Case : JAUNDICE IN PREGNANCY

HISTORY:

1.     Period of ammenorrhoea

2.     Duration of Jaundice

3.     Pruritis/Itching

4.     Abdominal pain/distension

5.     Pale/clay wloured stools

6.     History of Blood transfusion, I/V drugs, fluids, hepatoxtoxic drug, needle prick

7.     Nausea(mild/moderate/severe)

8.     History of malaise, anorexia, weight loss

9.     H/o fever, rash

10.   Any History suggestive of :-

-       coagnlopathy(bleeding diathesis)

-       encephalopathy(altered sensorium, conrulsions)

-       nephropathy(renal failure)

11.  Family H/o Jaundice

12.  H/o Jaundice in previous preganancies

CLINICAL EXAMINTATION

-       Weight of the patient

-       Icterus-eyes, palm, oral mucosa & skin

-       Signs of pruritis(scratch marks)

-       Bleeding spots(if any)

-       Oedema

-       Sensorium

-       Temperature

-       Blood Pressure

-       Liver:- Surface, span, margin, consistency, tenderness

-       Spleen

-       Ascites

-       Any evidence of dhydration

-       Obstertrical examination : - Height of uterus Presentation Fetal Heart

Any evidence of IUGR< Fetal distress

Patients of Pre-eclampsia with HELLP syndicrome are vry ill with hypertension, protecnuria, hemolysis    Jaundice, hemoglobinopathies, thrombocytopenia with activation of coagulation cascade

INVESTIGATION

1.     Complete hemogram including ESR

2.     Serum Bilirubin – Total Direct, Indirect

3.     SGOT, SGPT

4.     Serum alhaline phosphalase

5.     Urine-Bile salts, bile pcpinen ts, urobilingogen, ketone

6.     Serum proteins- Total Differential(A/G Ratio)

7.     PTI, PTTK

8.     Viral markers.hepatitis serology

9.     Blood sugar

10.  Serum creatinine

11.  Ultrasound of abdomen for

Liver echotexture

Splenoportal axis

Collaterals in portal hypertension

Ascites

Space occupying lesion

Biliary stone

Fetus & placenta

                        IUGR/IUD

 DIFFERENTIAL DIAGNOSIS 

Causes not specific to pregnancy

Viral hepatitis

Cholelithiasis

Autoimmune hepatitis

Neoplasia

Gilberts syndrome

Specific to pregnancy

Hyperemesis gravidarum

( Ist trimester)

Severe pre-eclampsia/HELLP

(2nd half of pregnancy)

Acute fatty liver of pregnancy

(2nd half of pregnancy)

Intrahepatic cholestasis

(2nd half of pregnancy)

MANAGEMENT Management will be as per aetiological cause:-

Hepatitis:- Antenatal(Prenatal)

Supportive care

Dietary advice

Monitor liver function tests

Testing for HbsAƒ

Asess fetal growth & health

Vigilance for uterine activity

Infection control measures

Labor/delivery and postnatal  Infection control measure

Watch for PPH

In HbsAƒ positive cases, newborn should receive passive(HBIG) and active immunization “Intrahepatic” Cholestasis of Pregnancy

Prenatal:-

1.     Local antipruritic measures

2.     Consider cholestyramine, ursodeoxycholic acid

3.     Vit K supplement

4.     Monitor fetal well being

5.     Consider elective deliver

6.     Biliary tract ultrasonography

Labor/delivery:-

1.     Anticipate preterm delivery

2.     Increased risk of PPH

Postnatal:-

1.     Monitor biochemical resolution

2.     Vit K supplement for baby

“Acute Fatty Liver of Pregnancy”  Prenatal:-

1.     Estabilish diagnosis, resuscilate

2.     Intensive care

3.     Supportive therapy

4.     Plan delivery

Labor/Delivery

1.     Maternal resuscitation by correction of

a.     Hypoglycemia

b.     Fluid imabalance

c.     Coagulopathy

2.     Treatment of liver failure

3.     Intensive fetal monitoring

4.     Urgent delivery when maternal condition is stabilized, vaginal delivery preferable for mother

5.     Meticulous hemostasis, including adequate wound drainage

Postnatal:-

1.     Continue intensive care management

2.     Watch for postpartum wound hematoma formation and spses, PPH

3.     Supportive contraceptive measure

“Severe Pre eclampsea:-

Prenatal & Labor

                                                                 I.     Control of hypertension

                                                                II.     Control coagulation disturbance

                                                               III.     Consider anticonvulasant prophylaxis

                                                             IV.     Close fetal monitoring

                                                              V.     Watch for fall in hemoglobing from hemolysis

                                                             VI.     Fluid and electrolyte management

                                                            VII.     Initiate deliver process

Postnatal

                                                                 I.     Anticipate delayed postnatal recovery

                                                                II.     Continue monitoring plalelets and renal function

                                                               III.     Monitor for hemolysis

                                                             IV.     Control severe hypertension

“Hyperemesis Gravidarum”

1.     Intravenous fluid and electrolyte therapy

2.     Diet-Discuss with dietitian

3.     Antremetic regimen

4.     Nutrient and Vitamin supplement

5.     Antressphageal reflerex measures

6.     Psychological and social support

7.     Steroids-controversial

Surgical Management

No role of surgery