; Goh, 2016). Clinical maniestations o cirrhosis inclue
jaunice, eema, coagulopathy, an metabolic abnormalities.
O associate conitions, portal hypertension can lea to gastroesophageal varices, an splenomegaly may cause thrombocytopenia. Also, the incience o venous thromboembolism is
increase. Te prognosis is poor, an 75 percent have progressive isease that leas to eath in 1 to 5 years.
Te incience in pregnancy was reporte to be 1 case in
3300 births (Palatnik, 2017). Common complications inclue
transient hepatic ailure, variceal hemorrhage, preterm elivery, etal-growth restriction, spontaneous bacterial peritonitis,
an maternal eath (an, 2008). Outcomes generally are poor,
especially i esophageal varices coexist. Another potentially
atal cirrhosis complication arises rom associate splenic artery
aneurysms. Up to 20 percent o aneurysm ruptures occur uring pregnancy, an 70 percent o these rupture in the thir
trimester (an, 2008). Te 20-percent maternal mortality rate
is likely relate to the emergent iagnosis o these aneurysms
(Ha, 2009).
■ Portal Hypertension and Esophageal Varices
In pregnant women, the causes o esophageal varices are
equally ivie between cirrhosis an extrahepatic portal vein
obstruction (Anrae, 2018). O the extrahepatic cases, some
evelop ollowing portal vein thrombosis associate with one
o the thrombophilia syndromes (Chap. 55, p. 976). Others ollow thrombosis relate to umbilical vein catheterization when
the woman was a neonate, especially i she was born preterm.
Last, the rare Budd-Chiari syndrome results rom hepatic vein
thrombosis that causes extrahepatic portal hypertension. O 16
pregnancies complicate by this synrome, one observational
stuy reporte avorable outcomes (Khan, 2017).
With either intrahepatic or extrahepatic resistance to ow,
portal vein pressure rises rom its normal range o 5 to 10 mm
Hg, an values may excee 30 mm Hg. Collateral circulation
evelops that carries portal bloo to the systemic circulation.
Bloo rains into the gastric, intercostal, an other veins to
reach the esophageal system, where varices evelop. In rare
cases, abominal wall varices evelop (Woo, 2018a). Bleeing
is usually rom varices near the gastroesophageal junction, anHepatic, Biliary, and Pancreatic Disorders 1041
CHAPTER 58
hemorrhage can be severe. Bleeing uring pregnancy rom
varices occurs in a thir to hal o aecte women an is the
major cause o maternal mortality in this group (an, 2008).
Maternal prognosis with esophageal varices largely epens
on whether these rupture. Te mortality rate is 18 percent i
varices are associate with cirrhosis compare with 2 percent
or varices without cirrhosis. Similarly, perinatal mortality rates
are high in women with varices an are worse i cirrhosis cause
the varices. Increase rates o neonatal emise, preterm birth,
low birthweight, preeclampsia, an postpartum hemorrhage
have been reporte (Puljic, 2016).
reatment is the same as or nonpregnant patients. Preventively, all patients with cirrhosis, incluing pregnant women,
shoul unergo enoscopic screening or variceal ilation
(Bacon, 2015). Beta-blocking rugs such as propranolol are
given to ecrease portal pressure an bleeing risk (Ge, 2016;
ran, 2016).
For acute bleeing an or prophylaxis, enoscopic ban
ligation is preerre to sclerotherapy because it avois any
potential risk o injecting sclerotherapeutic chemicals. Acute
meical management or bleeing varices verie enoscopically inclues the intravenous vasoconstrictors octreotie or
somatostatin along with enoscopic baning. Vasopressin is
less oten use. I enoscopy is not available, balloon tamponade using a triple-lumen Sengstaken-Blakemore tube, which is
place into the esophagus an stomach to compress bleeing
varices, can be liesaving. An interventional raiology proce-
ure—transjugular intrahepatic portosystemic stent shunting
(TIPSS)—also can control bleeing rom gastric varices that
is unresponsive to other measures (Ge, 2016; an, 2008). We
have ha goo outcomes with this proceure one electively
uring pregnancy in women with prior variceal hemorrhage
(Chanramouli, 2020).
■ Acetaminophen Hepatotoxicity
As iscusse earlier (p. 1030), acetaminophen is the most requent cause o acute liver ailure in the Unite States (Lee,
2018). Tis commonly use meication can be associate with
hepatotoxicity at oses above 4 g/, an even less in certain
populations (Clark, 2012). Te rug is oten use uring pregnancy, an overose–either accientally or by attempte suicie–may lea to hepatocellular necrosis an acute liver ailure
(aney, 2017). Massive necrosis causes a cytokine storm an
multiorgan ysunction. Early overose symptoms are nausea,
vomiting, iaphoresis, malaise, an pallor. Ater a latent perio
o 24 to 48 hours, liver ailure ensues, an it usually begins to
resolve in 5 ays. In a prospective Danish stuy, only 35 percent o patients who were treate or ulminant hepatic ailure
spontaneously recovere beore being liste or liver transplantation (Schmit, 2007).
Te antiote is N-acetylcysteine (NAC), which must be given
promptly. Te rug is thought to raise glutathione levels, which
ai metabolism o the toxic metabolite, N-acetyl-p-benzoquinoneimine. Te Rumack-Matthew nomogram uses serum acetaminophen levels to preict subsequent plasma hepatotoxic
levels as a unction o the time rom acute ingestion (Rumack,
1975). Te nee or treatment is base on these projections, an
online nomograms an calculators are available. I the plasma
level excees 150 μg/mL 4 hours ater ingestion, treatment is
given. When plasma eterminations are not available, empirical treatment is initiate i the ingeste amount is >7.5 g.
An oral loaing ose o 140 mg/kg is given ollowe by 70 mg/kg
every 4 hours or a total treatment uration o 72 hours (Hear,
2008). Both the oral an an equally efcacious intravenous
osing regimen have been reviewe by Hogman an Garrar
(2012). Although the rug reaches therapeutic concentrations
in the etus, any protective eects o NAC uring acetaminophen overose are unknown (Wiest, 2014).
Ater 14 weeks’ gestation, the etus has some cytochrome
P450 activity necessary or metabolism o acetaminophen to
the toxic metabolite. Riggs an associates (1989) reporte ollow-up ata rom the Rocky Mountain Poison an Drug Center in 60 women suering overose. Te likelihoo o maternal
an etal survival was better i the antiote was given soon ater
overose. At least one 33-week etus appears to have ie as
a irect result o hepatotoxicity 2 ays ater maternal ingestion. In another case, Wang an coworkers (1997) conrme
acetaminophen placental transer an oun maternal an cor
bloo levels measuring 41 μg/mL. Both the mother an the
emergently elivere neonate ie rom hepatorenal ailure.
■ Focal Nodular Hyperplasia
Tis benign lesion o the liver is characterize in most cases
by a well-elineate accumulation o normal but isorere
hepatocytes surrouning a central stellate scar. Tese usually
can be ierentiate rom hepatic aenomas by MR an C
imaging. Except in rare situations o unremitting pain, surgery
is rarely inicate, an most women remain asymptomatic uring pregnancy. In one review o 20 cases, no woman ha relate
complications uring pregnancy (Riai, 2013). Tree women
showe 20-percent tumor growth; in hal, the tumor iminishe in size; an the remaining seven tumors were unchange
across pregnancy. In another surveillance o 44 lesions with
MR imaging in 30 gravias, tumor size was unchange in 80
percent an ecrease in most o the remainer (RamírezFuentes, 2013). Investigators conclue that size changes were
unrelate to pregnancy, combination oral contraceptive use, or
menopause. Tis lesion is not a contrainication to estrogencontaining contraceptives (Chap. 38, p. 673).
■ Hepatocellular Adenoma
Tis rare benign neoplasm evelops most oten in young
women. Lesions are more common in iniviuals taking
combination oral contraceptives or other steroi meications
(Renzulli, 2019). Hepatic aenomas have a 5-percent risk o
malignant transormation an a signicant risk o ruptureassociate hemorrhage, particularly in pregnancy. Te rupture
risk progresses with lesion size, an surgery is generally recommene or tumors measuring >5 cm (Agrawal, 2015). Tus,
ierentiation rom ocal noular hyperplasia is important an
can be achieve by MR or C imaging.
ran an associates (2016) recommen sonographic surveillance o hepatic aenomas uring pregnancy. In a stuy o1042
Section 12
Medical and Surgical Complications
51 pregnancies in women with an aenoma <5 cm, 25 percent o the lesions expane approximately 14 mm (Gaspersz,
2020). In one review o 27 cases in pregnancy, 23 became apparent in the thir trimester an puerperium (Cobey, 2004). No
bleeing complications ollowe tumors measuring <6.5 cm.
However, 60 percent presente with tumor rupture that
resulte in seven maternal eaths an six etal eaths. O note,
13 o 27 women presente within 2 months postpartum, an
in hal, hemorrhage herale rupture. Bleeing aenomas can
be manage by angiographic embolization ollowe by resection (silimigras, 2019).
■ Liver Transplantation
Accoring to the Organ Procurement an ransplantation
Network (2020) more than 177,000 liver transplantations
have been perorme in the Unite States. Analysis o the
National Inpatient Sample atabase oun 2 liver transplantations per 100,000 eliveries (Ghazali, 2017). In most stuies,
the 80-percent live-birth rate compares avorably with that o
the general population. However, risks o preeclampsia, cesarean elivery, etal-growth restriction, an preterm birth are signicantly elevate (Coscia, 2010; Deshpane, 2012; Kanzaki,
2016). Although cesarean elivery is common, vaginal elivery
is not contrainicate (Maej, 2018). Mattila an colleagues
(2017) oun that hal o the women they care or ha maternal complications, incluing acute grat rejection. Importantly,
4 percent o mothers ha ie within a year ater elivery, but
this rate is comparable to that in nonpregnant liver transplantation patients.
GALLBLADDER DISORDERS
■ Cholelithiasis and Cholecystitis
In the Unite States, 17 percent o women have gallstones.
Most stones contain cholesterol, an its oversecretion into bile
is thought to be a major actor in stone ormation. Te cumulative risk o all patients with gallstones to become symptomatic
is 20 percent (Lammert, 2016). For this reason, prophylactic
cholecystectomy is not warrante or asymptomatic stones.
Symptomatic cholelithiasis typically presents with right upper
or epigastric abominal pain, bloating, belching, nausea, an
atty oo intolerance. Pain stems rom gallblaer contraction, which orces a stone up into the sac’s neck. With subsequent gallblaer relaxation, the stone alls back to relieve the
obstruction. Laboratory values are normal, an leukocytosis or
elevate liver an pancreatic enzymes shoul warn or acute
cholecystitis or pancreatitis. Stanar care or symptomatic
cholelithiasis is laparoscopic cholecystectomy (Caasso, 2014).
Less oten, oral ursoeoxycholic aci therapy or extracorporeal
shock wave lithotripsy are use, but experience with these uring pregnancy is lacking.
Acute cholecystitis usually evelops when a stone obstructs
the cystic uct, which connects the gallblaer to the common
bile uct. Bacterial inection plays a role in 50 to 85 percent o
cases. In more than hal o patients with acute cholecystitis, a
history o prior right upper quarant pain rom biliary colic is
elicite. With acute isease, pain is accompanie by anorexia,
nausea an vomiting, low-grae ever, an mil leukocytosis.
As shown in Figure 58-3, sonography will isplay stones, an
both alse-positive an alse-negative rates range rom 2 to 4
percent (Greenberger, 2018). In acute cases, meical therapy
consists o intravenous uis, antibiotics, analgesics, an in
some instances, nasogastric suction. Surgical therapy ollows,
an laparoscopic cholecystectomy is the preerre route or
most.
■ Gallbladder Disease During Pregnancy
Ater the rst trimester, the gallblaer asting volume an
the resiual volume ater postpranial emptying are ouble.
Incomplete emptying may result in retention o cholesterol
crystals, a prerequisite or cholesterol gallstones. From stuies,
the combine incience o biliary sluge an gallstones is 5 to
8 percent (Ko, 2005, 2014).
Postpartum, sluge requently regresses, an occasionally
gallstones will resorb. Still, gallblaer iseases are the most
common cause o nonobstetrical amissions in the rst year
ollowing elivery (Lyon-Rochelle, 2011). Tis is particularly
true or women manage conservatively uring pregnancy.
Jorge an coworkers (2015) reporte that hal o 53 women
with symptomatic cholelithiasis in pregnancy unerwent later
postpartum cholecystectomy. In 80 percent o these women,
recurrent symptoms ha evelope prior to surgery.
■ Medical versus Surgical Management
Symptomatic cholelithiasis is common in pregnancy. Othman an colleagues (2012) showe that gravias manage
conservatively ha greater pain, more recurrent emergency
epartment visits, more hospitalizations, an higher cesarean
elivery rate. Dhupar an associates (2010) reporte more
complications with conservative management o gallblaer
isease compare with laparoscopic cholecystectomy in pregnancy. Tese inclue multiple amissions, prolonge total
parenteral nutrition (PN), an unplanne labor inuction
or worsening gallblaer symptoms. Tereore, operative an
FIGURE 58-3 Sonogram shows multiple, hyperechoic gallstones
collecting along the inferior wall of an anechoic gallbladder.Hepatic, Biliary, and Pancreatic Disorders 1043
CHAPTER 58
enoscopic interventions are increasingly avore over conservative measures.
Acute cholecystitis uring pregnancy or the puerperium is
also common. Acute isease in pregnancy may be complicate
by sepsis, pancreatitis, venous thromboembolism, an bowel
obstruction (El-Messii, 2018). Cholecystitis is initially manage similarly to that or nonpregnant women. In the istant
past, most avore meical therapy. However, the recurrence
rate uring the same pregnancy is high, an 25 to 50 percent o
women ultimately require cholecystectomy or persistent symptoms (Dhupar, 2010). Moreover, i cholecystitis recurs later in
gestation, preterm labor is more likely an cholecystectomy is
technically more ifcult.
Cholecystectomy can be perorme saely in all trimesters
(Kwon, 2018). A metaanalysis oun that cholecystectomy
oes not raise the risk o preterm labor or o maternal or etal
mortality (Athwal, 2016). O surgical routes, laparoscopic
cholecystectomy has evolve as the avore approach (Pearl,
2017; Shigemi, 2019). Tis is iscusse urther in Chapter 49
(p. 867). Management at Parklan Hospital avors a surgical
approach, especially i biliary pancreatitis, as subsequently iscusse, is comorbi (Juo, 2018).
■ Endoscopic Retrograde
Cholangiopancreatography
Approximately 10 percent o patients with symptomatic stone
isease have common uct stones (Stinton, 2012). Symptomatic biliary uct gallstones uring pregnancy can be retrieve
by enoscopic retrograe cholangiopancreatography (ERCP)
(Fogel, 2014; Greenberger, 2018). Te proceure is perorme
i common uct obstruction is suspecte or proven. ERCP
can be moie in many cases so that raiation exposure rom
uoroscopy is avoie (Sethi, 2015). I stanar uoroscopy is
use, a lea apron shiel is place between the raiation source
an the etus.
In 68 ERCP proceures perorme in pregnant women at
Parklan Hospital, all but two women ha gallstones, an common uct stones were ientie in hal o 65 women (ang,
2009). Stones were successully remove in all but one woman.
A biliary stent was place in 22 percent o cases an remove
ater elivery. Complications were minimal, but post-ERCP
pancreatitis evelope in 16 percent. Pregnancy outcomes were
not ierent rom those in the general obstetrical population.
As a less invasive approach, MR cholangiopancreatography
(MRCP) in pregnancy has been reporte (Oto, 2009).
Ascending cholangitis can complicate acute biliary obstruction. Nearly 70 percent o aecte patients evelop Charcot
triad—jaunice, abominal pain, an ever. Te iagnosis is
aie by sonography, an treatment is broa-spectrum antibiotics an biliary rainage by ERCP (Greenberger, 2018).
PANCREATIC DISORDERS
■ Pancreatitis
Acute pancreatic inammation is triggere by actors that cause
activation o pancreatic trypsinogen ollowe by autoigestion.
It is characterize by cell-membrane isruption an proteolysis,
eema, hemorrhage, an necrosis (Conwell, 2018). Up to 10
percent o patients evelop necrotizing pancreatitis, which carries a mortality risk o 15 percent. Tis rate rises i inection
evelops (Cain, 2015).
Te incience o pancreatitis varies with the population
stuie. At Parklan Hospital, with a preominant MexicanAmerican population, acute pancreatitis complicate approximately 1 in 3300 pregnancies (Ramin, 1995). From other
reviews, the incience is 1 case in 3500 to 6000 pregnancies
(Ey, 2008; Hacker, 2015; Hernanez, 2007).
In nonpregnant patients, acute pancreatitis is almost
equally associate with gallstones an alcohol abuse. During
pregnancy, however, cholelithiasis is almost always the preisposing conition. Other causes are hyperlipiemias, usually
hypertriglyceriemia; hyperparathyroiism; congenital uctal
anomalies; recent ERCP; some rugs; an rarely autoimmune
pancreatitis (Conwell, 2018; ang, 2018). Nonbiliary pancreatitis occasionally evelops postoperatively, or it is associate
with trauma, rugs, or some viral inections. Certain metabolic
conitions, incluing acute AFLP an amilial hypertriglyceri-
emia, also preispose to pancreatitis (Nelson, 2013). Cases o
acute an chronic pancreatitis have been linke to numerous
mutations o the cystic brosis transmembrane conuctance
regulator gene (Chang, 2015).
Diagnosis
Acute pancreatitis incites incapacitating epigastric pain, nausea
an vomiting, an abominal istention. Patients are usually
istresse an have low-grae ever, tachycaria, hypotension,
an abominal tenerness. As many as 10 percent have sepsis,
which causes enothelial activation an can lea to acute respiratory istress synrome (Chap. 50, p. 887).
Serum lipase measurements are preerre or iagnosis,
however, amylase levels also can be use. In 173 pregnant
women with pancreatitis, the mean amylase value approximate 2000 IU/L, an the mean lipase value approache
3000 IU/L (Table 58-5). Importantly, the degree o enzyme
elevation and disease severity do not reliably correlate. By 48 to
72 hours amylase levels may return to normal espite other
evience or continuing pancreatitis. Serum lipase activity
typically remains increase with continue inammation.
Leukocytosis is usually oun, an 25 percent o patients have
hypocalcemia. Elevate serum bilirubin an aspartate transaminase levels may signiy concomitant gallstone isease.
TABLE 58-5. Laboratory Values in 173 Pregnant Women
with Acute Pancreatitis
Analyte Mean Range Normal
Serum amylase (IU/L) 1980 111–8917 28–100
Serum lipase (IU/L) 3076 36–41,824 7–59
Total bilirubin (mg/dL) 1.7 0.1–8.71 0.2–1.3
Aspartate transaminase
(U/L)
115 11–1113 10–35
Leukocytes (per μL) 10,700 1000–27,200 3900–10,700
From Ramin, 1995; Tang, 2010; Turhan, 2010.1044
Section 12
Medical and Surgical Complications
Several prognostic scoring systems are use to classiy pancreatitis severity. However, the Ranson criteria an the Apache
II scoring system may be less relevant or pregnancy. In contrast, the Atlanta Classication incorporates the egree o organ
ailure as a measure o severity an may be more applicable in
pregnancy (Cain, 2015; Conwell, 2018). With this last tool,
mild disease lacks organ ailure or systemic complications. Moderately severe disease shows organ ailure lasting <48 h, with or
without local or systemic complications. Severe disease is ene
by persistent single- or multi-organ ailure (Banks, 2013).
Management
Meical treatment mirrors that or nonpregnant patients.
Tis inclues analgesics, intravenous hyration, an measures to ecrease pancreatic secretion by interiction o oral
intake. Nasogastric suction oes not improve outcomes o
mil to moerate isease. In a series by Ramin an colleagues
(1995), all 43 aecte pregnant women respone to conservative treatment an were hospitalize or a mean o 8.5
ays. I bacterial superinection, necrotizing pancreatitis, sepsis, or cholangitis is oun, broa-spectrum antimicrobials
are aministere. I common uct stones are oun, ERCP
is inicate.
Enteral eeing may be helpul once pain improves an associate ileus resolves. For women with more severe pancreatitis an prolonge isease course, total enteral nutrition using
nasojejunal eeing is superior to PN (Cain, 2015; Conwell,
2018). Cholecystectomy is consiere ater inammation subsies because women with gallstone pancreatitis carry a greater
risk o recurrent inammation (Cain, 2015). Juo an coworkers (2018) reporte that a thir o women with biliary pancreatitis not treate with cholecystectomy were reamitte, an
30 percent o these ha recurrent pancreatitis. O the initial
group, those who instea i unergo cholecystectomy ha
only a 5-percent reamission rate.
Pregnancy Outcomes
Increasing severity o pancreatitis is associate with averse
maternal an etal outcomes (ang, 2018). In one review o
101 pancreatitis cases, Ey an coworkers (2008) oun a
30-percent preterm elivery rate, an 11 percent were elivere
beore 35 weeks’ gestation. Tere were also 4 percent stillbirths.
Tere were two pancreatitis-relate maternal eaths. Importantly, almost a thir o women ha recurrent pancreatitis
uring pregnancy. In another stuy o 342 pregnancies complicate by pancreatitis, preterm elivery an etal mortality
rates were comparable to the ata rom Ey (Hacker, 2015).
■ Pancreatic Transplantation
Few reports escribe pregnancy ollowing pancreas transplantation. O 44 pregnancies in 73 women ollowing pancreas-kiney
transplantation, outcomes are encouraging, an vaginal elivery has been escribe (Mastrobattista, 2008). Although the
incience o hypertension, preeclampsia, preterm elivery, an
etal-growth restriction are high, there was only one perinatal
eath. Four rejection episoes evelope uring pregnancy an
were treate successully. Pancreatic islet autotransplantation
an at least three subsequent successul pregnancies have been
reporte (Jung, 2007).
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