A prospective national study of acute fatty liver of pregnancy in the UK

Consultation for liver disease in pregnant women is a common and oftentimes vexing clinical consultation for the gastroenterologist. The challenge lies in the need to consider the safety of both the expectant mother and the unborn fetus in the clinical management decisions. This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women. Am J Gastroenterol 2016; 111:176-194; doi: 10.1038/ajg.2015 Initial evaluation of pregnant patientA pregnant patient presenting with abnormal liver tests should undergo standard workup as with any non-pregnant individual (strong recommendation, very low level of evidence). Imaging in pregnancyUltrasound is safe and the preferred imaging modality used in assessment of abnormal liver tests suggestive of biliary tract disease (strong recommendation, low level of evidence).Magnetic resonance imaging without gadolinium can be used in the second and third trimester (conditional recommendation, low level of evidence).Computed tomography scans carry a risk of teratogenesis and childhood hematologic malignancies but may be used judiciously with minimized radiation protocols (2-5 rads; conditional recommendation, very low level of evidence). Endoscopy in pregnancyEndoscopy is safe in pregnancy but should be deferred until the second trimester if possible (strong recommendation, low level of evidence).Meperidine and propofol can be used for endoscopic sedation (strong recommendation, moderate level of evidence). Management of biliary disease in pregnancyERCP can be performed when indicated for pregnant women presenting with biliary disease that strongly necessitates intervention such as biliary pancreatitis, symptomatic choledocholithiasis, and/or cholangitis. Minimizing fetal exposure to fl uoroscopy is imperative (strong recommendation, low level of evidence).Symptomatic cholecystitis should be managed with early surgical intervention with laparoscopic cholecystectomy (strong recommendation, low level of evidence). Liver masses in pregnancyAsymptomatic hemangioma and focal nodular hyperplasia do not need routine imaging or surveillance during pregnancy (strong recommendation, very low level evidence).Hepatic adenomas should be monitored with ultrasound during pregnancy for growth. Patients with large adenomas (>5 cm) should be referred for resection prior to pregnancy (strong recommendation, low level of evidence). Hepatitis B in pregnancyActive-passive immunoprophylaxis with hepatitis B immunoglobulin and the HBV vaccination series should be administered to all infants born to HBV-infected mothers to prevent perinatal transmission (strong recommendation, low level of evidence).Women chronically infected with HBV and high viral load (>10 6 log copies/ml (200,000 IU/ml) and higher) should be offered antiviral medication with tenofovir or telbivudine in the third trimester to reduce perinatal transmission of HBV (strong recommendation, low level of evidence).C-section should not be performed electively in HBV-pos...

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“…Th e median gestation age at the time of identifi cation is 36 weeks. Risk factors include twin pregnancies and low body mass index ( 68 ).…”

Section: Second and Third Trimestermentioning

confidence: 99%

ACG Clinical Guideline: Liver Disease and Pregnancy

Tran

Ahn

Reau

2016

American Journal of Gastroenterology

235

257

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“…This study only conducted follow-up to a maximum of 1 year following the event 27 and did not explore women's experiences. Surveillance studies of specific near-miss morbidities in the UK have been conducted through UKOSS, 8,[28][29][30][31][32] but further expanded work was required to conduct a comprehensive programme covering all the main causes of direct maternal death.…”

Section: Rationalementioning

confidence: 99%

“…[28][29][30]74 The methodology of the confidential enquiries into maternal deaths conducted through CMACE has been described in detail previously. 3,100 In summary, cases of maternal death were reported to CMACE through several different sources and, in addition, ascertainment of cases was undertaken through linkage of routine birth and death vital statistics records.…”

Section: Data Sourcesmentioning

confidence: 99%

“…Two sets of cases and controls were used. Cases included in the analysis of socioeconomic inequalities were women who suffered from one of the following six conditions of severe maternal morbidity directly attributable to pregnancy causes: AFE, 32 AFLP, 30 eclampsia, 28 peripartum hysterectomy, 31 peripartum haemorrhage 129 and uterine rupture. 181 For the ethnic inequality study, in addition to these six conditions, cases were included from a further five conditions: antenatal pulmonary embolism, 29 stroke in pregnancy, 74 placenta accreta, 72 HELLP syndrome 54 and severe sepsis.…”

Section: Secondary Data Analysismentioning

confidence: 99%

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Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight

Acosta

Brocklehurst

et al. 2016

Programme Grants Appl Res

101

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BackgroundStudies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision.ObjectivesTo (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts.MethodsMixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group.SettingMaternity units in all four countries of the UK.ParticipantsWomen with near-miss maternal morbidities, their partners and comparison women without severe morbidity.Main outcome measuresThe incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches.ResultsWomen and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services.LimitationsThis programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded.ConclusionsImplementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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“…Ch'ng et al first set the Swansea criteria for diagnosing AFLP. 3,4 Six or more of the following features are used to diagnose AFLP in the absence of other explanations: vomiting, abdominal pain, polydipsia/polyuria, encephalopathy, elevated bilirubin >14 mmol/L (0.8 mg%), hypoglycaemia <4 mmol/L (72 mg%), elevated urate >340 mmol/L (5.7 mg%), leukocytosis >11 Â 109/L; ascites or bright liver on ultrasound, elevated transaminases, elevated ammonia >47 mmol/L (27.5 mg%), renal impairment creatinine >150 mmol/L (1.7 mg %), coagulopathy (PT >14 s or APTT >34 s), or microvesicular steatosis on liver biopsy. Using these criteria we anticipated the diagnosis of AFLP.…”

Section: Discussionmentioning

confidence: 99%