From the Guidelines
Transaminitis in pregnancy requires prompt evaluation and management to prevent complications for both mother and baby, with the primary goal of minimizing morbidity, mortality, and improving quality of life. The first step is to determine the underlying cause, which could include preeclampsia, HELLP syndrome, acute fatty liver of pregnancy, viral hepatitis, or medication effects 1. Initial management includes close monitoring of liver function tests, blood pressure, and fetal well-being.
Key Considerations
- For mild transaminitis without other concerning symptoms, conservative management with regular monitoring may be sufficient.
- For preeclampsia-related transaminitis, antihypertensive medications like labetalol (200-800 mg/day in divided doses) or nifedipine (30-120 mg/day) may be needed, along with magnesium sulfate for seizure prophylaxis if severe features are present.
- In cases of HELLP syndrome or acute fatty liver of pregnancy, delivery is often necessary regardless of gestational age, as recommended by the EASL clinical practice guidelines 1.
Management Strategies
- Ursodeoxycholic acid (10-15 mg/kg/day) may help manage intrahepatic cholestasis of pregnancy.
- Supportive care includes adequate hydration, rest, and avoiding hepatotoxic medications.
- Daily aspirin prophylaxis for patients at risk for pre-eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome is advised beginning at week 12 of gestation 1.
Timing of Delivery
- In AFLP, there is no reason to delay delivery after diagnosis, and expedited vaginal induction could be considered instead of caesarean section if fetal demise has occurred 1.
- For ICP with high bile acids (>100 μmol/L), delivery should be triggered between 35-36 weeks due to the increased risk of sudden fetal demise 1. Early consultation with maternal-fetal medicine specialists and hepatologists is recommended for optimal management of this potentially serious condition, and the elevated liver enzymes typically resolve after delivery, but follow-up testing is important to ensure complete resolution 1.
From the Research
Transaminitis in Pregnancy Help Syndrome
- Transaminitis, or elevated liver enzymes, can occur in pregnancy due to various causes, including drug-induced liver injury (DILI) 2 and intrahepatic cholestasis of pregnancy (ICP) 3, 4, 5, 6.
- DILI is a common cause of transaminitis in pregnancy, and labetalol has been reported to cause chronic DILI in a postpartum patient 2.
- ICP is a special complication of pregnancy characterized by skin pruritus, abnormal liver function tests, and bile acids, and can be treated with ursodeoxycholic acid (UDCA) and S-adenosylmethionine (SAMe) 3, 4, 5.
- UDCA has been shown to be effective in improving pruritus and liver function tests in patients with ICP, and is considered a safe treatment option 3, 4, 5.
- However, a recent study suggested that UDCA may not be beneficial for all women with ICP, and its routine use should be reconsidered 6.
- The treatment of transaminitis in pregnancy depends on the underlying cause, and healthcare providers should carefully evaluate each patient to determine the best course of treatment 2, 3, 4, 5, 6.