Liver diseases in pregnancy: Diseases not unique to pregnancy

Table 1 Normal physiological alterations in liver tests in pregnancy

Test	First trimester	Second/third trimesters
Albumin	↓	↓
ALT	N	N
AST	N	N
Total bilirubin	↓	↓
Alkaline phosphatase	N	↑
GGT	N	↓
5’-nucleotidase	N	May increase in second and third trimesters
Fasting total bile acids	N	N
Prothrombin time	N	N

N: No change; ↑: Increase; ↓: Decrease; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; GGT: Gamma-glutamyl transpeptidase.

Table 2 Interpretation of hepatitis B blood tests

Test	HBsAg	Anti-HBs	Total Anti-HBc	Anti-HBc IgM	HBV DNA
Acute infection	+	-	+	+	+
Resolved infection with natural immunity	-	+	+	-	-
Immunity through vaccination	-	+	-	-	-
Chronic infection	+	-	+	-	+/-
Different possibilities1	-	-	+	-	-

¹Could represent resolving acute infection, resolved infection (most likely), chronic infection with low viral load or false positive. HBsAg: Hepatitis B surface antigen; Anti-HBs: Hepatitis B surface antibody; Total anti-HBc: Total hepatitis B core antibody; Anti-HBc IgM: Hepatitis B core antibody immunoglobulin M; HBV: Hepatitis B virus.

Table 3 Food and Drug Administration approved medications for hepatitis B treatment

Generic name	Trade name	Company	Approved for HBV treatment
Interferons
Interferon α-2b, recombinant	Intron® A	Schering Corporation/ Merck and Co	1992
Perinterferon α-2a	Pegasys®	Genentech/Roche group	2005
Nucleosides/nucleotides
Lamivudine1	EPIVIR-HBV®	GlaxoSmithKline	1998
Adefovir dipivoxil	HEPSERATM	Gilead Sciences	2002
Entecavir	BARACLUDETM	Bristol-Myers Squibb	2005
Telbivudine2	TYZEKATM	Novartis	2006
Tenofovir2	Viread	Gilead Sciences	2008

¹Pregnancy risk category C, can be used in the third trimester;

²Pregnancy risk category B. HBV: Hepatitis B virus.

Table 4 Options for portal hypertension management in pregnancy

Esophageal varices	Nonselective β-blockers
	Endoscopic and ligation and/or sclerotherapy
	TIPS: Data on TIPS and pregnancy is limited
Ascites	Sodium (salt) restriction, diuretics
Hepatic encephalopathy	Lactulose, rifaximin

TIPS: Transjugular portosystemic shunt.

Table 5 The Food and Drug Administration pregnancy risk categories of medicines

Pregnancy category	Definition
A	Controlled studies show no risk
B	Animal studies show no risk, and there are no human controlled studies. Or animal studies may have revealed an adverse effect that was not reproduced in human controlled studies
C	No human studies and either animal studies show an adverse effect or there are no studies available. Use if the risk is justified
D	Positive evidence of risk in human studies, only if the potential benefits outweigh the risk
X	Contraindicated in pregnancy: Risk is confirmed in animal and human studies and outweighs any advantage

Table 6 Food and Drug Administration pregnancy risk categories of some liver disease medications

Medicine	Pregnancy category	Medicine	Pregnancy category
Nadolol	C	Ribavirin	X
Propranolol	C	Telaprevir	B
Rifaximin	C	Boceprevir	B
Lactulose	B	Tenofovir	B
Furosemide	C	Entecavir	C
Spironolactone	C	Telbuvidine	B
Corticosteroids	B	Adefovir	C
Azathioprine	D	Lamuvidine	C
Cyclosporin	C	Acyclovir	B
Mycophenolate mofetil	D	Ursodeoxycholic acid	B
Tacrolimus	C	Penicillamine	D
Sirolimus	C	Trientine	C
Antithymocyte globulin	C	Zinc sulfate	C
Pegylated interferon	C (contraindicated in pregnancy)	Interferon alpha 2b	C (contraindicated in pregnancy)