Liver disorders

Intrahepatic cholestasis of pregnancy

What is ICP?
Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-related liver disorder in which there are abnormalities in the flow of bile (a substance produced by the liver that aids in the digestion and absorption of fats). These abnormalities lead to a build-up of bile acids (components of bile) in the mother's blood, resulting in symptoms such as severe skin itching.

What are the symptoms of ICP?
The symptoms of ICP can range from mild to severe. Symptoms usually start in the second or third trimester of pregnancy. The most common symptoms include:

  • Skin itching: Itching often is most severe on the palms of the hands and soles of the feet, but many affected women itch all over their bodies. It often gets progressively worse and may interfere with sleep and daily activities.
  • Jaundice: This yellowing of the skin and whites of the eyes occurs in 10 to 20 percent of women with ICP (1). Jaundice is caused by a build-up of a chemical called bilirubin in the blood, resulting from the liver disorder and decreased bile flow.

A pregnant woman should call her health care provider if she has these symptoms.

How common is ICP?
In the United States, ICP affects less than 1 percent of women (1).

What are the risks of ICP in pregnancy?
ICP can be very uncomfortable for the pregnant woman. It also can hurt the baby. Up to 60 percent of women with ICP deliver prematurely (before 37 weeks of pregnancy) (2). Premature babies are at increased risk for health problems during the newborn period and for lasting disabilities and death. ICP also increases the risk for stillbirth, though the risk is small (1 to 2 percent) (1). It is important to diagnose and treat ICP to help prevent these potential problems.

How is ICP diagnosed?
There are a number of skin disorders of pregnancy that can cause itching; most do not harm the mother or baby. Blood tests can tell if a woman's itching is due to ICP. These often include a blood test that measures various chemicals that show how well a woman's liver is functioning and the amount of bile acids in her blood.

How is ICP treated?
ICP often is treated with a medication called ursodeoxycholic acid (Actigall). This medication relieves skin itching, helps correct liver function abnormalities and may help prevent stillbirth.

The health care provider monitors the baby closely (with ultrasound and tests that measure heart rate) to see if the baby appears to be developing any difficulties, such as heart rate abnormalities, due to ICP. If the baby is having difficulties, the provider may recommend early delivery to help reduce the risk of stillbirth. The provider also may do a test called amniocentesis when the baby is at about 36 weeks gestation to see if the lungs are mature. If the baby's lungs are mature enough for the baby to breathe on his own, the provider may induce labor at 36 to 38 weeks to help prevent stillbirth (1).

What causes ICP?
The cause of ICP is not well understood. Pregnancy hormones and heredity appear to play a role. ICP appears to be more common in twin (or other multiple) pregnancies, possibly due to increased hormone levels (1). About half of women with ICP have a family history of related liver disorders (3).

Does ICP go away after giving birth?
Symptoms of ICP generally clear up on their own by about 2 days after a woman gives birth. However, about 60 to 70 percent of affected women develop ICP again in another pregnancy (1).

Hepatitis

What is hepatitis?
Hepatitis is inflammation of the liver, usually caused by a virus. Several viruses can cause hepatitis. The most common are called hepatitis A, B and C.

What are the symptoms of hepatitis?

Symptoms of hepatitis can range from mild to severe. Some infected individuals have no symptoms at all. Common symptoms include:

  • Jaundice
  • Fatigue
  • Nausea and vomiting
  • Upper-abdominal discomfort
  • Low-grade fever

What is chronic hepatitis?
Some individuals who contract hepatitis B or hepatitis C do not clear the virus from their bodies, and the virus can remain in their systems for life. Individuals with a chronic hepatitis infection are at increased risk for severe liver disease or liver cancer. About 10 to 15 percent of individuals with hepatitis B, and at least 50 percent with hepatitis C, develop chronic infections (4). Individuals with hepatitis A do not develop chronic infections.

How is hepatitis treated?
There are no medications to treat acute (recently acquired) hepatitis infections. There are medications to treat chronic hepatitis B and C, but these usually are not recommended during pregnancy (5).

There are at least six antiviral drugs that can be used to treat hepatitis B. Little is known about the safety of these drugs in pregnancy. Some are suspected of increasing the risk of birth defects and miscarriage. Women should tell their health care provider before starting any of these drugs if they are planning pregnancy. Women who become pregnant while taking any of these drugs should call their provider. These drugs also are not recommended during breastfeeding.

Chronic hepatitis C can be treated with a combination of two antiviral drugs (ribavirin and pegylated interferon alfa-2a). These drugs are believed to contribute to birth defects and miscarriage. Women should avoid pregnancy while taking them and for six months after completing treatment. A woman should notify her provider immediately if she becomes pregnant while taking these drugs. They also should not be used during breastfeeding, or by male partners of pregnant women.

What are the risks of hepatitis in pregnancy?
Hepatitis A generally does not pose a risk to the baby when the mother contracts it during pregnancy. It is rarely passed from mother to baby during delivery (6).

Hepatitis B poses the greatest risk in pregnancy. Women who carry the virus in their system (acute or chronic infection) can pass it on to their babies during labor and delivery. In most cases, the risk is about 10 to 20 percent, though it can be higher if the woman has high levels of the virus in her body (4). Babies who are infected at birth usually develop chronic hepatitis B infection and face a high risk of serious liver disease and liver cancer as adults.

Hepatitis C is passed along to the baby during labor and delivery in only about 4 percent of cases (5).

How can hepatitis infection be prevented in babies?
The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women be screened for hepatitis B with a blood test (5). If the blood test shows that a woman has acute or chronic hepatitis B, her baby should receive the hepatitis B vaccine and immune globulin (which contains hepatitis-fighting antibodies) within 12 hours of birth. This treatment prevents infection in more than 90 percent of babies at risk (5). The baby also should have two more doses of the vaccine in the first 6 months of life. The CDC also recommends that all babies be vaccinated against hepatitis B before leaving the hospital and at 1 to 2 months and 6 to 18 months (5).

There is currently no way to prevent a mother from passing hepatitis C to her baby.

How does a person get infected with a hepatitis virus?
Hepatitis A usually is spread through contaminated food and water. People who travel to developing countries are at increased risk. Hepatitis B and C occur after contact with blood or body fluids of an infected person. This may occur by sharing needles used to inject drugs or by having sex with an infected person (though hepatitis C is spread infrequently through sexual contact).

How can a pregnant woman protect herself from hepatitis?
The best defense against hepatitis A and B is vaccination. Women who are planning to travel to a developing country should ask their provider if they should be vaccinated against hepatitis A. The hepatitis A vaccine has not been studied for safety during pregnancy, but it is not believed to pose a risk (6).

The hepatitis B vaccine is considered safe in pregnancy. Health care workers, public safety workers and others at high risk (such as women living with an infected partner) should consider getting the hepatitis B vaccine before or during pregnancy.

There is no vaccine against hepatitis C. Women also can help protect themselves from hepatitis B and C by following safe sex practices, avoiding illicit injected drugs, and not sharing personal care items that might have blood on them (razors, toothbrushes).

Acute fatty liver of pregnancy

What is acute fatty liver of pregnancy?
Acute fatty liver of pregnancy is a rare, life-threatening complication of pregnancy. About 1 in 10,000 to 1 in 15,000 pregnant women are affected by this disorder, which is characterized by a build-up of fat in liver cells (11).

What are the symptoms of acute fatty liver of pregnancy?
Symptoms of this disorder generally begin in the third trimester of pregnancy and may resemble those seen in HELLP syndrome. A pregnant woman should call her health care provider if she has any of these symptoms:

  • Persistent nausea and vomiting
  • Pain in the stomach or upper-right abdomen
  • General malaise
  • Jaundice
  • Headache

What are the risks of acute fatty liver of pregnancy?
Without prompt treatment, acute fatty liver of pregnancy can lead to coma, organ failure and death of mother and baby.

How is acute fatty liver of pregnancy diagnosed?
Acute fatty liver of pregnancy can be diagnosed with blood tests that measure a number of factors related to liver and kidney functions.

How is acute fatty liver of pregnancy treated?
The mother may require blood transfusions to stabilize her condition. The baby is delivered as soon as possible to prevent serious complications.

What causes acute fatty liver of pregnancy?
The cause of this condition is not well understood. Genetics may play a role. A recent study found that 16 percent of women had this condition when their babies had certain inherited errors in body chemistry (fatty acid oxidation defects) (8). These disorders prevent an affected individual from properly processing certain fats. Babies with these disorders can develop life-threatening liver, heart and neuromuscular problems unless they are fed special low-fat foods. These findings suggest that all babies of women with acute fatty liver of pregnancy be tested for fatty acid oxidation defects so they can receive prompt treatment. (Many babies are routinely screened for these disorders as part of a panel of newborn screening tests. However, states vary in the newborn screening tests they require.)

Does acute fatty liver go away after pregnancy?
Most women start to improve within a few days of delivery and suffer no lasting harm from the condition. Women who carry a gene for a fatty acid oxidation defect (including women who have had an affected baby) have an increased risk of fatty liver occurring again in another pregnancy; the recurrence risk is unknown in other women (11).

Is the March of Dimes supporting research on liver diseases?
Yes. Several March of Dimes grantees are seeking to identify genes that may contribute to preeclampsia, a pregnancy-related form of high blood pressure that is related to HELLP syndrome. The goal of this research is to improve diagnosis and treatment of these disorders. Another recent grantee is seeking to develop treatment to stimulate liver regeneration in children with liver disease, including those with complications resulting from hepatitis.

References

  1. Riely, C.A., Bacq, Y. Intrahepatic Cholestasis of Pregnancy. Clinics in Liver Disease, volume 8, 2004, pages 167-176.
  2. Lammert, F., et al. Intrahepatic Cholestasis of Pregnancy: Molecular Pathogenesis, Diagnosis and Management. Journal of Hepatology, volume 33, 2000, pages 1012-1021.
  3. Kroumpouzos, G. and Cohen, L.M. Specific Dermatoses of Pregnancy: An Evidence-Based Systematic Review. American Journal of Obstetrics and Gynecology, volume 188, number 4, April 2003, pages 1083-1092.
  4. American College of Obstetricians and Gynecologists (ACOG). Viral Hepatitis in Pregnancy. ACOG Practice Bulletin, number 86, October 2007.
  5. Centers for Disease Control and Prevention (CDC). Viral Hepatitis. Accessed 11/29/07.
  6. Centers for Disease Control and Prevention (CDC). Planning for a Healthy Pregnancy and Traveling While Pregnant. Accessed 11/30/07.
  7. Moldenhauer, J.S., Sibai, B.M. Hypertensive Disorders of Pregnancy. In Scott, J.R., et al. (eds.): Danforth's Obstetrics and Gynecology, Ninth Edition, Philadelphia, Lippincott Williams & Wilkins, 2003, pages 257-271.
  8. Browning, M.F., et al. Fetal Fatty Acid Oxidation Defects and Maternal Liver Disease in Pregnancy. Obstetrics and Gynecology, volume 107, 2006, pages 115-120.
  9. Barton, J.R., Sibai, B.M. Diagnosis and Management of Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome. Clinics in Perinatology, volume 31, 2004, pages 807-833.
  10. Martin, J.N., et al. Understanding and Managing HELLP Syndrome: The Integral Role of Aggressive Glucocorticoids for Mother and Child. American Journal of Obstetrics and Gynecology, volume 195, 2006, pages 914-934.
  11. Sibai, B.M. Imitators of Severe Preeclampsia. Obstetrics and Gynecology, volume 109, 2007, pages 956-966.


Last reviewed: February, 2008

Intrahepatic cholestasis of pregnancy

What is ICP?
Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-related liver disorder in which there are abnormalities in the flow of bile (a substance produced by the liver that aids in the digestion and absorption of fats). These abnormalities lead to a build-up of bile acids (components of bile) in the mother's blood, resulting in symptoms such as severe skin itching.

What are the symptoms of ICP?
The symptoms of ICP can range from mild to severe. Symptoms usually start in the second or third trimester of pregnancy. The most common symptoms include:

  • Skin itching: Itching often is most severe on the palms of the hands and soles of the feet, but many affected women itch all over their bodies. It often gets progressively worse and may interfere with sleep and daily activities.
  • Jaundice: This yellowing of the skin and whites of the eyes occurs in 10 to 20 percent of women with ICP (1). Jaundice is caused by a build-up of a chemical called bilirubin in the blood, resulting from the liver disorder and decreased bile flow.

A pregnant woman should call her health care provider if she has these symptoms.

How common is ICP?
In the United States, ICP affects less than 1 percent of women (1).

What are the risks of ICP in pregnancy?
ICP can be very uncomfortable for the pregnant woman. It also can hurt the baby. Up to 60 percent of women with ICP deliver prematurely (before 37 weeks of pregnancy) (2). Premature babies are at increased risk for health problems during the newborn period and for lasting disabilities and death. ICP also increases the risk for stillbirth, though the risk is small (1 to 2 percent) (1). It is important to diagnose and treat ICP to help prevent these potential problems.

How is ICP diagnosed?
There are a number of skin disorders of pregnancy that can cause itching; most do not harm the mother or baby. Blood tests can tell if a woman's itching is due to ICP. These often include a blood test that measures various chemicals that show how well a woman's liver is functioning and the amount of bile acids in her blood.

How is ICP treated?
ICP often is treated with a medication called ursodeoxycholic acid (Actigall). This medication relieves skin itching, helps correct liver function abnormalities and may help prevent stillbirth.

The health care provider monitors the baby closely (with ultrasound and tests that measure heart rate) to see if the baby appears to be developing any difficulties, such as heart rate abnormalities, due to ICP. If the baby is having difficulties, the provider may recommend early delivery to help reduce the risk of stillbirth. The provider also may do a test called amniocentesis when the baby is at about 36 weeks gestation to see if the lungs are mature. If the baby's lungs are mature enough for the baby to breathe on his own, the provider may induce labor at 36 to 38 weeks to help prevent stillbirth (1).

What causes ICP?
The cause of ICP is not well understood. Pregnancy hormones and heredity appear to play a role. ICP appears to be more common in twin (or other multiple) pregnancies, possibly due to increased hormone levels (1). About half of women with ICP have a family history of related liver disorders (3).

Does ICP go away after giving birth?
Symptoms of ICP generally clear up on their own by about 2 days after a woman gives birth. However, about 60 to 70 percent of affected women develop ICP again in another pregnancy (1).

Hepatitis

What is hepatitis?
Hepatitis is inflammation of the liver, usually caused by a virus. Several viruses can cause hepatitis. The most common are called hepatitis A, B and C.

What are the symptoms of hepatitis?

Symptoms of hepatitis can range from mild to severe. Some infected individuals have no symptoms at all. Common symptoms include:

  • Jaundice
  • Fatigue
  • Nausea and vomiting
  • Upper-abdominal discomfort
  • Low-grade fever

What is chronic hepatitis?
Some individuals who contract hepatitis B or hepatitis C do not clear the virus from their bodies, and the virus can remain in their systems for life. Individuals with a chronic hepatitis infection are at increased risk for severe liver disease or liver cancer. About 10 to 15 percent of individuals with hepatitis B, and at least 50 percent with hepatitis C, develop chronic infections (4). Individuals with hepatitis A do not develop chronic infections.

How is hepatitis treated?
There are no medications to treat acute (recently acquired) hepatitis infections. There are medications to treat chronic hepatitis B and C, but these usually are not recommended during pregnancy (5).

There are at least six antiviral drugs that can be used to treat hepatitis B. Little is known about the safety of these drugs in pregnancy. Some are suspected of increasing the risk of birth defects and miscarriage. Women should tell their health care provider before starting any of these drugs if they are planning pregnancy. Women who become pregnant while taking any of these drugs should call their provider. These drugs also are not recommended during breastfeeding.

Chronic hepatitis C can be treated with a combination of two antiviral drugs (ribavirin and pegylated interferon alfa-2a). These drugs are believed to contribute to birth defects and miscarriage. Women should avoid pregnancy while taking them and for six months after completing treatment. A woman should notify her provider immediately if she becomes pregnant while taking these drugs. They also should not be used during breastfeeding, or by male partners of pregnant women.

What are the risks of hepatitis in pregnancy?
Hepatitis A generally does not pose a risk to the baby when the mother contracts it during pregnancy. It is rarely passed from mother to baby during delivery (6).

Hepatitis B poses the greatest risk in pregnancy. Women who carry the virus in their system (acute or chronic infection) can pass it on to their babies during labor and delivery. In most cases, the risk is about 10 to 20 percent, though it can be higher if the woman has high levels of the virus in her body (4). Babies who are infected at birth usually develop chronic hepatitis B infection and face a high risk of serious liver disease and liver cancer as adults.

Hepatitis C is passed along to the baby during labor and delivery in only about 4 percent of cases (5).

How can hepatitis infection be prevented in babies?
The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women be screened for hepatitis B with a blood test (5). If the blood test shows that a woman has acute or chronic hepatitis B, her baby should receive the hepatitis B vaccine and immune globulin (which contains hepatitis-fighting antibodies) within 12 hours of birth. This treatment prevents infection in more than 90 percent of babies at risk (5). The baby also should have two more doses of the vaccine in the first 6 months of life. The CDC also recommends that all babies be vaccinated against hepatitis B before leaving the hospital and at 1 to 2 months and 6 to 18 months (5).

There is currently no way to prevent a mother from passing hepatitis C to her baby.

How does a person get infected with a hepatitis virus?
Hepatitis A usually is spread through contaminated food and water. People who travel to developing countries are at increased risk. Hepatitis B and C occur after contact with blood or body fluids of an infected person. This may occur by sharing needles used to inject drugs or by having sex with an infected person (though hepatitis C is spread infrequently through sexual contact).

How can a pregnant woman protect herself from hepatitis?
The best defense against hepatitis A and B is vaccination. Women who are planning to travel to a developing country should ask their provider if they should be vaccinated against hepatitis A. The hepatitis A vaccine has not been studied for safety during pregnancy, but it is not believed to pose a risk (6).

The hepatitis B vaccine is considered safe in pregnancy. Health care workers, public safety workers and others at high risk (such as women living with an infected partner) should consider getting the hepatitis B vaccine before or during pregnancy.

There is no vaccine against hepatitis C. Women also can help protect themselves from hepatitis B and C by following safe sex practices, avoiding illicit injected drugs, and not sharing personal care items that might have blood on them (razors, toothbrushes).

Acute fatty liver of pregnancy

What is acute fatty liver of pregnancy?
Acute fatty liver of pregnancy is a rare, life-threatening complication of pregnancy. About 1 in 10,000 to 1 in 15,000 pregnant women are affected by this disorder, which is characterized by a build-up of fat in liver cells (11).

What are the symptoms of acute fatty liver of pregnancy?
Symptoms of this disorder generally begin in the third trimester of pregnancy and may resemble those seen in HELLP syndrome. A pregnant woman should call her health care provider if she has any of these symptoms:

  • Persistent nausea and vomiting
  • Pain in the stomach or upper-right abdomen
  • General malaise
  • Jaundice
  • Headache

What are the risks of acute fatty liver of pregnancy?
Without prompt treatment, acute fatty liver of pregnancy can lead to coma, organ failure and death of mother and baby.

How is acute fatty liver of pregnancy diagnosed?
Acute fatty liver of pregnancy can be diagnosed with blood tests that measure a number of factors related to liver and kidney functions.

How is acute fatty liver of pregnancy treated?
The mother may require blood transfusions to stabilize her condition. The baby is delivered as soon as possible to prevent serious complications.

What causes acute fatty liver of pregnancy?
The cause of this condition is not well understood. Genetics may play a role. A recent study found that 16 percent of women had this condition when their babies had certain inherited errors in body chemistry (fatty acid oxidation defects) (8). These disorders prevent an affected individual from properly processing certain fats. Babies with these disorders can develop life-threatening liver, heart and neuromuscular problems unless they are fed special low-fat foods. These findings suggest that all babies of women with acute fatty liver of pregnancy be tested for fatty acid oxidation defects so they can receive prompt treatment. (Many babies are routinely screened for these disorders as part of a panel of newborn screening tests. However, states vary in the newborn screening tests they require.)

Does acute fatty liver go away after pregnancy?
Most women start to improve within a few days of delivery and suffer no lasting harm from the condition. Women who carry a gene for a fatty acid oxidation defect (including women who have had an affected baby) have an increased risk of fatty liver occurring again in another pregnancy; the recurrence risk is unknown in other women (11).

Is the March of Dimes supporting research on liver diseases?
Yes. Several March of Dimes grantees are seeking to identify genes that may contribute to preeclampsia, a pregnancy-related form of high blood pressure that is related to HELLP syndrome. The goal of this research is to improve diagnosis and treatment of these disorders. Another recent grantee is seeking to develop treatment to stimulate liver regeneration in children with liver disease, including those with complications resulting from hepatitis.

References

  1. Riely, C.A., Bacq, Y. Intrahepatic Cholestasis of Pregnancy. Clinics in Liver Disease, volume 8, 2004, pages 167-176.
  2. Lammert, F., et al. Intrahepatic Cholestasis of Pregnancy: Molecular Pathogenesis, Diagnosis and Management. Journal of Hepatology, volume 33, 2000, pages 1012-1021.
  3. Kroumpouzos, G. and Cohen, L.M. Specific Dermatoses of Pregnancy: An Evidence-Based Systematic Review. American Journal of Obstetrics and Gynecology, volume 188, number 4, April 2003, pages 1083-1092.
  4. American College of Obstetricians and Gynecologists (ACOG). Viral Hepatitis in Pregnancy. ACOG Practice Bulletin, number 86, October 2007.
  5. Centers for Disease Control and Prevention (CDC). Viral Hepatitis. Accessed 11/29/07.
  6. Centers for Disease Control and Prevention (CDC). Planning for a Healthy Pregnancy and Traveling While Pregnant. Accessed 11/30/07.
  7. Moldenhauer, J.S., Sibai, B.M. Hypertensive Disorders of Pregnancy. In Scott, J.R., et al. (eds.): Danforth's Obstetrics and Gynecology, Ninth Edition, Philadelphia, Lippincott Williams & Wilkins, 2003, pages 257-271.
  8. Browning, M.F., et al. Fetal Fatty Acid Oxidation Defects and Maternal Liver Disease in Pregnancy. Obstetrics and Gynecology, volume 107, 2006, pages 115-120.
  9. Barton, J.R., Sibai, B.M. Diagnosis and Management of Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome. Clinics in Perinatology, volume 31, 2004, pages 807-833.
  10. Martin, J.N., et al. Understanding and Managing HELLP Syndrome: The Integral Role of Aggressive Glucocorticoids for Mother and Child. American Journal of Obstetrics and Gynecology, volume 195, 2006, pages 914-934.
  11. Sibai, B.M. Imitators of Severe Preeclampsia. Obstetrics and Gynecology, volume 109, 2007, pages 956-966.


Last reviewed: February, 2008