Gastroenterology Education and CPD for trainees and specialists

1. Which one of the following statements regarding liver dysfunction in pregnancy is false?

1. HG is intractable vomiting in the 1st trimester of pregnancy
2. Liver dysfunction occurs in 50% patients with aminotransferases up to 20-fold elevation
3. The most specific and sensitive marker of ICP ( intrahepatic cholestasis of pregnancy) is serum BA levels of greater than 10 umol/L
4. In ICP (intrahepatic cholestasis of pregnancy) GGT levels parallel other cholestatic markers
5. ICP occurs in second trimester of pregnancy

Explanation :ICP is defined as pruritus and elevated bile acid (BA) levels which appear in the second half of pregnancy (typically 25-32 weeks) and disappear after delivery, typically to recur in subsequent pregnancies. Aminotransferases levels are elevated and may reach values greater than 1000 IU/l; bilirubin is usually less than 100umol/l. Alkaline phosphatase will be elevated though diagnostically unhelpful in pregnancy (due to placental isoenzyme); mildly elevated levels of GGT are found in fewer than 30% cases. This is unusual as in most other forms of cholestatic liver disease; GGT levels parallel other cholestatic markers.

2. Which one of the following statements regarding liver dysfunction in pregnancy is true?

1. Ursodeoxycholic acid (10-15mg/kg) is the treatment of choice for relief of pruritus with improvement in liver tests in ICP (intrahepatic cholestasis of pregnancy)
2. ICP resolves with foetal delivery to recur in 45%-70% of subsequent pregnancies and occasionally with oral contraceptives.
3. The main risk in ICP is to the foetus
4. The most specific and sensitive marker of ICP is serum BA levels of greater than 10 umol/L
5. All of above

Explanation :ICP is defined as pruritus and elevated bile acid (BA) levels which appear in the second half of pregnancy (typically 25-32 weeks) and disappear after delivery, typically to recur in subsequent pregnancies. The main risk in ICP is to the foetus and necessitates referral to a high-risk obstetrician. Foetal monitoring for chronic placental insufficiency is essential. Foetal complications in ICP are placental insufficiency, premature labour, and sudden foetal death, probably due to elevated foetal levels of BA. Adverse foetal outcome can be prevented only by delivery as soon as the foetal lungs are mature.

3. Which one of the following statements regarding liver dysfunction in pregnancy is false?

1. Preeclampsia is the triad of hypertension, edema, and proteinuria.
2. Its only significance is that hepatic involvement in pre eclampsia indicates severe disease with need for immediate delivery to avoid eclampsia, hepatic rupture, or necrosis.
3. Preeclampsia occurs in the third trimester
4. HELLP syndrome occurs in the second trimester
5. HELLP syndrome is a triad of haemolysis (H) with a microangiopathic blood smear, elevated liver enzymes (EL), and a low platelet count (LP).

Explanation :Preeclampsia is the triad of hypertension, edema, and proteinuria in the third trimester. Liver involvement indicates severe preeclampsia with significant perinatal morbidity and mortality. Aminotransferases are variable from mild to 10-fold to 20-fold elevations; bilirubin is usually less than 100umol/l. Diagnosis of HELLPrequires the presence of all 3 laboratory criteria: (1) haemolysis (elevated indirect bilirubin, LDH>600U/L, abnormal blood smear, (2) elevated aminotransferases (AST >70U/L), and (3) thrombocytopenia (<150,000). Most patients present between 27 and 36 weeks’ gestation, but 25% in postpartum period. The most common clinical presentation is abdominal pain and tenderness. Many patients also have nausea, vomiting, and malaise. Hypertension and proteinuria are present in approximately 85 percent of cases. Jaundice is uncommon

4. Which one of the following statements regarding liver dysfunction in pregnancy is false?

1. Liver failure is most commonly seen in AFLP with coagulopathy hypoglycaemia or encephalopathy.
2. Preeclampsia, HELLP syndrome and Acute fatty liver of pregnancy (AFLP) all occur in third trimester of pregnancy
3. ICP occurs in third trimester of pregnancy
4. HG occurs in first trimester of pregnancy
5. Compared to HELLP, AFLP is associated with greater elevation of bilirubin

Explanation :AFLP is a sudden catastrophic illness characterised by microvesicular fatty infiltration, occurring almost exclusively in the third trimester from 28 to 40 weeks, rarely in late second trimester. In AFLP, aminotransferases vary from near-normal to 1000; bilirubin is usually also elevated. Severely affected patients also have coagulopathy with or without DIC, metabolic acidosis, renal dysfunction, hypoglycaemia and high ammonia. The main differential diagnosis of AFLP is HELLP. It may be impossible to differentiate them. However, evidence of hepatic insufficiency such as hypoglycaemia or encephalopathy is suggestive of AFLP. Most liver dysfunction in pregnancy is pregnancy-related and is due to one of the following 5 liver diseases: Hyperemesis gravidarum (HG), Intrahepatic cholestasis of pregnancy (ICP), Preeclampsia,, HELLP syndrome and Acute fatty liver of pregnancy (AFLP). Each of them has a characteristic timing: HG occurs in the first trimester, ICP in the second half of pregnancy, and the other 3 in the third trimester.

Gastroenterology training and education

MCQ On Liver disease in Pregnancy

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