AM report pearls 4/14: liver disease in pregnancy / HSV hepatitis!

Take-home pearl (thanks Jen!): pregnancy is a relatively immunocompromised state. In the post-partum period, think about immune reconstitution syndrome! See the attached CID review article from Jen on this! Also here: http://www.ncbi.nlm.nih.gov/pubmed/17918082

 

And one other take-home pearl (thanks Harry!): +HSV PCR in CSF in the absence of inflammatory CSF makes the diagnosis of HSV meningitis unlikely!

 

Liver disease in pregnancy: see attached article from Hepatology 2008! Also here: http://www.ncbi.nlm.nih.gov/pubmed/18265410

  • Great table from the article below. One approach to thinking about liver disease in pregnancy is: 1) is it coincidental to pregnancy? 2) Underlying liver disease? 3) Unique to pregnancy?
  • A bit more on HELLP (hemolysis, elevated liver enzymes, low platelets):
    • A complication of severe preeclampsia
    • Often in multiparous women
    • Often have HA, RUQ pain, n/v
    • Treatment = immediate deliver, high dose magnesium
    • Course: Most patients have rapid, early resolution of HELLP after delivery with normalization of platelets by 5 days.
      • Persistence beyond this is an indication fo specific treatment – eg plasmapheresis, antithrombotic agents, steroids, plasma exchange with FFP (though none have clinical trial data)
    • Complications include DIC, seizures, ARF, ARDS, severe ascites, liver failure, liver rupture (!)
  • A bit more on acute fatty liver of pregnancy
    • Microvesicular fatty infiltration – can range from asymptomatic to fulminant liver failure!
    • High perinatal and maternal mortality, requires early dx and tx!
    • Often in nulliparous women, with increased risk in twin pregnancies
    • Similar sxs to HELLP, can also have jaundice. There is some overlap with HELLP.
    • AST/ALT usually 300-500 range but can vary from near normal to 1000! Also see normocytic anemia, high WBC, nl/low plts, coagulopathy, acidosis, hypoglycemia, hyperammonemia
    • Treatment = immediate delivery (there are no reports of recovery before delivery!), intensive supportive care
    • Course: Most patients improve by 2-3d after delivery, though can take 1-4 weeks to fully resolve
  • Lastly, a note on HSV and acute liver failure – some good articles on pubmed on this, esp reported in pregnant women! Here is one review article on HSV sepsis and ALF: http://www.ncbi.nlm.nih.gov/pubmed/19930315 (attached)
    • At risk populations: patients on immunosuppressive meds (chemo, post-transplant), HIV, pregnancy esp in 3rd trimester
    • severe clinical course, mortality up to 75%
    • Accounts for 1% of all ALF
    • Start empiric ACV in ALF of unknown etiology!

 

 

See this old blog post about HLH!

And this one on acute liver failure

 

Evernote: https://www.evernote.com/shard/s34/sh/50abe8ac-c023-4f4a-983b-8912d61d9894/baf87fba30d7b63f08816ed89269fb4b

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