Transient postpartum diabetes insipidus associated with HELLP syndrome

Diabetes insipidus in pregnancy has different causes. The association of diabetes insipidus with disturbances of liver function has been reported, however, diabetes insipidus has rarely been reported in HELLP syndrome. We present a 23-year-old primigravida with a singleton gestation complicated by HELLP syndrome who developed postpartum diabetes insipidus. Labor was induced promptly to terminate pregnancy because of intrauterine fetal death and liver dysfunction. 1-deamino-8-D-arginine-vasopressin was administered. Diabetes insipidus and liver dysfunction resolved within 2 weeks. Development of diabetes insipidus may result from increased vasopressinase activity mainly caused by deterioration of liver functions caused by HELLP syndrome. In pregnant women with liver disease as a result of any cause, the development of diabetes insipidus should be assessed with particular attention.     

An unusual cause of neonatal coagulopathy and liver disease.

Congenital thyrotoxicosis is a rare and potentially fatal illness. We report a case in a preterm infant delivered to a mother known to have autoimmune endocrine disease. Diagnosis was difficult because the infant's presenting symptoms and signs closely resembled congenital viral infection with co-existent hepatic dysfunction and coagulopathy. The associated hepatic dysfunction was so severe that liver biopsy was scheduled before the diagnosis emerged. A high degree of clinical suspicion coupled with prenatal identification of pregnancies at risk of complication by congenital thyrotoxicosis is imperative to facilitate prompt diagnosis and treatment.     

Clinical significance of liver dysfunction in pregnancy-induced hypertension

Hepatic dysfunction is one of the frequent manifestations of multisystemic involvement in preeclampsia. This study was conducted to establish the impact of liver dysfunction on maternal and neonatal outcome in women with pregnancy-induced hypertension (PIH). The prevalence of liver dysfunction as determined by an elevated serum glutamic oxalacetic transaminase (SGOT) concentration was 21% in a population of 355 patients with PIH. Liver dysfunction was associated with the presence of severe hypertension, proteinuria, a lower platelet count, and renal compromise (elevated blood urea nitrogen, creatinine, and uric acid serum concentrations). Abdominal pain was also associated with an SGOT elevation. Liver dysfunction was associated with intrauterine growth retardation and prematurity. Furthermore, the association with these neonatal complications was independent from the severity of the hypertension and the presence of proteinuria. Thus, we conclude that liver dysfunction is a frequent complication of PIH and that it is an independent risk factor for maternal and perinatal complications.     

Pregnancies complicated by liver disease and liver dysfunction.

Although liver dysfunction is infrequently seen in pregnancy, it can result in severe maternal and fetal compromise. An unrecognized case of acute fatty liver may result in both maternal and fetal death. Failure to screen for hepatitis B can result in a newborn who will be a hepatitis carrier for life. Because of such consequences, the obstetrician must remain vigilant for signs of liver dysfunction and must understand the pathophysiology of these disorders.     

Peripheral arterial thrombosis induced by chemotherapy in ovarian carcinoma coexisted with endometrial carcinoma

Introduction Most patients with peripheral arterial occlusion have underlying atherosclerosis. Peripheral arterial thrombosis induced by chemotherapy in gynecological malignancies is rare.Case report A 60-year-old woman was diagnosed with ovarian carcinoma coexisting with endometrial carcinoma after surgical histopathological examination. Chemotherapy was started on postoperative day 11. On day 2 of chemotherapy, she developed bilateral lower extremity cyanosis. Thrombocytopenia due to chemotherapy was diagnosed and treated with repeated platelet transfusions. Anticoagulant therapy was also continued. However, the patient worsened steadily and died of liver dysfunction due to multiple liver metastases.Conclusion Although arterial thrombosis induced by chemotherapy is rare, it is important for physicians to consider this possibility in the course of treatment with cytotoxic agents because this complication has serious health implications.     

Diabetes insípida transitoria en gestante con disfunción hepática y embarazo gemelar. Revisión del síndrome polidipsia-poliuria en gestación

Diabetes insipidus (DI) is a rare endocrine complication of pregnancy. Traditionally, DI has been considered to be either central or nephrogenic. However, in pregnancy, a specific type has been described: transient DI or gestational DI. This entity occurs mainly in the third trimester of pregnancy and resolves spontaneously between the first and fourth week after delivery. The physiopathology of gestational DI has a placental origin, with excessive levels of placental vasopressinase leading to excessive catabolism of vasopressin and secondarily to polydipsia-polyuria syndrome in the pregnant woman. Screening for subclinical pregestational DI (central or nephrogenic) or transient gestation is mandatory whenever this entity is suspected clinically. Diagnosis is simple and treatment with desmopressin acetate significantly decreases the maternal and fetal risks of this disease. It is also necessary to exclude other frequently associated disorders (preeclampsia, HELLP syndrome, liver dysfunction) and to carry out close fetal monitoring, because of the risk of intrauterine growth retardation secondary to placental dysfunction.     

Venous Doppler evaluation of the growth-restricted fetus

Evaluation of venous Doppler parameters has significantly contributed to the understanding of the vascular mechanisms that lead to fetal growth restriction (FGR) and subsequent fetal deterioration in the setting of progressive placental dysfunction. Venous redistribution of umbilical venous blood flow away from the fetal liver precedes fetal growth delay. Venous Doppler examination allows adjustment of monitoring intervals in recognition of accelerating fetal deterioration. The timing of delivery in early-onset FGR remains challenging because gestational age has an overriding effect on the neonatal outcome until the late second trimester and randomized trials of specific delivery triggers are lacking.     

血浆置换在妊娠期急性脂肪肝中的应用

妊娠期急性脂肪肝是一种特发于妊娠期凶险的肝功能障碍的并发症。血浆置换是治疗妊娠期急性脂肪肝的一种新手段。本文从血浆置换机制、适用指征、方法及注意事项等方面总结了其在妊娠期急性脂肪肝中的应用,从而提高医护人员的认识。     

Hepatic dysfunction associated with moderate ovarian hyperstimulation syndrome. A case report

BACKGROUND: Liver dysfunction is a rare complication of severe ovarian hyperstimulation syndrome (OHSS). Based on a MEDLINE search from 1966 to September 2000, we report the second case of liver dysfunction associated with moderate OHSS. In addition, this is the first report of moderate OHSS with serum progesterone levels during the first trimester of pregnancy higher than the upper limit of normal for a third-trimester gestation. CASE: A 33-year-old nulligravida with a history of infertility had previously undergone three failed cycles of assisted reproduction. During her fourth attempt at in vitro fertilization and intracytoplasmic sperm injection, she developed moderate OHSS 11 days after embryo transfer. She was managed on an outpatient basis. Her serum progesterone and liver enzyme levels were significantly elevated, as is unusual for the moderate picture of OHSS in this patient. CONCLUSION: Hepatic dysfunction is not limited to the severe forms of OHSS. Liver function should be analyzed even in moderate cases. Further study is needed to understand the role of elevated liver function tests and serum progesterone in the pathogenesis of OHSS.     

Thrombocytopenia in preeclampsia: associated abnormalities and management principles

Severe thrombocytopenia, abnormal liver function, and renal dysfunction may occur as manifestations of preeclampsia. Failure to recognize that this cluster of abnormalities represents a form of preeclampsia may result in erroneous initial diagnoses. Management of 13 such patients has shown a direct correlation between the degree of thrombocytopenia and the measures of liver dysfunction. Platelet counts and liver functions improved prior to delivery in five patients treated with corticosteroids. Management should be directed toward investigation and correction of deranged physiology and appropriate monitoring of maternal-feto-placental status. Early delivery is indicated in patients with progressive thrombocytopenia and in those with evidence of fetal maturity or distress. Provided that the disease process remains stable, consideration should be given in cases of fetal immaturity, to the use of betamethasone therapy. The occurrence of severe thrombocytopenia in 20% of neonates should be a consideration in selecting the mode of delivery.     

Hepatotoxicity during low-dose flutamide treatment for hirsutism

Background. The nonsteroidal antiandrogenic drug flutamide is a safe and generally well-tolerated drug used for the treatment of prostate cancer and female hyperandrogenism.

Case. We describe the case of a 26-year-old girl with amenorrhea and severe hirsutism who was treated with flutamide 250 mg/day and developed liver toxicity during therapy.

Results. Other causes of liver toxicity were appropriately ruled out. The use of the standard Council for International Organization of Medical Sciences (CIOMS) scale and the Maria & Vitorino (M&V) scale indicated a highly probable relationship between the development of liver toxicity and flutamide therapy. Severe liver dysfunction has been rarely documented in women with hirsutism treated with flutamide, even though cases of fulminant liver failure have been described. The mechanisms responsible for the occurrence of hepatotoxicity during treatment with flutamide are unknown, but mitochondrial dysfunction seems to be implicated.

Conclusion. The potential of flutamide to act as a potent hepatotoxin should be kept in mind when treatment with this drug is being planned. This case reminds us that patients who are receiving flutamide should be regularly monitored for liver function. If drug-induced liver injury is suspected, flutamide must be discontinued promptly to avoid progression of liver injury.     

Conservative treatment of liver hematoma in the postpartum period. A report of two cases

Two pregnant women at term had antenatal symptoms of impending preeclampsia (thrombocytopenia, liver dysfunction) and developed clinical signs of a leaking subcapsular liver hematoma in the immediate postpartum period. They were managed conservatively, with blood transfusions and ultrasonic computerized tomographic monitoring of the hematoma. Both did well, and their hospital stays were brief. These cases suggest that immediate celiotomy may not always be necessary for suspected liver hematoma associated with preeclampsia.     

Childbirth and pelvic floor dysfunction: an epidemiologic approach to the assessment of prevention opportunities at delivery

Female pelvic floor dysfunction is integral to the woman's role in the reproductive process, largely because of the unique anatomic features that facilitate vaginal birth and also because of the trauma that can occur during that event. Interventions such as primary elective cesarean delivery have been discussed for the primary prevention of pelvic floor dysfunction; however, existing data about potentially causal factors limit our ability to evaluate such strategies critically. Here we consider the conceptual principles of epidemiologic function and the availability of data that are necessary to make informed recommendations about prevention opportunities for pelvic floor dysfunction at delivery. Available epidemiologic data on pelvic floor dysfunction suggest that there may be substantial opportunities for the primary prevention of pelvic organ prolapse at delivery. Although definitive recommendations await further epidemiologic studies of the potential risk and benefits of obstetric practice change, it is hoped that this discussion will provide a novel, quantitative framework for the assessment of pelvic floor dysfunction prevention opportunities.     

Preeclampsia: a microvesicular fat disease of the liver?

To study the interrelationship between preeclampsia, the syndrome of hemolysis, elevated liver enzymes, and low platelet count, and acute fatty liver of pregnancy, 41 liver specimens from 41 preeclamptic women with and without liver dysfunction were examined for the amount of fat deposited in hepatocytes. All 41 specimens stained with oil red O on frozen sections showed a significant amount of microvesicular fat droplets in varying degrees. In contrast, only 11 of the 41 stained conventionally (with hematoxylin-eosin) showed significant fatty infiltration. The density of hepatocellular fat correlated positively with plasma urate concentration and negatively with the platelet count. These findings suggest that preeclampsia may be one of several microvesicular fatty diseases of the liver and that acute fatty liver of pregnancy may be the most severe form.     

Correlation of Platelet Count Changes with Liver Cell Destruction in Hellp Syndrome

Objective. HELLP syndrome is defined as a subset of preeclampsia involving a combination of hemolysis, low platelets affecting the circulatory system, and elevated liver enzymes, reflecting liver cell destruction. Our objective was to assess the correlation between the platelet count changes and liver cell destruction as indicated by aspartate aminotransferase (AST) levels. Method. We reviewed the records of 15 preeclamptic patients who developed HELLP syndrome as defined by 1) hemolysis, 2) elevated liver enzymes with an AST greater than 70 U/L (>2 SD above mean), and 3) low platelets (<100×10⁹/L). In these patients, both platelet counts and AST were assessed every 4–6 hr before and after delivery until recovery. At least eight laboratory assessments were done on each patient and were available for review. In each patient, the correlation between platelet count and AST levels was done using the Spearman rank order correlation coefficient. Results. A negative correlation was found between platelet count and AST levels. A correlation coefficient of greater than 0.8 occurred in 53% of cases. The correlation coefficient ranged from 0.1 to 0.93. In all cases, improvement of liver cell dysfunction occurred within 4 hr of recovery of platelet count. At 72 hr postpartum, 73% of the platelet counts had not recovered to >150×10⁹/L, and 66% of patients with abnormally elevated AST levels had not returned to <35 U/L. Conclusions. Liver dysfunction and platelet count are poorly correlated in individual cases. This lack of correlation is evident both during decline and recovery of the platelet counts. Changes in platelet count cannot be used as a proxy for liver dysfunction in severe preeclampsia with HELLP syndrome.     

Pregnancy and delivery after liver transplantation: case report

We report a case of successful pregnancy in a 22-year-old primigravida who became pregnant 19 months after orthotopic liver transplantation for end-stage liver dysfunction caused by Wilson disease. The mother continued immunosuppressive therapy (tacrolimus) during the pregnancy. No complications were observed. Labour started spontaneously at 40th week's gestation. As a result the healthy male infant weighing 3900 g was born. Patient and the baby were discharged from hospital, both in good condition, on the fifth day after delivery.     

Umbilical cord gamma-glutamyl transpeptidase and placental dysfunction

Placental dysfunction has been suspected if human placental lactogen level and/or cystine-aminopeptidase activity were lower than 10th centile. Significant rise in gamma-glutamyl transpeptidase (GGTP) has been found in samples of arterial cord blood of newborns born to mothers with placental insufficiency. We observed the relationship between GGTP activity and decrease in cord pH and lower Apgar score of corresponding infants. We suggest that chronic hypoxemia as a consequence of placental dysfunction may result in damage of fetal liver cells.     

Etiology and management of acute fatty liver of pregnancy

Acute fatty liver of pregnancy (AFLP) remains a problem for which there is no discernible cause. Therefore, a precise definition awaits the discovery or elucidation of its exact etiology. AFLP is best described as acute hepatocellular dysfunction that occurs in pregnancy, generally during the third trimester or the early puerperium. It is characterized histopathologically by changes in the liver consistent with microvesicular fatty infiltration but occurring in a pregnant women with no clearly identifiable etiology. Management tenets include prompt delivery and supportive care of the mother.     

Liver dysfunction in ovarian hyperstimulation syndrome. A case report

Ovarian hyperstimulation syndrome (OHS) is one of the potential complications associated with the use of human menopausal gonadotropin therapy. We recently dealt with a case of severe OHS presenting features of liver dysfunction; such a case has not been reported on before.     

不孕症合并代谢综合征患者的非酒精性脂肪肝患病率及临床特点分析

目的:探讨不孕症合并代谢综合征(MS)患者的非酒精性脂肪肝(NAFLD)的患病率及临床特点。方法:选取2003年5月至2010年3月在我院就诊且符合2004年CDS的MS诊断标准的不孕症女性。患者均行糖耐量及胰岛素释放试验、肝脏B超检查及肝脏功能测定。按肝脏B超结果将患者分为无NAFLD组、轻度NAFLD组、中重度NAFLD组,比较3组患者的一般情况、血糖、胰岛素水平、肝功能水平。结果:不孕症合并MS患者的NAFLD患病率为69%。与无NAFLD组比较,轻度NAFLD组和中重度NAFLD组的空腹胰岛素水平、服糖后2h胰岛素水平均显著升高(P0.01,P0.05),HOMA-IR显著增加(P0.01);但中重度NAFLD组与轻度NAFLD组比较,差异均无统计学意义(P0.05)。3组的空腹血糖、服糖后2h血糖及IGT的比例比较,差异均无统计学意义(P0.05),但NAFLD组服糖后2h的血糖中位数达到或接近糖耐量异常标准。无NAFLD组、轻度NAFLD组、中重度NAFLD组的肝功能异常的程度和比例依次增加,差异有统计学意义(P0.05)。结论:不孕症合并MS患者有较高的NAFLD患病率;该类患者合并脂肪肝时糖耐量受损、胰岛素抵抗程度加重。随着NAFLD程度的加重,空腹血糖及胰岛素水平并未发生明显变化,肝功能异常的程度和比例随着NAFLD程度的加重而增高。