Please cite this paper as: Page L, Girling J. A novel cause for abnormal liver function tests in pregnancy and the puerperium: non‐alcoholic fatty liver disease. BJOG 2011;118:1532–1535. Non‐alcoholic fatty liver disease (NAFLD) is the commonest liver disease in the western world, but has never been reported in pregnancy before. We suggest that NAFLD should also be considered as a cause for abnormal liver function tests during pregnancy. As NAFLD is driven by insulin resistance, it is biologically plausible that pregnancy may reveal previously subclinical disease. Obstetricians have a vital role in optimising maternal health during and after pregnancy and therefore we need to include NAFLD in the differential diagnosis for abnormal liver function tests and recommend lifestyle modifications that may prevent progression to cirrhosis and hepatocellular carcinoma.

A 35-week pregnant 38-year-old woman presented with isolated thrombocytopenia (platelet count 4 · 10 9 /l). Investigations confirmed immune thrombocytopenic purpura, and she received treatment with prednisolone and intravenous immunoglobulins with no increment in the platelet count. At 37 and 38 weeks of the pregnancy, she received two doses of WinRho (anti-D immunoglobulin) at 50 mg/kg. Five days later, with a platelet count of 46 · 10 9 /l, she had an uncomplicated normal vaginal delivery. WinRho is a useful adjunct to other first-line treatment modalities for immune thrombocytopenia in pregnancy.Keywords: Anti-D, immune thrombocytopenia, pregnancy, WinRho. Case ReportA 38-year-old Kosovon woman presented to the Accident and Emergency department with bleeding from her gums and nose and extensive skin bruising, at 34 weeks and 6 days period of gestation. Her two previous pregnancies in Kosovo in 1994 and 1997 were uncomplicated, and both resulted in spontaneous normal vaginal births at 40 weeks of gestation, with the babies weighing 3500 and 4500 g, respectively. Two days previously, she had arrived from Kosovo, where she was being investigated for probable immune thrombocytopenic purpura (ITP) because of extensive bruising and a petechial rash across the abdomen that had commenced 6 weeks earlier. She was already on oral prednisolone 60 mg daily, and she had been transfused with platelets before air travel, but a bone marrow biopsy had not been performed. She had not noticed any significant improvement in her symptoms. She denied any skin rashes or joint pains. She had no personal or family history of bleeding disorders.On examination, she had a petechial rash on her limbs and trunk, blood pressure was 110/70, urinalysis showed 1+ proteinuria, and on abdominal palpation, there was no hepatosplenomegaly; uterine size was equivalent to dates. Investigations showed a haemoglobin level of 9.2 g/dl, mean cell volume of 90 femtolitre, white cell count of 5.4 · 10 9 /l, a platelet count of 4 · 10 9 /l. A blood film confirmed thrombocytopenia and showed mild polychromasia with no evidence of intravascular haemolysis. Other investigations included B12, ferritin, folate levels, coagulation screen, liver and renal function tests, urate, human immunodeficiency virus, antinuclear factor, lupus anticoagulant, anticardiolipin antibodies and a glucose tolerance test because of a high random glucose level. They were all normal except for her B12 level of 82 ng/l. Bone marrow aspirate showed plentiful megakaryocytes and normoblastic erythroid maturation. Her blood group was A Rh D positive, and haemoglobin electrophoresis was normal. Obstetric ultrasound showed no evidence of fetal growth restriction or abnormality and a normally sited placenta. A diagnosis of ITP was made, and treatment with steroids was continued. Intramuscular injections were prohibited. Following multidisciplinary discussions involving anaesthetists and paediatricians, a plan for labour was agreed that included an urgent full blood count on admission to th...

Objective: Direct current cardioversion (DCCV) in pregnancy is rarely required and typically only documented in single case reports or case series. A recent UK confidential enquiry reported on several maternal deaths where appropriate DCCV appeared to have been withheld. Design: Retrospective cohort study. Setting: Seventeen UK and Ireland specialist maternity centres. Sample: Twenty-seven pregnant women requiring DCCV in pregnancy. Main outcome measures: Maternal and fetal outcomes following DCCV. Results: Twenty-seven women had a total of 29 DCCVs in pregnancy. Of these, 19 (70%) initial presentations were to Emergency Departments and eight (30%) to maternity settings. There were no maternal deaths. Seventeen of the women (63%) had a prior history of heart disease. Median gestation at DCCV was 28 weeks, median gestation at delivery was 35 weeks, with a live birth in all cases. The abnormal heart rhythms documented at the first cardioversion were atrial fibrillation in 12/27 (44%) cases, atrial flutter in 8/27 (30%), supraventricular tachycardia in 5/27 (19%) and atrial tachycardia in 2/27 (7%). Fetal monitoring was undertaken following DCCV on 14/29 (48%) occasions (10 of 19 (53%) at ≥26 weeks) and on 2/29 (7%) occasions, urgent delivery was required post DCCV. Conclusions: Direct current cardioversion in pregnancy is rarely required but should be undertaken when clinically indicated according to standard algorithms to optimise maternal wellbeing. Once the woman is stable post DCCV, gestation-relevant fetal monitoring should be undertaken. Maternity units should develop multidisciplinary processes to ensure pregnant women receive the same standard of care as their non-pregnant counterparts.

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