Pregnancy-specific liver disease: ICP, HELLP and acute fatty liver
Reading LFTs in pregnancy (placental ALP, low albumin, any ALT rise is abnormal), sorting liver disease by trimester, intrahepatic cholestasis with RCOG 2022 bile acid bands and timing of birth, HELLP versus acute fatty liver (Swansea criteria, hypoglycaemia, coagulopathy, delivery and neonatal LCHAD testing), and the non-obstetric causes not to miss.
Tier 2Condition
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- Liver tests in pregnancy: ALP rises (placenta) and albumin falls. ALT, AST, GGT and bilirubin do not rise, so any raised ALT is abnormal. The physiology is in liver function tests.
- Three conditions are unique to pregnancy and turn on gestation:
- Hyperemesis gravidarum: first trimester, see hyperemesis.
- Intrahepatic cholestasis (ICP): itch from late second trimester. Common, usually benign for the mother, linked to stillbirth only when bile acids are very high.
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Sources
- Intrahepatic cholestasis of pregnancy: Green-top Guideline No. 43, June 2022Girling J, Knight CL, Chappell L; Royal College of Obstetricians and Gynaecologists. BJOG 2022;129(13):e95-e114, 3rd edition, August 2022 (current; review due 2026, no update found November 2026)
- Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancyLee RH et al. Am J Obstet Gynecol 2021;224(2):B2-9, 2021 (current)
- EASL Clinical Practice Guidelines on the management of liver diseases in pregnancyEuropean Association for the Study of the Liver. J Hepatol 2023;79:768-828, 2023
- Reproductive health and liver disease: practice guidance by the American Association for the Study of Liver DiseasesSarkar M et al. Hepatology 2021;73:318-65, 2021
- SOMANZ Hypertension in Pregnancy Guideline 2023 (HELLP)AU/NZSociety of Obstetric Medicine of Australia and New Zealand, 2023
- Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analysesOvadia C et al. Lancet 2019;393:899-909, 2019
- Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES)Chappell LC et al. Lancet 2019;394:849-60, 2019
- Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysisOvadia C et al. Lancet Gastroenterol Hepatol 2021;6:547-58, 2021
- Prospective study of liver dysfunction in pregnancy in Southwest Wales (Swansea criteria)Ch'ng CL et al. Gut 2002;51:876-80, 2002
- The latest on intrahepatic cholestasis of pregnancy: update 2026Jurk S, Kremer A, Schleussner E. Geburtshilfe Frauenheilkd 2026;86(6):528-37, 2026
- Last updated
- 14 November 2026
What changed
- 14 November 2026 Turnstile bot check on sign-in and signed-out feedback