Book of Medical Disorders in Pregnancy - Tintash

curs in 60 to 70 percent of subsequent
pregnancies.
Preeclampsia:
Hepatic dysfunction with preeclampsia
has long been recognized. 22 more recently,
this dysfunction has been associated
with other findings in the HELLP
syndrome. This syndrome may complicate
the course in 3 to 10 percent of
patients with preeclampsia and is noted
in 0.1 percent of all pregnancies. The
pathophysiology of HELLP syndrome
reflects that of preeclampsia, with
microvascular damage, platelet activation
and vasospasm. Liver biopsy reveals
periportal hemorrhage and fibrin deposition.
25 recent data suggest that a defect in
nitric oxide metabolism may con-tribute
to preeclampsia and HELLP syndrome.
Notable hepatic abnormalities in the
HELLP syndrome include hemolysis
(with elevated bilirubin levels and
lactate dehydrogenase levels greater than
600 IU per L), moderately elevated
transaminase levels (AST and ALT
levels of 200 to 700 IU per L) and a
platelet count less than 100,000 per mL
(100 × 10 9 per L). 2,3 Patients typically
present with right upper quadrant pain
and malaise. 2,3 Sixty percent of patients
exhibit significant weight gain or edema;
50 percent have nausea or emesis. 3 No
correlation has been noted between
extent of hypertension, liver function test
abnormalities or liver biopsy findings. 25
The maternal and fetal complications of
HELLP syndrome are significant. The
maternal mortality rate is 2 percent, and
the perinatal mortality rate is 33 percent.
Among the hepatic consequences are a 2
percent incidence of ruptured liver hematoma
(with frequent concomitant mortality)
and a 4 to 38 percent incidence of
disseminated intravascular coagulation. 3
119
The most effective treatment for HELLP
syndrome is prompt delivery. 2,3 Postpartum
corticosteroids have proved efficacious
in improving maternal platelet
counts, ALT levels and blood pressure. 28
Therapies that have not proved efficacious
include plasmapheresis, 29 antithrombotic
agents and immunosuppression.
3 Following delivery, laboratory
abnormalities peak in the first one to two
days postpartum and return to normal
within three to 11 days. The risk of recurrence
of HELLP syndrome in subsequent
pregnancies has been reported as
3.4 percent.
Acute fatty liver of pregnancy:
Acute fatty liver of pregnancy most
frequently complicates the third trimester
and is commonly associated with
preeclampsia (50 to 100 percent). 2,3 Although
rare (with an incidence of one in
13,000), acute fatty liver of pregnancy is
a life threatening condition, with an 18
percent maternal and a 23 percent fetal
mortality rate.
Symptoms associated with acute fatty
liver of pregnancy include anorexia,
nausea, emesis, abdominal pain, jaundice,
headache and central nervous system
disturbances. Hepatic histopathology
reveals pericentral micro vesicular
fat with minimal inflammation or
necrosis. Liver biopsy is not indicated
for diagnosis. 31 The laboratory
abnormalities in acute fatty liver of
pregnancy include moderate elevations
of transa-minase levels (AST and ALT
less than 1,000 IU per L), prolongation
of prothrombin time and partial
thromboplastin time, decreased
fibrinogen, renal failure, profound
hypoglycemia and bilirubin levels of 1 to