Intensive supportive measures and good obstetrical care are essential. In some cases, the fetus may already be dead when the diagnosis is made, and the route of delivery is less problematic. Oten, living fetuses tolerate labor poorly. Because significant procrastination in efecting delivery may increase maternal and fetal risks, we prefer a trial oflabor induction with close fetal surveillance. Although some recommend cesarean delivery to hasten hepatic healing, this increases maternal risk when coagulopathy is severe. Nonetheless, cesarean delivery is common, and rates approach 90 percent. Transfusions with whole blood or packed red cells, along with fresh-frozen plasma, cryoprecipitate, and platelets, are usually necessary if surgery is performed or if obstetricalrlacerations complicate vaginal delivery (Chap. 41, p. 788).
Hepatic dysfunction resolves postpartum. It usually normalizes within a week, and in the interim, intensive medical support may be required. Two associated conditions can be seen around this time. Perhaps a fourth of women have evidence for transient diabetes insipidus. This presumably stems from elevated vasopressinase concentrations caused by diminished hepatic production of its inactivating enzyme. Finally, acute pancreatitis develops in approximately 20 percent.
With supportive care, recovery usually is complete. lvIaternal deaths are caused by sepsis, hemorrhage, aspiration, renal failure, pancreatitis, and gastrointestinal bleeding. Two women died in the series from Parkland Hospital. One was an encephalopathic woman who aspirated before intubation during transfer to our care. The other was in a woman with massive liver failure and nonresponsive hypotension (Nelson, 2013). In some centers, other measures have included plasma exchange and even liver transplantation (Fesenmeier, 2005; Franco, 2000; Martin, 2008).
Although maternal mortality rates with acute fatty liver of pregnancy have approached 75 percent in the past, the contemporaneous outlook is much better. From his review, Sibai (2007) cites an average mortality rate of 7 percent. He also cited a 70-percent preterm delivery rate and a perinatal mortality rate of 15 percent, which in the past was nearly 90 percent. At Parkland Hospital, the maternal and perinatal mortality rates during the past four decades have been 4 percent and 12 percent, respectively (Nelson, 2013).
Although most viral hepatitis syndromes are asymptomatic, during the past 30 years, acute symptomatic infections have become even less common in the United States (Daniels, 2009). There are at least ive distinct types of viral hepatitis: A (HA V), B (HBV), D (HDV) caused by the hepatitis B-associated delta agent, C (HCV) , and E (HEV). he clinical presentation is similar in all, and although the viruses themselves probably are not hepatotoxic, the immunological response to them causes hepatocellular necrosis (Dienstag, 2015a,b).
Acute infections are most often subclinical and anicteric.
When they are clinically apparent, nausea and vomiting, headache, and malaise may precede jaundice by 1 to 2 weeks. Lowgrade fever is more common with hepatitis A. By the time jaundice develops, symptoms are usually improving. Serum transaminase levels vary, and their peaks do not correspond with disease severity (see Table 55-1). Peak levels that range from 400 to 4000 U/L are usually reached by the time jaundice develops. Serum bilirubin values typically continue to rise, despite falling serum transaminase levels, and peak at 5 to 20 mgl dL.