Liver diseases in pregnancy: Diseases unique to pregnancy

Table 1 Proposed (Swansea) diagnostic criteria for acute fatty liver of pregnancy

Vomiting	Abdominal pain
Polydipsia/polyuria	Encephalopathy
Elevated bilirubin	Hypoglycaemia
Elevated uric acid	Leucocytosis
Ascites or bright liver on US	Elevated transaminases
Elevated ammonia	Renal impairment
Coagulopathy	Microvesicular steatosis on liver biopsy

To meet the criteria the patient should have 6 or more of these clinical findings. Source: Ref. [80], with permission; US: Ultrasound scan.

Table 2 Hemolysis, elevated liver function tests, and low platelet counts syndrome diagnostic criteria

HELLP class	Tennessee classification	Mississippi classification
1	Platelets ≤ 100 × 109/L	Platelets ≤ 50 × 109/L
	AST ≥ 70 IU/L	AST or ALT ≥ 70 IU/L
	LDH ≥ 600 IU/L	LDH ≥ 600 IU/L
2		Platelets ≤ 100 × 109/L, ≥ 50 × 109/L
		AST or ALT ≥ 70 IU/L
		LDH ≥ 600 IU/L
3		Platelets ≤ 150 × 109/L, ≥ 100 × 109/L
		AST or ALT ≥ 40 IU/L
		LDH ≥ 600 IU/L

AST: Aspartate aminotransferase; Source: Haram et al. BMC Pregnancy and Childbirth 2009 9:8 doi:10.1186/1471-2393-9-8; ALT: Alanine aminotransferase; HELLP: Hemolysis, elevated liver function tests, and low platelet counts; LDH: Lactate dehydrogenase.

Table 3 Preeclampsia associated liver diseases

	Severe preeclampsia and eclampsia	HELLP syndrome	Acute fatty liver of pregnancy
Time	After gestational week 22	Late second trimester to early postpartum	Third trimester
Prevalence	Increases in multiple gestation (5%-7%)	0.10%	Increases in male fetus, multiple gestations, primiparous women (0.01%)
Findings	High blood pressure; proteinuria; edema; seizure; renal failure; pulmonary edema	Abdominal pain, nausea/vomiting, overlap with findings in preeclampsia	Abdominal pain, nausea/ vomiting, jaundice, hypoglycemia and hepatic failure
Tests	Platelets > 70000; urine protein > 5 g/24 h; abnormal liver enzymes (10%)	Low platelets; hemolysis; elevated liver enzymes; prothrombin time may remain normal; normal fibrinogen	Platelets < 100000; AST and ALT 300-1000 U/L; low antithrombin III; high prothrombin time; low fibrinogen; high bilirubin; DIC
Management	Blood pressure control; beta-blockers, methyldopa, magnesium sulfate, early delivery	Prompt delivery	Prompt delivery; liver transplant
		5% maternal death 1% hepatic rupture	≤ 10% maternal death
Outcome	1% maternal death	1%-30% fetal death	Up to 45% fetal death

HELLP: Hemolysis, elevated liver function tests, and low platelet counts; DIC: disseminated intravascular coagulation; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase.

Table 4 Complications of preeclampsia/hemolysis, elevated liver function tests, and low platelet counts syndrome

Maternal complications	Neonatal complications	Labor complications
Eclampsia	Fetal death	Preterm labor
HELLP syndrome	Prematurity
Hepatic subcapsular hematoma, infarction or rupture	IUGR
Acute renal failure	Respiratory distress syndrome
Stroke, cerebral hemorrhage, edema and herniation	Intraventricular hemorrhage
Pulmonary edema and acute respiratory distress syndrome	Sepsis
Laryngeal edema
Retinal detachment

HELLP: Hemolysis, elevated liver function tests, and low platelet counts; IUGR: Intrauterine growth retardation.