Journal of Dr. NTR University of Health Sciences

ORIGINAL ARTICLE
Year
: 2014  |  Volume : 3  |  Issue : 4  |  Page : 231--233

Maternal and fetal outcome in jaundice complicating pregnancy


Morthala Greeshma Reddy, GC Prabhakar, Vijaya Sree 
 Department of Obstetrics and Gynaecology, Mamata Medical College, Khammam, Andhra Pradesh, India

Correspondence Address:
Morthala Greeshma Reddy
H. No. 11-4-22, Nehru Nagar, Wyra Road, Khammam - 507 002, Andhra Pradesh
India

Abstract

Objective: This study is aimed at determining maternal and fetal outcome in women with jaundice complicating pregnancy. Materials and Methods: An analysis of maternal and fetal outcome of 18 pregnant women admitted with jaundice during June 2012 to May 2013. Results: All cases in this study were in their third trimester of pregnancy. Serum bilirubin was >10 mg in 8 (44.4%) cases. In patients with jaundice related to pregnancy serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase and alkaline phosphatase were raised in a majority of them. Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome, acute fatty liver of pregnancy, intrahepatic cholestasis of pregnancy, viral hepatitis, malaria and sickle cell anemia were the causes of jaundice in this study. In this study, HELLP syndrome (33.3%) was the most common cause of jaundice. Of 18 women, 10 (55.6%) of women the onset of labor was spontaneous and 16 (88.9%) delivered vaginally. Perinatal mortality in 6 cases (33.3%) among them 1 (16.6%) stillbirth and 5 (83.3%) intrauterine deaths. 15 (83.3%) women were discharged in improved condition. Maternal mortality in 3 cases (16.66%) 1 case died within 24 h of delivery, 1 on the 4 th postnatal day and 1 on the 8 th postnatal day. Cause of death was acute fatty liver of pregnancy with multiorgan failure with disseminated intravascular coagulation (DIC) with shock in 2 cases, HELLP syndrome with DIC with renal failure in 1 case. Conclusion(s): Jaundice and pregnancy is a deadly combination resulting in a very high perinatal as well as maternal morbidity and mortality, and requires an early diagnosis and careful management.



How to cite this article:
Reddy MG, Prabhakar G C, Sree V. Maternal and fetal outcome in jaundice complicating pregnancy.J NTR Univ Health Sci 2014;3:231-233


How to cite this URL:
Reddy MG, Prabhakar G C, Sree V. Maternal and fetal outcome in jaundice complicating pregnancy. J NTR Univ Health Sci [serial online] 2014 [cited 2020 Aug 13 ];3:231-233
Available from: http://www.jdrntruhs.org/text.asp?2014/3/4/231/146598


Full Text

 INTRODUCTION



Jaundice refers to yellow appearance of skin, sclera and mucous membranes resulting from increased bilirubin concentrations in body fluids. It is usually detectable clinically when plasma bilirubin exceeds 3 mg/dl. Jaundice in pregnancy is caused by the number of causes, some related and some coincidental. Liver disease complicating pregnancy is divided into 3 general categories. First includes those specifically related to pregnancy, examples are hyperemesis gravidarum, intra hepatic cholestasis, acute fatty liver, hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. Second category includes acute hepatic disorders that are coincidental to pregnancy, such as acute viral hepatitis. Third category includes chronic liver diseases. Worldwide, most common cause of jaundice is viral hepatitis. Jaundice in pregnancy is associated with high maternal and perinatal mortality rates. [1]

Objective

This study is aimed at determining maternal and fetal outcome in women with jaundice during pregnancy.

 Materials and METHODS



An analysis of maternal and fetal outcome of 18 pregnant women admitted with jaundice during June 2012 to May 2013.

 RESULTS



During the period from June 2012 to May 2013, 18 pregnant women were admitted with jaundice. All cases in this study were in their third trimester of pregnancy. 9 (50%) cases were in the age group 15-20 years [Table 1]. All cases presented with icterus at the time of admission [Table 2]. 11 (61.1%) cases were primigravidas [Table 3]. HELLP syndrome was the most common cause of jaundice [Table 4]. Serum bilirubin was >10 mg in 8 (44.4%) cases. In patients with jaundice related to pregnancy serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase and alkaline phosphatase were raised in a majority of them. HELLP syndrome, acute fatty liver of pregnancy, intrahepatic cholestasis of pregnancy, viral hepatitis, malaria and sickle cell anemia were the causes of jaundice in this study. In this study, HELLP syndrome was the most common cause of jaundice.{Table 1}{Table 2}{Table 3}{Table 4}

Pregnancy outcome

Of 18 women, in 10 (55.6%) cases onset of labor was spontaneous. 16 (88.9%) delivered vaginally. 15 (83.3%) of women were discharged in improved condition. Maternal mortality in 3 (16.66%) cases, of this 1 case died within 24 h of delivery, 1 on the 4 th postnatal day and 1 on 8 th postnatal day. Cause of death was acute fatty liver of pregnancy with multiorgan failure with disseminated intravascular coagulation (DIC) with shock in 2 cases, HELLP syndrome with DIC with renal failure in 1 case. Among the 4 cases of acute fatty liver of pregnancy, maternal mortality was in 2 cases (50%). Maternal morbidity was most common in women with acute fatty liver of pregnancy and HELLP syndrome. DIC was complication in 6 (33.3%) cases, preeclampsia in 8 (44.4%) cases, eclampsia in 5 (27.7%) cases, postpartum hemorrhage in 4 (22.2%) cases and acute renal failure in 3 (16.7%) of cases [Table 5].{Table 5}

Fetal outcome

Perinatal mortality in 6 (33.3%) cases among them 1 (16.7%) stillbirth and 5 (83.3%) intrauterine deaths. Perinatal mortality in HELLP syndrome was 50%, acute fatty liver of pregnancy 50%.

 DISCUSSION



The incidence of jaundice in India varies from 0.4 to 0.9/1000 deliveries. Jaundice in pregnancy is associated with high maternal and perinatal mortality rates.

Hemolysis, elevated liver enzymes, low platelets syndrome is present in 3-10% of preeclamptic toxemia. It is associated with weight gain and edema in 60%, maternal mortality of 20%, DIC in 4-38%, neonatal mortality rate of 31% and rupture and hematoma of the liver in 2%. [2] In this study, 6 women (33.3%) the jaundice was due to HELLP syndrome of whom 1 died; 3 had intra uterine deaths.

Acute fatty liver during pregnancy usually occurs in the 3 rd trimester. Preeclampsia is associated in 50-100% of cases. There is moderately increased liver enzyme level of <1000 IU/mL, bilirubin level of 1-10 mg% and hypoglycemia. The maternal mortality is 18% while preterm labor is increased and the perinatal mortality is 23%. [2] In this study, four cases of acute fatty liver (22.2%), half of them had preeclampsia. In this study, all 4 cases were primigravida, among them 1 case was twin gestation and 50% had preeclampsia. In this study, maternal mortality in 2 (50%) cases of women with acute fatty liver of pregnancy and perinatal mortality in 3 (50%) cases.

Jaundice in pregnancy is associated with high maternal and perinatal mortality rates. In the present study jaundice in pregnancy accounted for perinatal mortality in 6 (33.3%) cases. High perinatal mortality rate of 45.45% was observed by Singh et al. [3] In this study, jaundice in pregnancy accounted for maternal mortality in 3 (16.6%) cases. Various studies also report jaundice as one of the major cause of maternal death, responsible for 5-30% of all maternal deaths [2],[4],[5],[6],[7],[8] [Table 6]. Hepatorenal failure, encephalopathy, DIC and postpartum hemorrhage were responsible for the maternal deaths.{Table 6}

The factors responsible for high maternal mortality in our country were poor nutrition, prevalence of anemia, delay in seeking medical advice and delay in referral to the hospital. Many of the patients when brought to the hospital are already in moribund condition and often, do not respond to treatment. Jaundice and pregnancy is a deadly combination resulting in a very high perinatal as well as maternal morbidity and mortality and requires an early diagnosis and careful management.[9]

References

1Cunningham G, Leveno KJ, Bloom SL, Hauth JC, Rouse DW, Spong CY. Hepatic, gallbladder, and pancreatic disorders. Williams Obstetrics. 23 rd ed. McGraw Hill, New York; 2010. p. 1063.
2Bera SK, Sen Gupta A. A 12 years study of maternal deaths in Eden hospital. J Obstet Gynecol India 1992;42:182-8.
3Singh S, Chauhan R, Patel RS. Jaundice in pregnancy. J Obstet Gynecol India 1991;41:187-9.
4Kamalajayaram V, Rama Devi A. A study of maternal mortality in jaundice. J Obstet Gynecol India 1988;38:439-41.
5Roncaglia N, Trio D, Roffi L, Ciarla I, Tampieri A, Scian A, et al. Intrahepatic cholestasis in pregnancy: Incidence, clinical course, complications. Ann Ostet Ginecol Med Perinat 1991;112:146-51.
6Rao KB, Rudra G. Hepatitis in pregnancy. In: Krishna U, Tank DK, Daftary S, editors. Pregnancy at Risk; Current Concepts. 4 th ed. Delhi: Japee Publication; 2001. p. 128-31.
7Roychowdhary G, Ganju V, Dewan R. Review of maternal mortality over nine year period at Safdarjang Hospital, New Delhi. J Obstet Gynecol India 1990;40:84-8.
8Sapre S, Joshi V. Changing trends of maternal mortality rate in last 26 years at a apex level teaching hospital in Northern Madhya Pradesh. J Obstet Gynecol India 1999;49:53-6.
9Trivedi SS, Goyal U, Gupta U. A study of maternal mortality due to viral hepatitis. J Obstet Gynecol India 2003;53:551-3.