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Gastroenterologie up2date 2022; 18(02): 115-133
DOI: 10.1055/a-1543-1661
Leber/Galle/Pankreas

Hepatologische Erkrankungen in der Schwangerschaft

Lars Brodowski
,
Vincent Zimmer
,
Constantin von Kaisenberg
,
Peter Hillemanns
,
Frank Lammert
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Lebererkrankungen komplizieren etwa 5% aller Schwangerschaften. Da neben maternalen insbesondere fetale Komplikationen auftreten können, erfordern diese eine kompetente hepatologische Betreuung in enger interdisziplinärer Kooperation mit dem Geburtshelfer. Der Artikel stellt die schwangerschaftsspezifischen Lebererkrankungen, die klinisch relevanten Aspekte koinzidenter und präexistenter Lebererkrankungen sowie die Besonderheiten im Rahmen der Schwangerschaft zusammen.
Kernaussagen

  • Bei epigastrischen Schmerzen, Übelkeit, Erbrechen oder Pruritus ohne Exanthem in der Schwangerschaft kann eine spezifische Lebererkrankung vorliegen.

  • Bei rechtsseitigen Oberbauchschmerzen sollte in der Schwangerschaft an ein HELLP-Syndrom (Hemolysis – elevated Liver Enzymes – low Platelets) gedacht und eine unverzügliche laborchemische Abklärung durchgeführt werden. Eine nicht diagnostizierte Lebererkrankung kann für Mutter und Kind fatale Konsequenzen haben.

  • Im Rahmen einer Präeklampsie kommt es bei 20% der Patientinnen zu einer Leberbeteiligung, die einen schwerwiegenden Präeklampsieverlauf mit erhöhter perinataler Morbidität und Mortalität anzeigt.

  • Lebererkrankungen in der Schwangerschaft können Indikatoren anderer Leber-, Gallenwegs- und Stoffwechselerkrankungen sein (Beispiele: intrahepatische Schwangerschaftscholestase [ICP], akute Schwangerschaftsfettleber [AFLP]).

  • Bei HBsAg-positiven Schwangeren mit einer Viruslast > 106 Kopien/ml (> 200 000 IU/ml) sollte zwischen SSW 24 und 28 eine antivirale Therapie mit Tenofovir zur Transmissionsprophylaxe eingeleitet werden.

Schlüsselwörter

Eklampsie - HELLP-Syndrom - Nukleotidanalogon - Schwangerschaftscholestase - Schwangerschaftsfettleber - Ursodeoxycholsäure - Virushepatitis


Publication History

Article published online:
01 July 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
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  • Literatur

  • 1 Schutt VA, Minuk GY. Liver diseases unique to pregnancy. Best Pract Res Clin Gastroenterol 2007; 21: 771-792
    CrossrefPubMedSearch in Google Scholar
  • 2 Joshi D, James A, Quaglia A. et al. Liver disease in pregnancy. Lancet 2010; 375: 594-605
    CrossrefPubMedSearch in Google Scholar
  • 3 Duraiswamy S, Sheffield J, McIntire D. et al. The change in etiology of hyperbilirubinemia in pregnancy over the last 35 years. Hepatology 2012; 56: 550A
    PubMedSearch in Google Scholar
  • 4 Pusl T, Beuers U. Intrahepatic cholestasis of pregnancy. Orphanet J Rare Dis 2007; 2: 26
    CrossrefPubMedSearch in Google Scholar
  • 5 Mullenbach R, Linton KJ, Wiltshire S. et al. ABCB4 gene sequence variation in women with intrahepatic cholestasis of pregnancy. J Med Genet 2003; 40: e70
    CrossrefPubMedSearch in Google Scholar
  • 6 Dixon PH, van Mil SW, Chambers J. et al. Contribution of variant alleles of ABCB11 to susceptibility to intrahepatic cholestasis of pregnancy. Gut 2009; 58: 537-544
    CrossrefPubMedSearch in Google Scholar
  • 7 Van Mil SW, Milona A, Dixon PH. et al. Functional variants of the central bile acid sensor FXR identified in intrahepatic cholestasis of pregnancy. Gastroenterology 2007; 133: 507-516
    CrossrefPubMedSearch in Google Scholar
  • 8 Reyes H, Sjovall J. Bile acids and progesterone metabolites in intrahepatic cholestasis of pregnancy. Ann Med 2000; 32: 94-106
    CrossrefPubMedSearch in Google Scholar
  • 9 Debry P, Nash EA, Neklason DW. et al. Role of multidrug resistance P-glycoproteins in cholesterol esterification. J Biol Chem 1997; 272: 1026-1031
    CrossrefPubMedSearch in Google Scholar
  • 10 Zimmer V, Mullenbach R, Simon E. et al. Combined functional variants of hepatobiliary transporters and FXR aggravate intrahepatic cholestasis of pregnancy. Liver Int 2009; 29: 1286-1288
    CrossrefPubMedSearch in Google Scholar
  • 11 Ropponen A, Sund R, Riikonen S. et al. Intrahepatic cholestasis of pregnancy as an indicator of liver and biliary diseases: a population-based study. Hepatology 2006; 43: 723-728
    CrossrefPubMedSearch in Google Scholar
  • 12 Locatelli A, Roncaglia N, Arreghini A. et al. Hepatitis C virus infection is associated with a higher incidence of cholestasis of pregnancy. Br J Obstet Gynaecol 1999; 106: 498-500
    CrossrefPubMedSearch in Google Scholar
  • 13 Ziol M, Barbu V, Rosmorduc O. et al. ABCB4 heterozygous gene mutations associated with fibrosing cholestatic liver disease in adults. Gastroenterology 2008; 135: 131-141
    CrossrefPubMedSearch in Google Scholar
  • 14 Glantz A, Marschall HU, Mattsson LA. Intrahepatic cholestasis of pregnancy: Relationships between bile acid levels and fetal complication rates. Hepatology 2004; 40: 467-474
    CrossrefPubMedSearch in Google Scholar
  • 15 EASL Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol 2009; 51: 237-267
    CrossrefPubMedSearch in Google Scholar
  • 16 Bacq Y, Sentilhes L, Reyes HB. et al. Efficacy of Ursodeoxycholic Acid in Treating Intrahepatic Cholestasis of Pregnancy: A Meta-analysis. Gastroenterology 2012; 143: 1492-1501
    CrossrefPubMedSearch in Google Scholar
  • 17 Chappell LC, Gurung V, Seed PT. et al. Ursodeoxycholic acid versus placebo, and early term delivery versus expectant management, in women with intrahepatic cholestasis of pregnancy: semifactorial randomised clinical trial. BMJ 2012; 344: e3799
    CrossrefPubMedSearch in Google Scholar
  • 18 Beuers U. Drug insight: Mechanisms and sites of action of ursodeoxycholic acid in cholestasis. Nat Clin Pract Gastroenterol Hepatol 2006; 3: 318-328
    CrossrefPubMedSearch in Google Scholar
  • 19 Hague WM, Callaway L, Chambers L. et al. A multi-centre, open label, randomised, parallel-group, superiority Trial to compare the efficacy of URsodeoxycholic acid with RIFampicin in the management of women with severe early onset Intrahepatic Cholestasis of pregnancy: the TURRIFIC randomised trial. BMC Pregnancy Childbirth 2021; 21: 51
    CrossrefPubMedSearch in Google Scholar
  • 20 Ibdah JA. Acute fatty liver of pregnancy: an update on pathogenesis and clinical implications. World J Gastroenterol 2006; 12: 7397-7404
    Search in Google Scholar
  • 21 Ibdah JA. Role of genetic screening in identifying susceptibility to acute fatty liver of pregnancy. Nat Clin Pract Gastroenterol Hepatol 2005; 2: 494-495
    CrossrefPubMedSearch in Google Scholar
  • 22 Van Dyke R. The Liver in Pregnancy. In: Zakim D, Boyer TD. eds. Hepatology. A textbook of Liver Disease. Philadelphia: Saunders; 2002: 1591-1616
    Search in Google Scholar
  • 23 Sandhu BS, Sanyal AJ. Pregnancy and liver disease. Gastroenterol Clin North Am 2003; 32: 407-436 ix
    CrossrefPubMedSearch in Google Scholar
  • 24 Abildgaard U, Heimdal K. Pathogenesis of the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP): a review. Eur J Obstet Gynecol Reprod Biol 2013; 166: 117-123
    CrossrefPubMedSearch in Google Scholar
  • 25 Clark EA, Silver RM, Branch DW. Do antiphospholipid antibodies cause preeclampsia and HELLP syndrome?. Curr Rheumatol Rep 2007; 9: 219-225
    CrossrefPubMedSearch in Google Scholar
  • 26 Tallarek AC, Stepan H. [Preeclampsia and HELLP syndrome as an obstetric emergency]. Med Klin Intensivmed Notfmed 2012; 107: 96-100
    PubMedSearch in Google Scholar
  • 27 Rath W, Fischer T, Klockenbusch W. Diagnostik und Therapie hypertensiver Schwangerschaftserkrankungen. Leitlinie der Arbeitsgemeinschaft Schwangerschaftshochdruck/Gestose der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe e.V. (DGGG). AWMF-Leitlinien-Register Nr. 015/018. letzte Aktualisierung 05/2008.
    PubMed
  • 28 Ismail SK, Kenny L. Review on hyperemesis gravidarum. Best Pract Res Clin Gastroenterol 2007; 21: 755-769
    CrossrefPubMedSearch in Google Scholar
  • 29 Hay JE. Liver disease in pregnancy. Hepatology 2008; 47: 1067-1076
    Search in Google Scholar
  • 30 Elinav E, Ben-Dov IZ, Shapira Y. et al. Acute hepatitis A infection in pregnancy is associated with high rates of gestational complications and preterm labor. Gastroenterology 2006; 130: 1129-1134
    CrossrefPubMedSearch in Google Scholar
  • 31 Kumar A, Beniwal M, Kar P. et al. Hepatitis E in pregnancy. Int J Gynaecol Obstet 2004; 85: 240-244
    CrossrefPubMedSearch in Google Scholar
  • 32 Cornberg M, Protzer U, Petersen J. et al. Prophylaxis, diagnosis and therapy of hepatitis B virus infection – the German guideline. Z Gastroenterol 2011; 49: 871-930
    PubMedSearch in Google Scholar
  • 33 Shepard CW, Simard EP, Finelli L. et al. Hepatitis B virus infection: epidemiology and vaccination. Epidemiol Rev 2006; 28: 112-125
    CrossrefPubMedSearch in Google Scholar
  • 34 Wiseman E, Fraser MA, Holden S. et al. Perinatal transmission of hepatitis B virus: an Australian experience. Med J Aust 2009; 190: 489-492
    CrossrefPubMedSearch in Google Scholar
  • 35 ter Borg MJ, Leemans WF, de Man RA. et al. Exacerbation of chronic hepatitis B infection after delivery. J Viral Hepat 2008; 15: 37-41
    PubMedSearch in Google Scholar
  • 36 Han GR, Cao MK, Zhao W. et al. A prospective and open-label study for the efficacy and safety of telbivudine in pregnancy for the prevention of perinatal transmission of hepatitis B virus infection. J Hepatol 2011; 55: 1215-1221
    CrossrefPubMedSearch in Google Scholar
  • 37 Brown Jr RS, Verna EC, Pereira MR. et al. Hepatitis B virus and human immunodeficiency virus drugs in pregnancy: findings from the Antiretroviral Pregnancy Registry. J Hepatol 2012; 57: 953-959
    CrossrefPubMedSearch in Google Scholar
  • 38 EASL Clinical Practice Guidelines: management of hepatitis C virus infection. J Hepatol 2011; 55: 245-264
    CrossrefPubMedSearch in Google Scholar
  • 39 Zanetti AR, Tanzi E, Newell ML. Mother-to-infant transmission of hepatitis C virus. J Hepatol 1999; 31 Suppl 1: 96-100
    CrossrefPubMedSearch in Google Scholar
  • 40 Sarrazin C, Berg T, Ross RS. et al. [Prophylaxis, diagnosis and therapy of hepatitis C virus (HCV) infection: the German guidelines on the management of HCV infection]. Z Gastroenterol 2010; 48: 289-351
    PubMedSearch in Google Scholar
  • 41 Conte D, Fraquelli M, Prati D. et al. Prevalence and clinical course of chronic hepatitis C virus (HCV) infection and rate of HCV vertical transmission in a cohort of 15,250 pregnant women. Hepatology 2000; 31: 751-755
    CrossrefPubMedSearch in Google Scholar
  • 42 Schramm C, Herkel J, Beuers U. et al. Pregnancy in autoimmune hepatitis: outcome and risk factors. Am J Gastroenterol 2006; 101: 556-560
    CrossrefPubMedSearch in Google Scholar
  • 43 Westbrook RH, Yeoman AD, Kriese S. et al. Outcomes of pregnancy in women with autoimmune hepatitis. J Autoimmun 2012; 38: J239-J244
    CrossrefPubMedSearch in Google Scholar
  • 44 Beuers U, Wiedmann KH, Kleber G. et al. Therapy of autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis. Consensus of the German Society of Digestive System and Metabolic Diseases. Z Gastroenterol 1997; 35: 1041-1049
    PubMedSearch in Google Scholar
  • 45 Hoffmann JC, Preiss JC, Autschbach F. et al. Clinical practice guideline on diagnosis and treatment of Crohnʼs disease. Z Gastroenterol 2008; 46: 1094-1146
    PubMedSearch in Google Scholar
  • 46 Lammert F, Rath W. Lebererkrankungen. In: Kainer FK. Hrsg. Facharzt Geburtsmedizin. 2. Aufl.. München: Urban & Fischer; 2011: 498-526
    Search in Google Scholar
  • 47 Ko CW, Beresford SA, Schulte SJ. et al. Incidence, natural history, and risk factors for biliary sludge and stones during pregnancy. Hepatology 2005; 41: 359-365
    CrossrefPubMedSearch in Google Scholar
  • 48 Gutt C, Jenssen C, Barreiros AP. et al. Aktualisierte S3-Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) zur Prävention, Diagnostik und Behandlung von Gallensteinen. Z Gastroenterol 2018; 56: 912-966
    Thieme ConnectPubMedSearch in Google Scholar
  • 49 Ovadia C, Seed PT, Sklavounos A. et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet 2019; 393: 899-909
    CrossrefPubMedSearch in Google Scholar
  • 50 Di Mascio D, Quist-Nelson J, Riegel M. et al. Perinatal death by bile acid levels in intrahepatic cholestasis of pregnancy: a systematic review. J Matern Fetal Neonatal Med 2021; 34: 3614-3622
    CrossrefPubMedSearch in Google Scholar