Book of Medical Disorders in Pregnancy - Tintash

Hepatic causes - Viral hepatitis both A
and B, types can produce jaundice. Drugs
such as chloroform, halothane,
phenothiazine and tetracycline can also
produce jaundice due to toxicity or
hypersensitivity. Jaundice may also be
produced in cases of cirrhosis of the
liver.
Post hepatic obstructive jaundice –
The most common cause of the clinical
pattern of obstructive jaundice is
blockage of the main extra hepatic bile
channels, "surgical jaundice". This is
usually due to impaction of gall stones in
the common bile duct or due to neoplasm
which involves most commonly
the head of the pancreas with extrinsic
pressure. Since the obstruction occurs at
a point distal to the hepatic cell, the
resultant hyperbilirubinemia is composed,
initially at least, of conjugated pigment.
Following prolonged obstructtion
secondary degenerative changes in
hepatic parenchymal cells are probably
responsible for a subsequent rise in the
unconjugated fraction.
By preventing bile pigments from
reaching the intestine the stools become
pale and the increased quantity of
conjugated, water soluble bilirubin
retained in the circulation passes through
the glomerular membrane and appears in
the urine. Since bacterial degradation in
the gut is prevented, urobilinogen is not
found in the urine.
Absence of bile salts from the intestine
may cause steatorrhea with its resultant
secondary effects, and their retention
within the blood stream gives rise to
pruritus. There will be increased alkaline
phosphatase, hyperlipidemia, and
lipoprotein.
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Diagnosis - This can be made from
detailed review of the history, Enquiry
into the events of previous pregnancies
such as jaundice or pruritus es are important.
Similar signs and symptoms if
appeared while the patient was on the
pill are very significant. Recent exposure
to viral hepatitis, blood or serum transfusion
or any invasive procedure should
be noted. Drugs used, biliary tract surgery,
history of cholecystitis or biliary
colic should be carefully evaluated.
Clinical examination - Enlargement and
consistency of liver should be noted. It
may be tender. The spleen may be enlarged.
Other viscera like the gall-bladder
and abdominal wall veins should be
palpated for any neoplastic growth.
Spider nevi should be noted; these are
normally present in pregnancy and
should not be confused with liver
disease. Rectal examination 5hould is
done to exclude any growth. The urine
and stools should be examined for bilirubin
and colour.
Investigations - Serum bilirubin both
conjugated and unconjugated should be
estimated. Alkaline Phosphatase is usually
raised to levels above 35 I.U. in
obstructive jaundice.
Transaminases are markedly ele-vated in
infective hepatitis. Both Pro-thrombin
and Fibrinogen may be dep-leted. These
are of great importance, especially if
labour is imminent. Re-ticulocyte count
may be elevated due to hemolysis,
ultrasounds can or a chole-cysttography
may show gall stones.
Management: prophylaxis includes
(1) Administration of gammaglobulin to
contacts at high risk like; in pregnancy.