Jaundice in pregnancy
Jaundice in pregnancy, whilst relatively rare, has potentially serious consequences for maternal and fetal health. It can be caused by pregnancy or occur intercurrently. Causes of jaundice specific to pregnancy include:
- pre- eclampsia associated with HELLP syndrome (= haemolysis, elevated liver enzymes and low platelet count).
- Acute fatty liver of pregnancy.
- hypermesis gravidarum
- Intrahepatic cholestasis of pregnancy
Approximately 3-5% of pregnant women may have abnormal liver function tests.
The course of most viral hepatitis infections is unaltered by pregnancy – the exception is hepatitis E , where pregnant women who contract the disease exhibit fatality rates of 10-20%.
- Isolate the infected patient to prevent spread.
- Symptomatic treatment includes maintenance of adequate hydration and nutrition.
- Pregnant women exposed to the virus can be given immune globulin within 2 weeks of exposure, together with vaccine.
- It is not clear if the virus is transmitted from mother to baby but, if the illness has occurred in the final month of pregnancy, the neonate should receive immune globulin.
- This is the most common cause of acute viral hepatitis in pregnancy and can occur in acute, subclinical or chronic form.
- The presence of HBeAg is associated with a very high risk of neonatal infection.
- All women should now be offered hepatitis B screening as part of routine antenatal screening
- Infants of HBsAg-positive women should receive hepatitis B immune globulin immunoprophylaxis at birth and hepatitis B vaccine at one week, one month and six months old. This regime reduces the incidence of hepatitis B vertical transmission to less than 3%.
- The prevalence of neonatal infection depends on the time during gestation that maternal infection takes place: rare in the first trimester, 6% in the second trimester and 67% of those in the third trimester.
- No therapy has been shown to influence the neonatal transmission of hepatitis C virus.
- Interferon should not be used during pregnancy because of possible adverse effects on the fetus.
This develops as a co-infection with hepatitis B. When present, it increases the incidence of acute hepatic failure.
- This is rare in the developed world but, in developing countries (where it is more common), it is responsible for a high level of fulminant hepatic failure and mortality in pregnant women.
- In India it appears to be associated with a higher maternal mortality rate and worse obstetric and fetal outcomes compared with other causes of acute viral hepatitis in pregnancy.
This may affect as many as 6% of pregnant women but jaundice occurs only in about 1 in 20 of these women. Pregnancy alters bile composition and gallbladder emptying slows in the second trimester, increasing the risk of gallstones.
Individual risk factors are multiparity and previous gall bladder disease
Obstructive jaundice requires surgical intervention, usually via laparoscopic cholecystectomy. There is an associated fetal loss of approximately 6%.
- In patients with primary biliary cirrhosis (PBC), ursodeoxycholic acid can be safely continued. Cholestasis may worsen during pregnancy with PBC.
- Infants of patients with marked hyperbilirubinaemia during pregnancy may require exchange transfusion at birth.