How is increased bilirubin managed in pregnancy?

Management of Increased Bilirubin in Pregnancy

The most common causes of elevated bilirubin during pregnancy are gallstones (25%) and preeclampsia/HELLP syndrome (24%), followed by intrahepatic cholestasis of pregnancy (13%), with viral hepatitis no longer being a common etiology in the United States. 1

Etiology and Significance

• Elevated bilirubin during pregnancy is relatively uncommon, occurring in approximately 0.5% of pregnancies 1
• Maternal hyperbilirubinemia is associated with increased risk of adverse fetal outcomes including stillbirths, fetal malformations, neonatal deaths, and small for gestational age births 1
• Common causes in order of frequency:
  • Gallstone disease (cholelithiasis/cholecystitis) 1
  • Preeclampsia/eclampsia/HELLP syndrome 1
  • Intrahepatic cholestasis of pregnancy 1
  • Other less common causes include viral hepatitis, autoimmune hepatitis, and medication-induced liver injury 1

Diagnostic Approach

• Measure total and direct (conjugated) bilirubin levels to differentiate between conjugated and unconjugated hyperbilirubinemia 2
• Perform liver function tests including ALT, AST, alkaline phosphatase, and GGT to assess for hepatocellular damage 1
• Check complete blood count to evaluate for hemolysis 2
• Evaluate for preeclampsia with blood pressure measurements and urinary protein 1
• Consider ultrasound to assess for gallstones or biliary obstruction 1
• Test for viral hepatitis markers if clinically indicated 1

Management Strategy

General Measures

• Monitor maternal protein levels, as low protein (<6.0 g/dl) is associated with higher maternal bilirubin levels 3
• Ensure adequate hydration and nutrition 2
• Monitor fetal well-being with appropriate surveillance based on gestational age and underlying etiology 1

Specific Management Based on Etiology

1. For gallstone disease:

   • Conservative management for uncomplicated cases 1
   • Consider surgical intervention only for severe cases unresponsive to medical management 1

2. For preeclampsia/HELLP syndrome:

   • Manage according to standard preeclampsia protocols 1
   • Consider delivery if maternal condition deteriorates or at term 1

3. For intrahepatic cholestasis of pregnancy:

   • Ursodeoxycholic acid to reduce maternal pruritus and potentially improve fetal outcomes 1
   • Consider earlier delivery (37-38 weeks) due to increased risk of stillbirth 1

4. For viral hepatitis:

   • Supportive care and monitoring 1
   • Specific antiviral therapy if indicated based on viral etiology 1

Fetal Considerations

• Maternal hyperbilirubinemia can affect the fetus, though prolonged fetal exposure to elevated maternal bilirubin levels does not necessarily result in developmental or neurological handicap 4
• Newborns of mothers with hyperbilirubinemia may have elevated bilirubin levels at birth that require monitoring and possibly treatment 4
• Consider antenatal phenobarbital therapy in selected cases of very preterm delivery risk to enhance fetal bilirubin conjugation, which may reduce the need for phototherapy in the newborn 5

Monitoring and Follow-up

• Regular monitoring of bilirubin levels and liver function tests throughout pregnancy 1
• Increased fetal surveillance, particularly in cases of intrahepatic cholestasis of pregnancy 1
• After delivery, monitor newborn closely for development of hyperbilirubinemia 2
• Assess umbilical cord blood bilirubin levels at delivery in cases of maternal hyperbilirubinemia 3

Pitfalls and Caveats

• Do not assume viral hepatitis is the cause of jaundice in pregnancy without appropriate testing, as this is no longer the most common etiology in the US 1
• Be aware that oxytocin administration during labor may be associated with increased umbilical bilirubin levels 3
• Maternal hyperbilirubinemia, even when mild, warrants close monitoring of the newborn for development of neonatal jaundice 3
• Do not delay evaluation and management of preeclampsia/HELLP syndrome when it presents with elevated bilirubin, as this can lead to serious maternal and fetal complications 1