Liver and intrahepatic bile ducts - nontumor
Systemic diseases / conditions
Pregnancy

Author: Komal Arora, M.D. (see Authors page)

Revised: 10 November 2017, last major update May 2012

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PubMed Search: Pregnancy[TI] liver[TI] free full text[sb]

Cite this page: Arora, K. Pregnancy. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/liverpregnancy.html. Accessed November 23rd, 2017.
Acute fatty liver of pregnancy
Definition / general
  • Minimal to modest hepatic dysfunction due to defect in mitochondrial fatty acid oxidation that may progress to hepatic failure
  • Usually presents in third trimester of primiparas with bleeding, nausea, vomiting, jaundice, coma
  • Incidence of 1 case per 15,000 pregnancies
  • 20% have coexisting preeclampsia
  • Usually mild but may cause death


Treatment
  • Terminate pregnancy


Gross description
  • Pale, yellow, small liver


Microscopic (histologic) description
  • Microvesicular steatosis in zones 2 or 3 (vacuoles may be very small)
  • Also marked ballooning of hepatocytes and macrovesicular fat
  • In severe cases, hepatocyte dropout, reticulin collapse, portal tract inflammation


Positive stains (frozen tissue)

Differential diagnosis
  • Carnitine deficiency
  • Jamaican vomiting sickness
  • Lábrea hepatitis
  • Reye syndrome
  • Salicylate intoxication
  • Yellow fever


Additional references
Intrahepatic cholestasis of pregnancy
Definition / general
  • Second leading cause of gestational jaundice (after viral hepatitis)
  • Usually occurs late in pregnancy
  • Estrogenic hormones may inhibit hepatocellular bile secretory activity
  • Mother at risk for gallstones, malabsorption
  • Associated with higher incidence of fetal distress, stillbirths, prematurity
  • Symptoms: pruritis in third trimester, dark urine, light stools, jaundice


Laboratory
  • Elevated serum bilirubin (< 5 mg/dl), usually conjugated; mildly elevated alkaline phosphatase


Microscopic (histologic) description
  • Mild cholestasis without cirrhosis
Preeclampsia and eclampsia
Definition / general
  • Preeclampsia: complication of pregnancy in third trimester, usually primiparas, with maternal hypertension, proteinuria, peripheral edema, coagulation abnormalities, DIC
  • Ecclampsia: preeclampsia, seizures and hyperreflexia; leading cause of maternal death, often due to delay in diagnosis
  • Liver disease as part of HELLP syndrome: hemolysis, elevated liver enzymes, low platelets; associated with 4 - 12% of cases of preeclampsia; microangiopathic hemolysis with thrombocytopenia; 10 - 60% infant mortality due to placental abruption, intrauterine ischemia or prematurity


Laboratory
  • Early mild increase in liver enzymes, late coagulopathy


Case reports

Treatment
  • Termination of pregnancy in severe cases


Gross description
  • Pale, firm liver with small red hemorrhagic patches (hematoma dissecting under Glisson capsule and causing hepatic rupture)


Gross images

Images hosted on other servers:

Small hemorrhagic infarcts and atrophy

CT, gross and micro image
of preeclampsia and
subcapsular liver hematoma
at 23 weeks gestation



Microscopic (histologic) description
  • Periportal fibrin deposits with hemorrhage into space of Disse, causing periportal hepatocellular necrosis
  • Less commonly bile inspissation in canaliculi and ductules, steatosis, portal lymphoplasmacytic infiltrate


Microscopic (histologic) images

Images hosted on other servers:

Focal hepatocellular necrosis with fibrin thrombi (image on right)



Differential diagnosis

Additional references
Viral hepatitis
Definition / general
  • Leading cause of gestational jaundice, although also most common cause of jaundice in all women in this age group
  • Similar to hepatitis in nongestational cases
  • Risks of hepatitis B to fetus include acute infection, chronic carrier state, hepatocellular carcinoma