# **Liver Disorders in Pregnancy — Complete, Exam-Ready Medical Reference**

Below is a **single-place, concise but exhaustive** medical summary covering **definition, pathophysiology, causes, clinical features, investigations, differential diagnoses, and full management** of all major liver disorders specific to pregnancy.

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# **1. Classification of Liver Disorders in Pregnancy**

## **A. Disorders Unique to Pregnancy**

1. **Hyperemesis Gravidarum (HG) with hepatic dysfunction**
2. **Intrahepatic Cholestasis of Pregnancy (ICP)**
3. **Pre-eclampsia related liver dysfunction**
4. **HELLP Syndrome**
5. **Acute Fatty Liver of Pregnancy (AFLP)**

## **B. Pre-existing Liver Diseases Aggravated by Pregnancy**

* Viral hepatitis (A, B, C, E)
* Autoimmune hepatitis
* Wilson disease
* Cirrhosis/portal hypertension

## **C. Coincidental Liver Disorders**

* Gallstones, biliary colic
* Acute cholecystitis
* Drug-induced hepatotoxicity

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# **2. Hyperemesis Gravidarum (HG)**

### **Definition**

Severe nausea/vomiting in early pregnancy → dehydration, ketosis, >5% weight loss, with mild ↑LFTs.

### **Pathophysiology**

* High **β-hCG and estrogen** → trigger vomiting center
* Starvation → hepatic stress → mild ↑AST/ALT

### **Clinical Features**

* Persistent vomiting
* Dehydration, tachycardia
* Mild jaundice (rare)

### **Investigations**

* LFTs: ALT/AST mildly ↑ (usually <300 IU/L)
* Electrolytes: ↓K⁺, ↓Na⁺
* Ketonuria

### **Differentials**

* ICP
* Hepatitis
* GI obstruction

### **Management**

* IV fluids (NS + thiamine BEFORE dextrose)
* Antiemetics:

* **Ondansetron** (5-HT₃ antagonist)
* **Doxylamine + pyridoxine**
* **Metoclopramide**
* Manage electrolytes
* Rarely hospitalisation + enteral/parenteral feeding

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# **3. Intrahepatic Cholestasis of Pregnancy (ICP)**

### **Definition**

Reversible **hormone-triggered cholestasis** in 2nd–3rd trimester → **generalized pruritus**, ↑serum bile acids.

### **Pathophysiology**

* Estrogen → ↓bile flow
* Genetic factors (ABCB4, ABCB11 mutations)
* Accumulation of **bile acids → placental vasoconstriction**

### **Clinical Features**

* Severe **itching**, especially palms/soles
* No rash
* Mild jaundice (10–20%)

### **Investigations**

* **Serum bile acids >10–14 µmol/L** = diagnostic
* ALT/AST mildly ↑
* Bilirubin normal/slightly ↑

### **Differentials**

* Viral hepatitis
* Drug-induced cholestasis
* AFLP / HELLP

### **Management**

**Maternal**

* **Ursodeoxycholic acid (UDCA)**: 10–15 mg/kg/day

* Improves bile flow, reduces pruritus
* Antihistamines for itch
* Vitamin K supplementation if prolonged PT

**Fetal**

* Weekly NST/BPP
* **Delivery at 36–37 weeks** to prevent stillbirth

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# **4. Pre-eclampsia-Related Liver Dysfunction**

### **Mechanism**

Generalized endothelial dysfunction → hepatic vasospasm → ischemia → periportal necrosis → ↑LFTs.

### **Features**

* Hypertension, proteinuria
* RUQ/epigastric pain
* Mild ↑AST/ALT (<300 IU/L)

### **Management**

* Control BP (labetalol, hydralazine)
* Magnesium sulfate for seizure prophylaxis
* **Delivery = definitive treatment**

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# **5. HELLP Syndrome**

(Hemolysis, Elevated Liver enzymes, Low Platelets)

### **Pathophysiology**

Microangiopathic hemolysis + hepatic sinusoidal obstruction → liver ischemia → ↑LFTs + thrombocytopenia.

### **Clinical Features**

* RUQ pain
* Nausea/vomiting
* Hypertension ± proteinuria
* Jaundice (mild)

### **Investigations**

* AST/ALT ↑ (usually 300–1000 IU/L)
* Platelets <100,000
* ↑LDH, ↑bilirubin
* Schistocytes on smear

### **Management**

* Stabilize mother
* Magnesium sulfate
* Control BP
* **Immediate delivery** (≥34 weeks or earlier if unstable)
* Platelet transfusion if <20,000 or surgery needed

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# **6. Acute Fatty Liver of Pregnancy (AFLP)**

**Most severe pregnancy-specific liver disorder**

### **Definition**

Acute microvesicular fatty infiltration of hepatocytes → **acute liver failure** in 3rd trimester.

### **Pathophysiology**

* Mitochondrial **fatty acid oxidation defect** (LCHAD deficiency in fetus)
* Maternal inability to metabolize fatty acids → toxic metabolites → hepatic failure

### **Clinical Features**

* Prodrome: nausea, vomiting
* **Jaundice prominent**
* **Hypoglycemia**
* **Encephalopathy**
* Polyuria/polydipsia (diabetes insipidus-like)
* Coagulopathy, DIC

### **Investigations**

* AST/ALT moderately ↑ (300–500 IU/L)
* **Hypoglycemia**
* ↑Ammonia
* ↑Bilirubin
* **Prolonged PT/INR**
* Leukocytosis
* US: bright fatty liver (not always)

### **Differentials**

* HELLP
* Severe hepatitis
* Sepsis

### **Management**

* **Immediate delivery — life-saving**
* ICU care
* Manage hypoglycemia (IV dextrose)
* Correct coagulopathy (FFP, cryoprecipitate)
* Treat encephalopathy (lactulose)

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# **7. Viral Hepatitis in Pregnancy**

### **Key Points**

* **Hepatitis E** → highest maternal mortality (up to 20–30%)
* Hepatitis B transmission risk highest if HBeAg positive

### **Features**

* Markedly raised LFTs
* Jaundice
* Coagulopathy (severe cases)

### **Management**

* Supportive
* **Hepatitis B**: give **HBIG + vaccine** to newborn
* Avoid ribavirin in pregnancy

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# **8. Gallstone Disease and Acute Cholecystitis**

### **Pathophysiology**

Progesterone → biliary stasis
Estrogen → ↑cholesterol in bile → gallstones

### **Features**

* RUQ pain
* Fever (in cholecystitis)
* Nausea/vomiting

### **Investigations**

* US abdomen: first-line

### **Management**

* Pain control
* IV antibiotics (cephalosporins safe)
* ERCP if choledocholithiasis
* Cholecystectomy (2nd trimester safest)

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# **9. Differentiating HELLP vs AFLP vs ICP**

| Feature | HELLP | AFLP | ICP |
| ---------------- | --------- | --------- | ------------- |
| Jaundice | Mild | Prominent | Mild |
| Platelets | ↓↓↓ | Mild ↓ | Normal |
| Glucose | Normal | **Low** | Normal |
| Bile acids | Normal | Normal | **Very high** |
| Delivery urgency | Immediate | Immediate | 36–37 weeks |

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# **10. Summary of Management Principles**

### **A. Maternal stabilization**

* Correct fluids, electrolytes
* Manage coagulation issues
* BP control
* Seizure prophylaxis where indicated

### **B. Fetal monitoring**

* NST, BPP, Doppler
* Early delivery if maternal/fetal compromise

### **C. Delivery**

* ICP → 36–37 weeks
* HELLP/AFLP → **immediate**

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Here are **30 high-yield, exam-quality case scenarios WITH management** on **Liver Disorders in Pregnancy** — concise but complete (following your preference).

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# ✅ **30 Case Scenarios with Management — Liver Disorders in Pregnancy**

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## **1. Acute Fatty Liver of Pregnancy (AFLP) – Encephalopathy**

**Case:** 30-year-old at 34 weeks with nausea, vomiting, hypoglycemia, jaundice, confusion, ↑INR.
**Management:**

* Immediate **ICU admission**
* Correct hypoglycemia, electrolytes, coagulopathy
* **Expedited delivery** after maternal stabilization
* Monitor for renal failure, DIC; consider NAC

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## **2. HELLP Syndrome – Severe**

**Case:** BP 160/110, RUQ pain, platelets 48k, LDH ↑, AST 420.
**Management:**

* **Magnesium sulfate**, antihypertensives
* Platelet transfusion if <50k for delivery
* **Immediate delivery** (preferably within 24 hrs)
* Monitor for hepatic hematoma

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## **3. Intrahepatic Cholestasis of Pregnancy (ICP) – Moderate**

**Case:** 33 weeks, intense pruritus, bile acids 45 µmol/L.
**Management:**

* **Ursodeoxycholic acid**
* Weekly bile acids
* Plan delivery around **37 weeks**
* Fetal surveillance (NST/BPP)

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## **4. ICP – Severe**

**Case:** 34 weeks, bile acids 120 µmol/L.
**Management:**

* Start UDCA
* Administer steroids
* **Early delivery (34–36 weeks)** due to stillbirth risk

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## **5. Acute Viral Hepatitis (HAV / HBV / HCV)**

**Case:** 26 years, jaundice, ALT 1200, AST 1500.
**Management:**

* Supportive care
* Correct coagulopathy
* Hepatitis serology
* Antivirals only for **HBV fulminant cases** or vertical transmission prophylaxis

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## **6. Fulminant Hepatic Failure**

**Case:** Encephalopathy, INR ↑, ammonia ↑.
**Management:**

* ICU; consider **N-acetylcysteine**
* Treat cause (viral, drug)
* **Urgent delivery** if maternal condition worsening
* Transplant team involvement

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## **7. Budd–Chiari Syndrome**

**Case:** RUQ pain, hepatomegaly, Doppler → hepatic vein thrombosis.
**Management:**

* **Therapeutic anticoagulation (LMWH)**
* Hepatology + maternal medicine team
* Interventions: TIPS if decompensated

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## **8. Gallstone Pancreatitis**

**Case:** Pregnant woman with severe epigastric pain, ↑amylase, gallstones.
**Management:**

* Fluids, analgesia
* ERCP if CBD obstruction
* Cholecystectomy during pregnancy if recurrent

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## **9. Gallstone Cholangitis**

**Case:** Fever, jaundice, RUQ pain (Charcot triad).
**Management:**

* IV antibiotics
* **Urgent ERCP**
* Delivery not required unless fetal distress

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## **10. Hyperemesis Gravidarum – Severe Transaminitis**

**Case:** 12 weeks, ALT 200, ketonuria, dehydration.
**Management:**

* IV fluids + thiamine
* Antiemetics
* Correction of electrolytes
* LFTs normalize after hydration

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## **11. HELLP – Subcapsular Hepatic Hematoma**

**Case:** Sudden severe RUQ pain, hypotension, ultrasound shows hematoma.
**Management:**

* **Emergency delivery**
* Surgical team; consider hepatic packing/embolization
* ICU monitoring

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## **12. Wilson Disease in Pregnancy**

**Case:** Low ceruloplasmin, ↑urinary copper.
**Management:**

* Continue chelation (penicillamine at lowest safe dose)
* Monitor liver function
* Multidisciplinary management

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## **13. Autoimmune Hepatitis Flare**

**Case:** ALT ↑, IgG ↑, ANA/SMA positive.
**Management:**

* **Continue / escalate prednisone**
* Continue azathioprine
* Avoid methotrexate

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## **14. Preeclampsia With Liver Involvement**

**Case:** Moderate AST elevation, normal platelets.
**Management:**

* Treat preeclampsia
* Delivery based on severity

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## **15. ICP With Twin Pregnancy**

**Case:** Twin gestation, bile acids 60.
**Management:**

* Start UDCA
* **Earlier delivery (36–37 weeks)**

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## **16. HELLP With Platelets <20k**

**Case:** Platelets 18k, severe epigastric pain.
**Management:**

* **Urgent transfusion of platelets**
* Delivery after stabilization
* Magnesium sulfate

---

## **17. AFLP With Renal Failure**

**Case:** Creatinine 3.0, oliguria.
**Management:**

* Fluids + dialysis if needed
* **Immediate delivery**
* Correct coagulopathy

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## **18. Hepatic Adenoma in Pregnancy**

**Case:** Known adenoma 5 cm, increasing pain.
**Management:**

* Monitor if <5 cm
* ≥5 cm → consider resection/embolization
* Delivery if rupture

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## **19. Acute Hepatitis E (HEV)**

**Case:** Severe jaundice, INR ↑, high mortality in pregnancy.
**Management:**

* ICU supportive care
* Manage encephalopathy
* Early delivery if maternal deterioration

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## **20. Drug-Induced Liver Injury (DILI)**

**Case:** After anti-tuberculosis drugs, severe jaundice.
**Management:**

* Stop offending drug
* Supportive care
* ALT monitoring

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## **21. Cirrhosis With Variceal Bleeding**

**Case:** Hematemesis, tachycardia.
**Management:**

* **Octreotide + antibiotics**
* Urgent endoscopy for band ligation
* Delivery later after stabilization

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## **22. Hepatic Rupture (HELLP Complication)**

**Case:** Shock, distended abdomen.
**Management:**

* Resuscitation
* Emergency laparotomy
* **Immediate delivery**

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## **23. Cholestasis With Fetal Distress**

**Case:** ICP + abnormal CTG.
**Management:**

* **Immediate delivery** (induction or LSCS depending on cervix)

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## **24. NAFLD in Pregnancy**

**Case:** Obese woman with ALT mildly elevated.
**Management:**

* Risk factor control
* Monitor LFTs
* Delivery usual obstetric indications

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## **25. Hepatitis B Positive Mother**

**Case:** HBsAg+, high viral load.
**Management:**

* Start **tenofovir at 28–32 weeks**
* Newborn: **HBV vaccine + immunoglobulin** within 12 hours

---

## **26. Hepatitis C Positive Mother**

**Case:** HCV RNA positive.
**Management:**

* DAAs generally **avoided** in pregnancy
* Monitor LFTs
* Breastfeeding allowed
* Treat postpartum

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## **27. AFLP – Jaundice + Coagulopathy + Hypoglycemia**

**Case:** Classic Swansea criteria met.
**Management:**

* ICU
* **Immediate delivery**
* Avoid delay for fetal lung maturity

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## **28. HELLP Postpartum**

**Case:** Occurs 48 hrs postpartum with ↑LFT & ↓platelets.
**Management:**

* Magnesium sulfate if hypertension persists
* BP control
* Platelets/FFP if needed
* High surveillance

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## **29. Hepatic Hemangioma**

**Case:** 8 cm hemangioma, increasing pain.
**Management:**

* Serial imaging
* If symptomatic / enlarging → resection or embolization
* Delivery per obstetric indications

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## **30. Acute Alcoholic Hepatitis in Unrecognized Alcohol Use**

**Case:** Jaundice, AST/ALT ratio >2, fatty liver on USG.
**Management:**

* Supportive care
* Abstinence counseling
* Thiamine & nutrition
* Psychiatric support

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