Management of Jaundice in Pregnancy
The management of jaundice in pregnancy requires prompt identification of the underlying cause, with gallstones and preeclampsia-related disorders being the most common etiologies in contemporary practice, followed by intrahepatic cholestasis of pregnancy (ICP). 1
Etiology and Diagnosis
Jaundice in pregnancy can be caused by several conditions:
- Gallstone disease (25%) - Most common cause 1
- Preeclampsia/eclampsia/HELLP syndrome (24%) - Second most common cause 1
- Intrahepatic cholestasis of pregnancy (13%) - Characterized by pruritus and mild jaundice 2
- Viral hepatitis - Less common in developed countries but still significant in some regions 3
- Rare causes - Acute fatty liver of pregnancy, fibrolamellar hepatocellular carcinoma 4
Diagnostic Approach
- Obtain comprehensive liver function tests including:
- Total and direct bilirubin levels
- Transaminases (ALT, AST)
- Alkaline phosphatase
- Gamma-glutamyl transferase
- Serum bile acids (particularly for ICP)
- Blood type (ABO, Rh) testing for mother
- Viral hepatitis serology
- Ultrasound of liver and biliary tract
- Consider MR cholangiography for suspected biliary obstruction
Management Based on Etiology
1. Intrahepatic Cholestasis of Pregnancy (ICP)
- Ursodeoxycholic acid (UDCA) - First-line treatment, though efficacy may vary 2, 5
- Strict fetal monitoring during final weeks of pregnancy
- Consider early delivery once fetal maturity is achieved to prevent adverse fetal outcomes 2
- Monitor maternal liver function tests until resolution (typically within 1-2 weeks postpartum)
2. Gallstone Disease
- Conservative management if possible during pregnancy
- Consider surgical intervention if complications arise (cholecystitis, cholangitis)
- Adequate hydration and pain management
3. Preeclampsia/Eclampsia/HELLP Syndrome
- Delivery is the definitive treatment
- Magnesium sulfate for seizure prophylaxis
- Antihypertensive therapy as needed
- Close maternal and fetal monitoring
4. Viral Hepatitis
- Supportive care
- Avoid hepatotoxic medications
- Specific antiviral therapy may be considered for certain types of viral hepatitis
- Hepatitis E requires particular attention due to high mortality rate (up to 22%) 3
Monitoring and Follow-up
- Regular assessment of liver function tests until resolution
- Fetal monitoring with non-stress tests and biophysical profiles
- Ultrasound for fetal growth assessment
- Consider early delivery if:
- Worsening maternal condition
- Signs of fetal distress
- Term or fetal maturity achieved in cases of ICP 2
Special Considerations
- Maternal risks: Complications such as disseminated intravascular coagulation (DIC), postpartum hemorrhage, and hepatic encephalopathy can occur in up to 65% of cases 3
- Fetal risks: Increased risk of premature delivery, fetal distress, and perinatal mortality, particularly with ICP 2, 1
- Postpartum monitoring: Some cases, particularly severe ICP, may have prolonged course extending beyond delivery 5
Pitfalls and Caveats
- Don't assume all jaundice in pregnancy is due to ICP; comprehensive evaluation is essential
- Hepatitis E, though less common in developed countries, carries high mortality in pregnancy and should not be overlooked in endemic areas 3
- Rare but serious conditions like fibrolamellar hepatocellular carcinoma can present similarly to ICP but fail to respond to standard treatment 4
- Maternal jaundice is associated with increased risk for adverse fetal outcomes regardless of etiology 1
- Consider early referral to hepatology and high-risk obstetrics for multidisciplinary management