A9 month old pregnant lady presents with Jaundice and distension, pedal edema after delivering normal baby. Her clinical condition deteriorates with increasing abdominal distension and severe ascites. Her bilirubin is 5 mg/dl, S. alkaline phosphatase was 450 u/L and ALT (345 Iu). There is tender hepatomegaly 6 cm below costal margin and ascitic fluid shw protein less than 2 mg%. Diagnosis is

Budd chiari syndrome The most common cause of an acute severe livery injury in a young pregnant women are - Viral hepatitis (HAV, HBV) - Eclampsia, preeclampsia (HELLP syndrome) - Acute fatty liver of pregnancy - Budd chiary syndrome Let us discuss the options Preeclampsia and Eclampsia - It is the most common cause of abnormal liver chemistry test in women. Liver enzyme tests are only mildly abnormal in patients with liver diseases. Aminotransferases are modestly elevated. Alkaline phosphatase is subtantially increased But in these cases delivery of the fetus is followed by rapid normalization of the hepatic abnormalities. Moreover there is no mention of history of P.I.H, hemolysis and thrombocytopenia (HELLP syndrome) Acute Fatty liver of pregnancy Acute fatty liver develops after 34th week of pregnancy Jaundice develops a few days after the onset, the serum bilirubin is rarely above 10 mg/dl. Alkaline phosphate is markedly elevated. Aminotransferases are moderately elevated. A markedly raised serum ammonia is the most diagnostic finding in establishing the diagnosis of acute fatty liver-of pregnancy Fulminant hepatic failure The patient presents with features of severe acute hepatitis leading to the development of hepatic encephalopathy within 8 weeks of onset. The bilirubin increases to 20-30 mg/d1. The aminotransferase levels are very high (> 1000) alkaline phosphatase moderately elevated. Delivery is usually the best treatment. Paurition usually results in resolution. Budd chiary syndrome It is a disorder characterized by thrombotic occlusion of the hepatis veins. It is a rare complication of pregnancy. Most of the cases presents within few weeks of delivery but in several cases onset occurs during pregnancy. Clinical triad of B.C. syndrome includes sudden onset of abdominal pain, hepatontegaly and ascites near tee_ rn or sholy after delivery. Tender hepatomegaly is one of the hallmark of Budd chiari syndrome. Ascites with a high protein content is always present. Aminotransferases are mildly elevated. Jaundice is seen in only half of the cases.