Advances in understanding and treating liver diseases during pregnancy: A review

Table 1 Classification of pregnancy-related liver disease

	HG	ICP	Hypertension-related liver diseases and pregnancy		AFLP
			Pre-eclampsia, Eclampsia	HELLP
Time (trimester)	1	2 and 3	3	3	3
Frequency (%)	0.3-2.0	0.1-1.5	5-10	0.2-0.6	0.01
Clinical features	Nausea	Pruritis	High BP	High BP	Nausea
	Vomiting	Mild jaundice	Edema	Edema	Vomiting
	Dehydration	Mild elevation of transaminase	Proteinuria	Proteinuria	Hypoglycemia
		Elevation of bile acids	Seizure	Seizure	Lactic acidosis
			Mild elevation of transaminases	DIC	Severe elevation of transaminases
				Mild to severe elevation of transaminases
Pathogenesis -physiologic	starvation, gastric motility, hormonal factors, psychological factors	Hormonal factors	Capillary thrombi, fibrin deposition, endothelial dysfunction, coagulation activation		Microvascular fatty infiltration
Pathogenesis -molecular components	Genetic mutation of LCHAD, Palmitoyltransferase I deficiency	Genetic mutation of MDR3, BSEP	Vascular remodeling, fatty acid oxidation, and immunological factors		Genetic mutation of LCHAD
Managements	Supportive, Hydration	UDCA	BP control	Prompt delivery	Prompt delivery
					Plasmapheresis
					Liver transplantation
Recurrence	Often	50%-70%	rare	rare	higher ratio with genetic mutation in LCHAD

HG: Hyperemesis gravidarum; ICP: Intrahepatic cholestasis of pregnancy; HELLP: Haemolysis, elevated liver enzymes, and low platelets; AFLP: Acute fatty liver of pregnancy; BP: Blood pressure; DIC: Disseminated intravascular coagulation; LCHAD: Long-chain 3-hydroxyl coenzyme A dehydrogenase; MDR3: Multidrug resistance protein; BSEP: Bile salt export protein.

Table 2 Representative laboratory data of intrahepatic cholestasis of pregnancy

Hematology		Biochemistry
WBC	10080/μL	TP	6.8 g/dL	Bile acid	89.6 μmol/L
RBC	410 × 104 /μL	Alb	3.7 g/dL	U acid	0.9 μmol/L
Hb	13.3 g/dL	BUN	8 mg/dL	C acid	21.7 μmol/L
Ht	39.8%	Cre	0.36 mg/dL	C/BA	0.24
PLT	25.5 × 104/μL	T-Bil	6.3 mg/dL	HbA1c	4.2%
		D-Bil	4.0 mg/dL	Serum marker
Coagulation		AST	264 IU/L	HBs Ag	(-)
PT%	121%	ALT	545 IU/L	Anti-HBs	(-)
		ALP	310 IU/L	Anti-HBc	(-)
		LDH	241 IU/L	Anti-HCV	(-)
		γ-GTP	14 IU/L	AFP	36 ng/mL
		ChE	137 IU/L	AFP-L3	32.8%
		TG	197 mg/dL	PIVKAII	44 mAU/mL
		TC	191 mg/dL	ANA	(-)
		IgG	908 mg/dL	AMA	(-)
		CRP	0.05 mg/dL

TG: Triglyceride; TC: Total cholesterol; IgG: Immunoglobulin G; U acid: Ursodeoxycholic acid; C acid: Chenodeoxycholic acid; AFP: Alpha fetal protein; PIVKA: Protein induced by Vitamin K absence or antagonists-II; ANA: Anti-nuclear antibody; AMA: Anti-mitochondrial antibody. Reconstructed from ref [19] with permission.

Table 3 Representative laboratory data of haemolysis, elevated liver enzymes, and low platelets syndrome

Hematology		Biochemistry		Serum marker
WBC	7100 μL	TP	6.1 g/dL	HBs Ag	(-)
RBC	452 × 104/μL	Alb	2.4 g/dL	Anti-HBs	(-)
Hb	14.3 g/dL	BUN	21 mg/dL	Anti-HBc	(-)
Ht	41.2%	Cre	1.55 mg/dL	Anti-HCV	(-)
PLT	9.7 × 104/μL	T-Bil	1.7 mg/dL	ANA	(-)
		D-Bil	0.9 mg/dL	AMA	(-)
Coagulation		AST	137 IU/L
PT%	72%	ALT	106 IU/L
ATIII	15%	ALP	315 IU/L
FDP	23.3 μg/mL	LDH	639 IU/L
		γ-GTP	151 IU/L
		ChE	143 IU/L
		CRP	0.62 mg/dL

WBC: White blood cells; RBC: Red blood cells; Hb: Hemoglobin; Ht: Hematocrit; PLT: Platelet; PT: Prothrombin time; ATIII: Antithrombin III; FDP: Fibrin degradation product; TP: Total protein; Alb: Albumin; BUN: Blood urea nitrogen; Cre: Creatinine; T-Bil: Total bilirubin; D-Bil: Direct bilirubin; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; LDH: Lactate dehydrogenase; γ-GTP: γ-glutamyltransferase; ChE: Choline esterase; CRP: C-reactive protein; ANA: Anti-nuclear antibody; AMA: Anti-mitochondrial antibody.