Jaundice (see Approach to the Patient With Liver Disease: Jaundice) may result from nonobstetric or obstetric conditions. Nonobstetric causes include drugs, acute cholecystitis, and biliary obstruction by gallstones. Gallstones appear to be more common during pregnancy, probably because bile lithogenicity is increased and gallbladder contractility is impaired. Obstetric causes include hyperemesis gravidarum (usually causing mild jaundice) and septic abortion; both cause hepatocellular injury and hemolysis.

Acute viral hepatitis

The most common cause of jaundice during pregnancy is acute viral hepatitis. It may predispose to preterm delivery but does not appear to be teratogenic. Acute viral hepatitis is generally mild, but hepatitis E, common in underdeveloped countries, may be severe. Hepatitis B virus may be transmitted to the neonate immediately after delivery or, less often, to the fetus transplacentally. Transmission is particularly likely if women are e-antigen–positive and are chronic carriers of hepatitis B surface antigen (HBsAg) or if they contract hepatitis during the 3rd trimester. Affected neonates are more likely to develop subclinical hepatic dysfunction and become carriers than to develop clinical hepatitis. All pregnant women are tested for HBsAg to determine whether precautions against vertical transmission are needed (for prenatal prophylaxis with immune globulin and vaccination for neonates exposed to hepatitis B virus, see Infections in Neonates: Prevention).

Chronic active hepatitis

Chronic active hepatitis, especially with cirrhosis, impairs fertility. When pregnancy occurs, risk of spontaneous abortion and prematurity is increased, but risk of maternal mortality is not. Corticosteroids given for chronic active hepatitis can be continued during pregnancy because fetal risks due to corticosteroids have not been proved to exceed those due to maternal chronic active hepatitis. Azathioprine and other immunosuppressants, despite fetal risks, are sometimes indicated for severe disease.

Cholestasis (pruritus) of pregnancy

This relatively common disorder apparently results from idiosyncratic exaggeration of normal bile stasis due to hormonal changes. Intense pruritus, the earliest symptom, develops during the 2nd or 3rd trimester; dark urine and jaundice sometimes follow. Acute pain and systemic symptoms are absent. The disorder usually resolves after delivery but tends to recur with each pregnancy or with use of oral contraceptives.

For severe pruritus, oral cholestyramine 4 to 6 g bid or 3 to 4 g tid is usually effective. Bleeding due to hypoprothrombinemia occasionally develops but is readily reversed by vitamin K (phytonadione) 5 to 10 mg IM once/day for 2 to 3 days.

Fatty liver of pregnancy: This rare, poorly understood disorder occurs near term, sometimes with preeclampsia. Symptoms include acute nausea and vomiting, abdominal discomfort, and jaundice, followed in severe cases by rapidly progressive hepatocellular failure. Maternal and fetal mortality rates are high in severe cases.

Clinical and laboratory findings resemble those of fulminant viral hepatitis except that aminotransferase levels may be < 500 units/L and hyperuricemia may be present.

Diagnosis is based on clinical criteria, liver function tests, hepatitis serologic tests, and liver biopsy. Biopsy shows diffuse small droplets of fat in hepatocytes, usually with minimal apparent necrosis, but in some cases, findings are indistinguishable from viral hepatitis.

Depending on gestational age, prompt delivery or termination of pregnancy is usually advised, although whether either alters maternal outcome is unclear. Survivors recover completely and have no recurrences. A seemingly identical disorder may develop at any stage of pregnancy if high doses of tetracyclines are given IV.

Preeclampsia

Severe preeclampsia (see Abnormalities of Pregnancy: Preeclampsia and Eclampsia) can cause liver problems with hepatic fibrin deposition, necrosis, and hemorrhage that can result in abdominal pain, nausea, vomiting, and mild jaundice. Subcapsular hematoma with intra-abdominal hemorrhage occasionally occurs, most often in women with preeclampsia that progresses to the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). Rarely, the hematoma causes the liver to rupture spontaneously; rupture is life threatening, and pathogenesis is unknown.

Chronic hepatic disorders

Pregnancy may temporarily worsen cholestasis in primary biliary cirrhosis and other chronic cholestatic disorders, and the increased plasma volume during the 3rd trimester slightly increases risk of variceal hemorrhage in women with cirrhosis. However, pregnancy usually does not harm women with a chronic hepatic disorder. Cesarean delivery is reserved for the usual obstetric indications.

Last full review/revision December 2008 by Sean C. Blackwell, MD