A 25-year-old female at 34 weeks of pregnancy had been admitted to the hospital with jaundice for 5 days, altered mental status, and decreased urine output for 8 h. Her antenatal status was fine, with no history of pregnancy-induced hypertension. HBsAg and HIV were negative.

Jaundice in pregnancy can occur due to pregnancy-related and unrelated diseases. Pregnancy-related liver diseases are real threat to the survival of the fetus and the

mother.

Rapid diagnosis is needed to manage them appropriately.

Step 1: Initiate resuscitation

Airway intervention may be required in the following conditions:

•Altered mental status and seizures.

•Acute respiratory failure not responding to conservative measures.

•Cesarean section under general anesthesia.

•Shock – to reduce work of breathing.

•Always anticipate difficult airway in pregnant patients.

•Endotracheal intubation should be performed sooner rather than later to protect the airway.

•Intubation must be performed by the senior intensivist.

R. Chawla, M.D., F.C.C.M. (*)

Department of Respiratory, Critical Care & Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India

e-mail: drchawla@hotmail.com

P. Nasa, M.D., F.N.B.

Department of Critical Care Medicine, Max Superspeciality Hospital, New Delhi, India

•Difficult airway equipment for airway management must be thoroughly checked before proceeding to intubation, and the alternative plan for definitive airway including surgical access should be identified.

•Raised intracranial pressure (ICP) in the jaundiced pregnant patient is a serious concern, and therefore, proper sedation should be ensured with minimal manipulation during intubation.

•Supplemental oxygen may be required in some patients depending on their oxygen saturation, target SpO2 more than 95%.

Circulation

•Two large-bore intravenous cannulae (14G or 16G) should be placed to administer fluids.

•Be careful of associated coagulopathy.

•A Foley’s catheter should be placed to monitor urine output.

•Use fluid administration judiciously to optimize preload and at the same time to avoid overload, which might increase ICP.

•Nurse in the left lateral position (30° wedge to the right hip) to prevent supine hypotension syndrome.

Disability (neurological)

•Perform a brief neurological assessment including Glasgow coma score, pupil size, and reaction to light in case of altered mental status.

Step 2: Take history and perform physical examination

Take detailed history that should cover the following:

•Details about pregnancy (trimester of pregnancy)

•Antenatal evaluation and immunization

•History of hypertension, pregnancy-induced hypertension during the previous pregnancy, complications and outcome of previous pregnancy, and family history of hypertension

•Duration of jaundice and pruritus, other constitutional symptoms such as malaise, nausea, anorexia, fever, weight loss or increased abdominal girth from ascites, and seizures

•History of abdominal surgery, medication history (amount and time of acetaminophen, herbal medications), and transfusion history

•History of alcohol consumption, HIV and hepatitis risk factors, intravenous drug abuse, exposure to travel, occupational, and recreational history

•History of hepatitis B or C in the spouse

In physical examination, also look for the signs of acute liver failure:

•Altered mental status

•Icterus, anemia

•Ecchymotic patches/bleeding from gastrointestinal tract or urinary tract

•Epigastric or right upper quadrant abdominal tenderness

•Peripheral edema, hyperreflexia, or clonus

•Seizures

•Hypotension (hypovolemia, hemolysis, sepsis)

•Spider angioma and palmar erythema may be normal in pregnancy

Step 3: Assess the severity of hepatic encephalopathy

One should assess the severity of hepatic encephalopathy to plan the appropriate treatment (Table 73.1).

Step 4: Send investigations

•Complete blood cell count.

•Liver function tests—remember normal physiological changes in pregnancy (Table 73.2).

•Renal function tests and serum electrolytes.

•Arterial blood gas analysis and blood glucose.

•Hepatotropic virus profile (IgM anti-HEV, IgM anti-HAV, IgM anti-HCV, antiHBc antibody, HBeAg, HBsAg).

•Coagulation profile (prothrombin time, activated partial thromboplastin time, fibrinogen, fibrin degradation product).

•Uric acid.

•The antinuclear factor—to exclude autoimmune hepatitis.

•Additional tests—peripheral smear, serum lactate dehydrogenase levels, reticulocyte count, and Coombs’ test—to exclude thrombotic thrombocytopenic purpura (TTP).

•Ultrasonography is considered safe and is the preferred abdominal imaging modality during pregnancy.

•MRI with contrast is preferable to CT scanning during pregnancy to avoid ionizing radiation.

•Transthoracic echocardiography.

Step 5: Differential diagnosis

The various conditions that can cause acute hepatic failure can be divided into those related to pregnancy and those unrelated to pregnancy (Tables 73.3 and 73.4).

A.Hyperemesis gravidarum

•Incidence: 0.3–2.0% of all pregnancies.

•Usually within the first trimester.

•Symptoms: intractable vomiting, resulting in dehydration, ketosis, and weight loss of 5% or more.

•The cause remains unclear.

•Risk factors: obesity, psychiatric illness, molar pregnancy, preexisting diabetes, multiple pregnancies, and hyperthyroidism (60%).

•Serum aminotransferases can rise up to 20 times, but jaundice is rare.

B.Viral hepatitis

•Diagnosis of viral hepatitis in pregnancy is not different from the diagnosis in the nonpregnant state.

•Herpes simplex virus in patients who are immunosuppressed, and in the pregnant woman, can cause fulminant hepatitis. Aminotransferases are high, and other signs of hepatic failure such as prothrombin time are elevated, but jaundice (increase in bilirubin) is rare.

Step 6: Management

A.AFLP

•Prompt delivery is essential (steroids if fetal maturity in doubt).

•Supportive treatment, control of hypertension (discussed in Chap. 19), and correction of coagulation abnormalities and hypoglycemia.