Am J Gastro 2004;99:2479; Nejm 1996;335:569

Liver disease in pregnancy may represent a disease present at conception, a disease acquired unique to pregnancy, or a disease acquired coincident with but notunique to pregnancy. Pregnancy results in several changes in LFTs that might be interpreted as pathologic. Albumin falls 10-60% in the second trimester, and alk phos rises to 2-4 × normal in the third trimester. Transaminases remain normal. There are several hepatic disorders unique to pregnancy, including:

Hyperemesis gravidarum, intractable vomiting seen in the first trimester, can be associated with mild transaminase abnormalities (usually <2 × normal).

Intrahepatic cholestasis of pregnancy presents as pruritus, generally in the third trimester of pregnancy. Jaundice follows pruritus in 20-60% of women. Bilirubin is usually <6 mg/dL, alk phos is 4 × normal, and transaminases are 2-10 × normal. Serum bile acids are markedly elevated. There is an increased risk of premature delivery or stillbirth. Vitamin K is given prophylactically to prevent deficiency due to malabsorption. Ursodeoxycholic acid improves itch and LFTs, and reduces preterm deliveries more effectively than cholestyramine (GE 2005;129:894).

Preeclampsia/eclampsia is a disorder in which the liver is 1 of several target organs. Abnormal transaminases are frequent in moderate to severe disease but are usually less than 500 U/L. Hepatic rupture is a rare, catastrophic event typically associated with preeclampsia/eclampsia.

HELLP syndrome and acute fatty liver of pregnancy are discussed in the following sections.