Lavinia Iordache, PA: Presentation, Diagnosis of Hepatobiliary Issues in Pregnancy

Liver disease in pregnancy is estimated to affect 3% to 10% of all pregnancies, posing serious risks to both the mother and the fetus if not promptly detected and treated. Recognizing common hepatobiliary issues in pregnancy and how they may present differently from the general population is crucial for timely intervention and improved outcomes.

At the 2024 annual Gastroenterology and Hepatology Advanced Practice Providers (GHAPP) conference in National Harbor, Maryland, Lavinia Iordache, PA, a physician assistant at the University of Miami, conducted a workshop on hepatobiliary disease in pregnancy.

“The diagnosis of hepatobiliary disease in pregnancy tends to present several challenges,” Iordache explained to HCPLive, citing the lack of thorough investigation of hepatobiliary issues in pregnant women compared with the general population as well as the limited number of pregnancies complicated by liver disease.

Describing how these issues typically present in pregnant women versus the general population, Iordache emphasized the importance of considering the etiology of the specific liver disease, breaking it down into 3 main categories: pregnancy-related liver diseases, non-pregnancy-related liver diseases, and pregnancy occurring in patients with preexisting liver disease.

Pregnancy-Related Liver Diseases

Iordache noted hyperemesis gravidarum typically occurs earlier in pregnancy and is one of the most prevalent pregnancy-related liver diseases. However, she pointed out it generally presents with “unremarkable” symptoms like nausea and vomiting that may be easily missed during pregnancy, although she called attention to the fact that these patients also present with elevated liver enzymes.

Looking at liver diseases occurring later in pregnancy, Iordache mentioned acute fatty liver of pregnancy; hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome; and intrahepatic cholestasis of pregnancy.

Non-Pregnancy-Related Liver Diseases

Describing cases of de-novo presentation of liver disease in pregnancy, Iordache mentioned autoimmune hepatitis and viral hepatitis, both of which she noted can occur at any time during a person's life but may happen to be diagnosed during pregnancy on routine blood work with elevated liver enzymes. Although the presentation would likely be similar to the general population, Iordache explained how the overall severity and related complications may differ in pregnant women.

Pregnancy in Patients with Preexisting Liver Disease

Finally, Iordache described cases in which liver disease manifests in the setting of the hemodynamic and hormonal changes that occur during pregnancy, including cirrhosis, decompensation of cirrhosis with ascites, and hepatitis. However, she was careful to note that traditional hallmarks of liver disease can occur in “normal” pregnancies and lead to wrongly diagnosed liver disease.

References

1. ^{Wakim-Fleming, J. Liver Diseases in Pregnancy. Cleveland Clinic. Accessed September 11, 2024. https://my.clevelandclinic.org/departments/digestive/medical-professionals/hepatology/liver-disease-in-pregnancy#definition-causes-tab}
2. ^{Lim E, Mouyis M, MacKillop L. Liver diseases in pregnancy. Clin Med (Lond). 2021;21(5):e441-e445. doi:10.7861/clinmed.2021-0497}