OC and Acute Fatty Liver of Pregnancy Flashcards

1
Q

What happens to the liver in pregnancy?

A
  • Displaced by the uterus
  • Fat and glycogen stores are
    unchanged
  • There is a change in the
    production of plasma
    proteins, enzymes, lipids
    and bilirubin
  • These changes are a
    response to increased
    blood volume and increase
    in oestrogen
  • LFT’s (liver function tests)
    can mimic liver disease
  • There is an increase in
    albumin levels
  • There is a decrease
    cholesterol, fibrinogen and
    liver proteins
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2
Q

What happens to the gallbladder in pregnancy?

A
- Increase in progesterone 
  causes hypotonic 
  gallbladder
- Bile storage is increased
- Rate of emptying slows
- Bile becomes diluted 
- Cholesterol conversion is 
  decreased
- Cholesterol based gall 
  stones more likely, 
  especially in the 2nd and 3rd 
  trimester 
- Bile salts are retained
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3
Q

Incidence of OC

A

The most common disorder of the liver in pregnancy. The incidence is 1:200 to 1:2000 and is poorly recognised by HCP

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4
Q

When does OC usually present?

A

30/40

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5
Q

What is OC known to be due to?

A

An accumulation of bile salts but isn’t really a cause

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6
Q

Risk factors for OC

A
  • OC in previous pregnancy
  • Genetic; OC in a first degree relative and also certain ethnic groups
  • Twin pregnancy
  • Environmental factors
  • Symptoms can reoccur with the use of contraceptives containing oestrogen
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7
Q

Presenting signs and symptoms of OC

A
- Pruritus (itching) of the trunk 
  and limbs (often worse at 
  night) and without a rash
- Epigastric pain
- Mild jaundice
- Pale stools
- Dark urine and/or UTI
- Nausea and/or vomiting 
- Irritability 
- Exhaustion from disturbed 
  sleep
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8
Q

Potential maternal complications associated with OC

A
- Incidence of gallstones 
  increased
- Increased risk of PPH due to 
  deranged clotting
- Emotional and 
  psychological wellbeing 
  affected
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9
Q

Potential fetal complications associated with OC

A
- Increased risk of preterm 
  labour
- Increased risk of fetal 
  distress
- Increased risk of stillbirth
- Increased risk of 
  haemorrhagic disease
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10
Q

What is the treatment of OC?

A

No treatment except to deliver

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11
Q

OC bloods to be taken

A
LFTs
Clotting screen
Bile acids
Viral serology
Auto-immune screen
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12
Q

Medical management of OC

A
- Topical use of aqueous 
  cream with menthol to 
  soothe pruritus
- Oral cholpheniramine 
  (piriton), 4mg, up to 4 times 
  daily, to cause sedation but 
  not to alleviate pruritus 
- Oral Ursodeoxycholic acid, 
  10mg/kg, once a day, 
  displaces bile salts
- Oral vitamin K, 10mg, once a 
  day, to prevent vitamin K 
  deficiency and reduce the 
  risk of PPH
- Elective early delivery should 
  be offered between 37-38 
  weeks to reduce the risk of 
  stillbirth
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13
Q

Ways to relieve symptoms

A

Advise to take cool baths, wear loose clothing and avoid stressful situations

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14
Q

Postnatal care for OC

A

Ensure women understands there are implications for future pregnancies, as well as for family members. Obstetrician should ensure LFTs have returned to normal at GP
Advise to avoid oestrogen based contraceptives.

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15
Q

Acute fatty liver of pregnancy (AFLP) incidence

A

Very rare affecting around 1:10,000 pregnancies

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16
Q

When does acute fatty liver of pregnancy usually occur?

A

3rd trimester

17
Q

Mortality rate of acute fatty liver of pregnancy

A

Maternal mortality rate of 18% but higher if diagnosis is delayed.
Fetal mortality rate of 23%

18
Q

Risk factors for acute fatty liver of pregnancy

A
  • Primigravida
  • Multiple pregnancy
  • Raised BMI
  • Male fetus
  • Hypertension and/or pre-
    eclampsia
19
Q

Presenting signs and symptoms of AFLP

A
  • Nausea and vomiting
  • Flu like symptoms
  • Confusion
  • Jaundice
  • Loss of appetite
  • Pruritus
  • Upper right quadrant abdo
    pain
  • Symptoms of PET, PIH
    and/or diabetes
20
Q

Complications associated with AFLP

A
  • Severe jaundice
  • Renal and hepatic failure
  • Pancreatitis
  • Infection; sepsis
  • Haemorrhage and DIC
  • Stillbirth
  • RDS
  • Death
21
Q

Management of AFLP

A
- Management must be on 
  HDU with a MDT
- Swift response essential
- Treat hypoglycaemia 
- Correct coagulopathy with 
  vitamin K and FFP
- Strict fluid balance 
- Stabilize then deliver, GA 
  due to deranged clotting
- CTG
- Notify NNU
- Avoid episiotomy