What is a typical physiologic change in pregnancy among the given options: increased gallbladder contractility, elevated alkaline phosphatase (ALP), elevated alanine aminotransferase (ALT)/aspartate aminotransferase (AST), direct hyperbilirubinemia, or indirect hyperbilirubinemia?

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Physiologic Changes in Pregnancy: Elevated Alkaline Phosphatase

The correct answer is (b) elevated alkaline phosphatase, which is a normal physiologic change during pregnancy.

Normal Liver Biochemistry Changes in Pregnancy

  • Alkaline phosphatase (ALP) levels physiologically increase during pregnancy, particularly in the second and third trimesters, due to placental production 1
  • This elevation is considered a normal finding and does not indicate pathology 1
  • According to the American Association for the Study of Liver Diseases, alkaline phosphatase is one of the few liver enzymes that normally increases during pregnancy while other liver function tests remain within normal ranges 1

Evaluation of Other Options

  • (a) Increased gallbladder contractility - This is incorrect. Pregnancy actually causes decreased gallbladder contractility, which increases the risk of developing gallstones 1
  • (c) Elevated ALT/AST - This is incorrect. Serum aminotransferases (ALT and AST) should remain normal throughout pregnancy, and any elevation warrants evaluation 1
  • (d) Direct hyperbilirubinemia - This is incorrect. Bilirubin levels remain normal throughout pregnancy, and elevated direct (conjugated) bilirubin would indicate pathology 1
  • (e) Indirect hyperbilirubinemia - This is incorrect. Total and indirect (unconjugated) bilirubin levels should remain normal throughout pregnancy 1

Physiologic Basis for Alkaline Phosphatase Elevation

  • Alkaline phosphatase is produced by multiple tissues, including the liver, bone, intestines, kidneys, and placenta 1
  • During pregnancy, the placenta becomes a significant source of alkaline phosphatase production 1
  • The American College of Radiology guidelines specifically note that ALP levels are "physiologically higher in childhood, associated with bone growth, and in pregnancy, due to placental production" 1

Clinical Implications

  • When evaluating liver function tests in pregnant women, it's important to recognize that elevated alkaline phosphatase alone is expected 1
  • If alkaline phosphatase elevation is accompanied by other abnormal liver tests (such as elevated transaminases or bilirubin), further evaluation is warranted 1
  • To differentiate between hepatic and placental sources of elevated alkaline phosphatase, gamma-glutamyl transferase (GGT) can be measured, as it would be elevated in liver disease but not with isolated placental ALP production 1

Other Normal Physiologic Changes in Pregnancy

  • Decreased albumin levels during the second half of pregnancy due to hemodilution 1
  • Increased alpha-fetoprotein of fetal liver origin 1
  • Increased clotting factors II, V, VII, X, XII, and fibrinogen, contributing to hypercoagulability 1
  • Spider angiomas and palmar erythema may develop due to the hyperestrogenic state 1

Understanding these normal physiologic changes is essential for correctly interpreting laboratory results during pregnancy and avoiding unnecessary diagnostic testing or interventions.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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