GALLBLADDER DISORDERS . . . . . . . . . . . . . . . . . . . . . 1069
PANCREATIC DISORDERS ...........i......i.......i. 1070
Prenancy is comparativey seldom complicated by jaundice. Notwithstanding the act that in most cases the jaundice disappears without treatment, too avorable a prognosis should not be ventured, or the reason that now and again the condition may represent the initial symptom of acute yellow atrophy of the liver.
-J. Whitridge Williams (1903)
Even though Williams only mentions acute hepatic fatty metamorphosis, in practice, disorders of the liver, gallbladder, and pancreas together comprise a formidable list of complications that may arise in pregnancy. Some stem from preexisting conditions and some are unique to gestation. The relationships of several of these with pregnancy can be fascinating, intriguing, and challenging.
Customarily, liver diseases complicating pregnancy are placed into three general categories. he first includes those specifically related to pregnancy that resolve either spontaneously or following delivery. Examples are intrahepatic cholestasis and acute fatty liver, both discussed in the next sections. Also, hepatic dysfunction from hyperemesis gravidarum may involve the liver. Mild hyperbilirubinemia with elevated serum transaminase levels is seen in up to half of afected women requiring hospitalization. However, these levels seldom exceed 200 U/L (Table 55-1). Liver biopsy may show minimal fatty changes. Hyperemesis gravidarum is discussed in detail in Chapter 54 (p. 1043). Another in this first category is hepatocellular damage with preeclampsia-the HELLP syndrome-which is characterized by hemolysis, �levated serum liver enzyme levels, and low 2latelet counts. hese changes are discussed in detail in Chapter 40 (p. 721).
The second category involves acute hepatic disorders that are coincidental to pregnancy, such as acute viral hepatitis. The third category includes chronic liver diseases that predate pregnancy, such as chronic hepatitis, cirrhosis, or esophageal varices.
Importantly, several normal pregnancy-induced physiological changes induce appreciable liver-related clinical and laboratory manifestations (Chap. 4, p. 68, and Appendix, p. 1257). Findings such as elevated serum alkaline phosphatase levels, palmar erythema, and spider angiomas, which might suggest liver disease, are common during normal pregnancy. Metabolism is also afected, due to altered expression of the cytochrome P450 system. This alteration is mediated by higher levels of estrogen, progesterone, and other pregnancy hormones. For example, hepatic CYFIA2 expression declines, whereas that of CYF2D6 and CYF3A4 rises. Importantly, cytochrome enzymes are expressed in many organs besides the liver, most notably the
Hepatic, Biliary, and Pancreatic Disorders 1059
TABLE 55-1 . Clinical and Laboratory Findings with Acute Liver Diseases in Pregnancy
Plat = platelets; PT = prothrombin time.
placenta. The net efect is complex and likely influenced by gestational age and organ of expression (Isoherranen, 2013). Despite all of these functional changes, no major hepatic histological changes are induced by normal pregnancy.