Acute Cholecystitis

Despite the cholestatic effect of estrogen and impaired gallbladder emptying, there is no proved increased incidence of acute cholecystitis or common duct obstruction during gestation. Cholecystectomy is performed in 1 per 1000 to 3000 pregnancies. Clinical presentation generally does not differ from that in nonpregnant individuals. During late gestation, however, cholecystitis can be confused with the right upper quadrant pain that often accompanies preeclampsia. Acute appendicitis during pregnancy may also present with right upper quadrant pain. The presence of gallstones can usually be established with ultrasonography.

Initial management, even when pancreatitis is present, should be conservative. Surgery should be reserved for cases in which there is suspicion of perforation, failure to respond to medical therapy within 4 to 5 days, persistent obstructive jaundice, or repeated attacks of biliary colic, and for patients in whom other acute surgical abdominal diseases (e.g., acute appendicitis) cannot be ruled out.

Acute Fatty Liver of Pregnancy

Acute fatty liver of pregnancy (AFLP) is a relatively uncommon disease of unknown cause. In the past, maternal and fetal mortality rates had been reported to be as high as 85%. At present, early detection, rapid delivery following diagnosis, and aggressive supportive care have reduced maternal and fetal mortality to less than 20%.

The obstetric history of a patient with AFLP parallels preeclampsia. The disease presents during the third trimester, with the mean gestational age at onset of 36 weeks. The incidence of AFLP is highest in primiparas and women with multiple gestations.

Initial manifestations are sudden but nonspecific. Nausea, vomiting, and abdominal pain are the most common presenting complaints. Jaundice often follows these nonspecific symptoms. If untreated, the disease typically progresses to hepatic failure, disseminated intravascular coagulation, renal failure, gastrointestinal or uterine bleeding, pancreatitis, seizures, coma, and/or death.

Transaminases are typically elevated in the range of 300 to 500 units. Levels above 1000 units suggest fulminant hepatitis. Serum bilirubin may be normal early in the course of AFLP, but it rises if pregnancy is not terminated. Hematologic abnormalities include leukocytosis, microangiopathic hemolytic anemia, and thrombocytopenia. Hypoglycemia is common and may be profound. Liver biopsy is usually diagnostic and characterized by the accumulation of microvesicular fat within hepatocytes, but may not be appropriate to perform in the presence of significant coagulopathy.

AFLP is managed by immediate delivery and intensive medical support. Despite appropriate care, the patient's condition may deteriorate further postpartum. Survivors have no long-term sequelae and liver histologic condition returns to normal. Liver transplantation has been successful in women with fulminant hepatic failure whose condition did not improve. In subsequent pregnancies, AFLP does not appear to recur.