@TasPirani presents of Liver disease in pregnancy. A lot to cover! #OBAnes #OAA23ASM
Causes of liver derangement in pregnancy: flare of pre-existing liver disease (known or unknown). Incidence of pregnancy in people with chronic liver disease at King’s College Hospital. Historically, cirrhotic patients have been infertile d/t anovulation. Population based data… twitter.com/i/web/status/1…
A reminder that MELD score >10 (UKELD > 48) predicts maternal complications related to pregnancy. Relevance of pre-existing liver disease? Hemorrhage: highest risk 2nd trimester & during labour. TIPPS have been described. An algorithm for the management of variceal bleeding.… twitter.com/i/web/status/1…
What about drugs used for management of variceal bleeding during pregnancy - terlipressin is relatively contraindicated (crossed out of algorithm) due to effects on uterine blood flow & uterine contractions. Beta blockers have neonatal effects, best withdrawn 24-48h prior to… twitter.com/i/web/status/1…
Case 1. 33/40, actively bleeding variceal in splenic hilum. Massive transfusion. Fetal loss. Provisional Dx portal HTN, massive splenomegaly and varices.
Hx clarified: Child Pugh B, MELD 17, UKELD 57 (😱). Intolerant of beta blockers. CT abdomen: massive and diffuse varices.… twitter.com/i/web/status/1…
What next? Survived. Advised against another pregnancy.
Splenic artery aneurysm: rare, 50% rupture in pregnancy (66.7% 3rd trimester, some postpartum). Materno-fetal mortality 70-90%. Rupture during labour uncommon. Mx unruptured SAA undefined. Elective Mx recommended for SAA >… twitter.com/i/web/status/1…
Causes of liver derangement in pregnancy - unique to pregnancy: HG, ICP, AFLP, PET/HELLP. HG early, rest tend to be second trimester onwards. #OBAnes #OAA23ASM
Case. Hyperlactatemia & distributive shock requiring exploratory lap day1 post emergency section for PET. HELLP is a leading cause of maternal & perinatal mortality worldwide. PET complicates 2-8% pregnancies, 20-30% liver involvement. 1 in 4 serious maternal complications.… twitter.com/i/web/status/1…
Clinical picture: symptoms & labs. Mississippi & Tennessee systems for diagnosis of HELLP (Mississippi class 1 is most severe) - uniform reporting is important, but not decide clinical care. Complications of HELLP: extrahepatic & hepatic. #OBAnes #OAA23ASM
Liver ischemia/subcapsular hematoma occurs in up to 1.6%. Management of HELLP: if unstable, deliver; steroid for fetus (NO role in mother); aggressive HTN Mx; Magnesium. Lab values normalize 48h to 2 weeks. Indications for imaging: hemodynamic instability, AST>1000, severe… twitter.com/i/web/status/1…
Acute Fatty Liver of Pregnancy (AFLP) = medical and OB emergency, incidence 1 in 7,000-15,000 pregnancies. Mitochondrial cytopathy (Reye’s syndrome). Ubiquitous risk factors. 1 in 5 POSTPARTUM. 20-40% preeclampsia patients diagnosed with AFLP, up to 20% AFLP diagnosed with HELLP.… twitter.com/i/web/status/1…
Swansea criteria for diagnosis of AFLP. Pathophysiology (mitochondrial disease, majority = no genetic defects)
AFLP cont. Complications include acute liver failure, overwhelming sepsis, pancreatitis, DIC, etc. Maternal mortality 10% (based on recognition, timely delivery and improved ICU Mx). 10-20% fetal mortality. Management complicated by no universal diagnostic criteria/ algorithm.… twitter.com/i/web/status/1…
@TasPirani now leads #OBAnes audience into #OBCritcare realm with management of liver disease in pregnancy at ICU (ITU) level (@MelissaEBauer1 @TheMillennialMD). Thankfully not often seen during pregnancy, however, peri delivery and postpartum encounters involve badness with… twitter.com/i/web/status/1…
Acute Liver Failure. Definition. Management: 2 areas of focus - hepatic/ cause specific & extrahepatic/ general. Multiorgan Failure, cerebral oedema & herniation, and sepsis are major concerns. Prognostication has 3 end points: survive with medical management; death; and liver… twitter.com/i/web/status/1…
Management priorities while awaiting transfer to transplant centre: MDT approach - resuscitation, neuroprotection, aggressive sepsis treatment, and vigilance for bleeding. Good history essential. How do we decide who needs a transplant? INR & bilirubin good for predicting… twitter.com/i/web/status/1…
Interesting case report: extending the reach of emergency liver transplantation to pregnant people by bridging with ECMO. Summary slide. Got questions? Ask @TasPirani. #OBAnes #OAA23ASM
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