From the Guidelines
Elevated Liver Function Tests (LFTs) do prompt early delivery in pregnancy, particularly in cases of intrahepatic cholestasis of pregnancy (ICP) with high bile acid levels.
Key Considerations
- The decision to deliver early should be based on risk-stratification, considering patient-specific factors such as total bile acid levels and the presence of other complications like excruciating pruritus or preexisting liver disease 1.
- For patients with ICP and total bile acid levels of ≥100 mmol/L, delivery is recommended at 36 weeks of gestation or earlier if symptoms are severe, due to the increased risk of stillbirth 1.
- In cases with lower bile acid levels (<100 mmol/L), delivery can be delayed until 37-39 weeks of gestation, with individualized management based on the patient's condition and preferences 1.
- The use of ursodeoxycholic acid (UDCA) is recommended for treating ICP, as it has been shown to improve pruritus, serum bile acid levels, and outcomes, including reducing the risk of preterm birth and stillbirth 1.
Management Guidelines
- The Society for Maternal-Fetal Medicine recommends delivery at 36 weeks for patients with total bile acid levels of ≥100 mmol/L, while the European Association for the Study of the Liver suggests considering early delivery in patients with bile acids >100 mmol/L due to the increased risk of stillbirth after 35 weeks 1.
- For patients with ICP and total bile acid levels of <100 mmol/L, delivery is recommended between 36 and 39 weeks of gestation, with individualized management based on the patient's condition and preferences 1.
- In all cases, management should be based on shared decision-making, considering the patient's values and preferences, as well as the potential risks and benefits of early delivery 1.
From the Research
Elevated Liver Function Tests (LFTs) and Pregnancy
Elevated LFTs can be an indicator of underlying liver disease or other conditions that may affect the outcome of pregnancy. The following points summarize the relationship between elevated LFTs and pregnancy:
- Elevated LFTs can be a sign of worsening hypertensive disease of pregnancy and adverse outcomes, leading to their inclusion as a diagnostic criterion for severe features of preeclampsia 2
- Abnormal LFTs may indicate liver injury or other conditions, but normal LFTs do not always mean that the liver is normal 3
- Pregnancy-specific disorders, such as pre-eclampsia, are the leading cause of abnormal LFTs during pregnancy, particularly in the third trimester 4
Implications of Elevated LFTs on Pregnancy Outcomes
The implications of elevated LFTs on pregnancy outcomes are:
- Adverse neonatal outcomes in patients with preeclampsia with severe features and above threshold LFTs are driven by earlier gestational age at delivery 2
- Pregnancy-specific disorders, such as pre-eclampsia, can have a significant effect on the outcome of both mother and fetus 4
- Elevated liver enzyme levels can be associated with increased risk of subsequent complications, especially gestational diabetes mellitus 5
Diagnostic Approach to Elevated LFTs during Pregnancy
The diagnostic approach to elevated LFTs during pregnancy involves:
- Distinguishing among the first presentation or exacerbation of chronic liver disease, acute liver disease non-specific to pregnancy, and pregnancy-specific liver disease 6
- Considering the causes and mechanisms underlying elevated LFTs, which can be unclear in up to 30-40% of cases 6
- Looking out for non-alcoholic fatty liver disease, which can be associated with an increased risk of pregnancy complications and abnormal fetal growth 5