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Section III: Topics in Obstetrics
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Abdominal pain (commonly epigastric) Malaise Anorexia Jaundice What laboratory findings may be seen in patients with acute fatty liver of pregnancy Elevated AST and ALT Elevated bilirubin Prolonged prothrombin time Elevated liver enzyme levels Low platelets and fibrinogen Elevated serum creatinine Low glucose levels (30% of patients) What other major disorder with similar laboratory results must be ruled out and how is this condition characterized What is the gold standard for diagnosis of acute fatty liver of pregnancy HELLP syndrome It is characterized by hemolysis, elevated liver enzymes, and low platelets Liver biopsy revealing microvesicular fatty infiltration of hepatocytes However, this is rarely performed since it is an invasive procedure Maternal stabilization (fluids, blood products, antibiotics) Supportive care (mechanical ventilation, dialysis) Prompt delivery of the fetus What test should be considered for newborns of mothers with acute fatty liver of pregnancy What is the rate of recurrence Deficiency of LCHAD
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It can recur in future pregnancies but the rate is unclear
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Intrahepatic Cholestasis of Pregnancy
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What is intrahepatic cholestasis of pregnancy (ICP) It is a condition characterized by jaundice and pruritis secondary to the accumulation of bile acids in the liver and plasma Onset is more common in the third trimester, but sometimes occurs in the second Defects in either the ABCB4 (adenosine triphosphate-binding cassette, subfamily 4, member 4)
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In what trimesters does it usually occur
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What genetic factors may be involved in the pathogenesis of ICP
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9: Complications of Pregnancy
gene or multidrug resistance 3 (MDR3) gene (encoding for a canalicular phospholipid translocator) may be involved in ICP What hormonal factors may be involved in the pathogenesis of ICP What is the cardinal clinical manifestation of ICP that helps distinguish this disease from other liver conditions What do laboratory values reveal in patients with ICP High concentrations of estrogen and excess progesterone may be risk factors for ICP Severe pruritis (especially on the palms and soles of the feet) (Jaundice is present 10% of the time; jaundice without pruritis warrants other causes of liver disease) Increased serum total bile acids (chenodeoxycholic acid, deoxycholic acid, cholic acid) Marked elevation of the cholic/ chenodeoxycholic acid ratio Elevated alkaline phosphatase Elevated total and direct bilirubin Elevated AST and ALT Normal prothrombin time (usually) What are the main liver conditions that must be ruled out Hepatitis (autoimmune and viral) Biliary tract disease Acute fatty liver of pregnancy HELLP syndrome What is the treatment of ICP Treatment is focused on relieving symptoms and preventing maternal and fetal complications Ursodeoxycholic acid (500 mg bid until delivery) has been shown to alleviate pruritis and normalize bile acids and improve liver function test results Early delivery (36 38 weeks) improves symptoms in majority of patients suffering from ICP Can oral contraceptives that contain estrogen be given postpartum Yes Oral contraceptives containing low-dose estrogen can be given after normalization of liver function tests Women should be advised of a potential recurrence of pruritis Fetal death Spontaneous preterm birth Postpartum hemorrhage
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What are several fetal complications of ICP
Section III: Topics in Obstetrics
Neonatal respiratory syndrome Meconium-stained amniotic fluid What is the rate of recurrence It recurs 60 70% in future pregnancies, but may be milder in severity
Hyperemesis Gravidarum
What is hyperemesis gravidarum It is persistent vomiting typically in the first trimester that is severe enough to cause weight loss, dehydration, acidosis from starvation, alkalosis from vomiting, and hypokalemia It may be related to high or rapidly rising levels of serum estrogen or hCG, or both Elevated levels of hCG or serum thyroxine Elevated levels of serum transaminases (typically <200 IU/L, and ALT > AST) Elevated levels of bilirubin, amylase, lipase, and electrolytes What is the association between hyperthyroidism and hyperemesis gravidarum Although there are biochemical signs of hyperthyroidism (elevated thyroxine levels), this is most likely the effect of hCG on the TSH receptor (seen in 60 70% of patients) Clinical symptoms of hyperthyroidism during hyperemesis gravidarum are not seen First-line pharmacotherapy consists of vitamin B6 or vitamin B6 plus doxylamine Vitamin B1 should also be administered to prevent Wernicke encephalopathy Antiemetics, IV crystalloids, and IV fluids should be given until the vomiting is controlled Mallory-Weiss tears Esophageal rupture Pneumothoraces Pneumomediastinum
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