In acute fatty liver, HELLP syndrome deliver the patient immediately otherwise you will lose the mother as well

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 PSSLD Conference Proceedings-III

In acute fatty liver, HELLP syndrome deliver
the patient immediately otherwise you
will lose the mother as well

Long gestational period after onset of coma
is dangerous for the mother

ISLAMABAD: Dr. Arif Amir Nawaz along with Prof. Rizwan Chaudhry, Prof. Jiang, Dr. Bushra Ali and others were the members of the expert’s panel during the workshop on Liver diseases in pregnancy organized during the Pakistan Society for Study of Liver Diseases conference held at Islamabad recently. During the discussion challenges in liver diseases in pregnancy were highlighted. It was stated that the patient may go into PPH or Hepatic coma. These patients need support of gastroenterologists. Importance of physical examination and ultrasound test was also emphasized.

Dr. Bushra talked about pathophysiology. HEV is most common during pregnancy. She also referred to fulminant hepatic failure and pregnancy, HELLP syndrome. Prof. Jiang pointed out that Hepatitis E is not common in China. Fetal mortality is between 40-77%. Do not give too much importance to GD but be careful of Spidor angiomas in physical examination. Acute fatty liver disease can be seen in pregnancy related to liver diseases. However in case of pre-existing liver disease during pregnancy, the patient may suffer from cirrhosis and portal hypertension or auto immune liver disease. In case of co-incidental liver disease during pregnancy the patient can suffer from acute viral hepatitis, gall stones and biliary disease. Fetal mortality, it was reiterated was very high in such cases. There is 60-70% risk of recurrence in later pregnancies.

Acute fatty liver of pregnancy is very rare. About 2.4% of these patients will develop HCC during one year. Development of HCC after one year use of DAA was noted. It was also pointed out that we can easily miss acute liver failure. In case of acute liver failure during third trimester one should terminate the pregnancy and save the patient. It is also important to exclude other diseases. Clinical condition of the patient should be looked into and in case of coagulopathy, one can go ahead and deliver the baby adopting an aggressive approach. Monitor the patient for fifteen days after delivery.

Discussing another case, it was pointed out that cholangitis was an emergency. One can put the stent and the patient can be saved. In case of Hepatitis-E, IGM test should be done. Make the diagnosis quickly. HCV core antigen test report can be ready within two hours while PCR report will take seven to ten days. It was also important that the report should be taken from a standard laboratory. You need to suspect it to diagnose it as it was a very rare disease. In this case there was an intrauterine fetal demise at 29 weeks. Virus serology test was done, Hepatitis IGM E test was positive.

In management, the patient will need supportive care for liver failure. One has to decide about induction of labour, C. Section. Good ICU support is important. Correction of coagulopathy is important if any intervention is planned. One also has to think should the dead fetus be delivered as soon as possible but if the things are improving, the patient should not be delivered. In case of acute fatty live and HELLP syndrome deliver the patient immediately otherwise you will lose the mother as well. Hepatitis E is a different area and it is a problem. Liver transplant in pregnancy is done overseas and the patient do well. In case of emergency, do cesarean section but if there is no emergency, one can wait for twenty four hours and think whether to deliver or not and how to deliver? Early delivery ensures better survival. Long gestational period after onset of coma is dangerous for the mother.

In acute hepatitis E, supportive treatment, early delivery is safe. One should not forget the patient, monitor the patient for few days. Do not give these patients Paracetamol, let them be in pain for some time, otherwise they will die. In acute hepatic failure, chronic hepatitis B should be treated. Do not give Ribavirin in pregnancy as it is contra indicated. In case of severe disease, start treatment. Baby should get active and passive vaccine. Mothers suffering from HBV can do breast feeding. In case of Hepatitis- C mild form, do not start treatment. It is also not a contra indication for breast feeding. Transmission risk is low but advise the patient not to become pregnant during treatment which should consist of SOF plus DECLA. However, if pregnancy is noted, stop treatment and carry on with the pregnancy. Prof. Jiang also informed the participants that China has approved a vaccine for Hepatitis-E. For prevention, one should use clean, boiled water, ensure better sanitation and use thoroughly cooked food.

Prof. Saeed Khokhar along with Prof. Saeed Hamid chaired the next free paper session. The topics discussed in this session included HBV elimination in China by Jia, When to stop the NUCs in CHB by Prof.Jiang, HBV, HDV and co infections in Pakistan by Prof. Zaigham Abbas.

Dr. Subhash Gupta from India talked about HCC: Resection vs. Liver Transplant. He pointed out that liver transplant programme in India started in April 1996 which became popular after HCC. It is important to reduce recurrence of infection for the success of liver transplant programme. He then talked about down staging the therapy and said that at present their Living Donor Liver Transplant mortality was less than 0.1%. Our complications have also reduced considerably during the last eight hundred cases as compared to the first six hundred cases. He was of the view that in case of HCC, we should not give up early. He also discussed the criteria for transplant in HCC in detail. Resection should precede transplantation when possible. Replying to a question he said that ablation was limited as compared to resection.

Speaking in the next session on Autoimmune Hepatitis – what is the new treatment, Dr. Amna Subhan said that early identification was important and we still have to learn a lot about it. Brig. Farrukh Saeed discussed treatment options for adult Cholestatic Liver Disease. Treatment has to be for a longer period with steroids. He also briefly referred to drug induced liver disease and its diagnosis is exclusion of the disease. The patient starts improving as soon as the drug is withdrawn, he added. Prof. A. Durrani‘s presentation was on Wilson’s Disease: Challenges in its management. He pointed out that families and siblings are affected. It has lot of morbidity and mortality. It is diagnosed between 5-35 years of age. Children are diagnosed by family screening. Treatment goal is to reverse copper overload. He also discussed the various treatment options in this condition. Zinc is used to induce negative copper balance. Problems with chelation therapy, early miscarriage were also discussed. Zinc is safe therapy in pregnancy but the diagnosis can be missed, he remarked.

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