Antiphospholipid syndrome (APS)- Hughes syndrome, is a disorder of the immune system that causes an increased risk of blood clots.

The immune system produces abnormal antibodies that make the blood "stickier" than normal. This means people with APS are at greater risk of developing conditions such as:

• DVT (deep vein thrombosis, a blood clot that usually develops in the leg

• Arterial thrombosis (a clot in an artery), which can cause a stroke or heart attack

• Blood clots in the brain, leading to problems with balance, mobility, vision, speech and memory

Pregnant women with APS also have an increased risk of having a miscarriage, although the exact reasons for this are uncertain.

What causes antiphospholipid syndrome?

APS is an autoimmune condition. This means the immune system, which usually protects the body from infection and illness, attacks healthy tissue by mistake. In APS, the immune system produces abnormal antibodies called antiphospholipid antibodies. These target proteins attached to fat molecules (phospholipids), which makes the blood more likely to clot.

It's not known what causes the immune system to produce abnormal antibodies.

As with other autoimmune conditions, genetic, hormonal and environmental factors are thought to play a part.

Who's affected?

APS can affect people of all ages, including children and babies. But most people are diagnosed with APS between 20 and 50 years of age, and it affects 3 to 5 times as many women as men.

Diagnosing APS

An accurate diagnosis of antiphospholipid syndrome (APS) is important because blood clots can have serious consequences. Diagnosis of APS is based on the results of specific blood tests and a medical assessment. If APS is suspected, you'll usually be referred to hospital to see either a:

• Haematologist (a specialist in conditions affecting the blood)

• Rheumatologist (a specialist in conditions affecting the immune system)

Specific blood tests

To diagnose APS, the blood needs to be tested for the abnormal antiphospholipid antibodies that increase the risk of blood clots. This requires a blood test specifically designed to look for these antibodies. A diagnosis of APS can only be made after 2 abnormal blood test results, with at least a 12-week gap between them. This is because harmless antiphospholipid antibodies can sometimes develop in the body for short periods of time. Usually, this is the result of an infection or a side effect of medication, such as antibiotics.

If antiphospholipid antibodies are identified during the first blood test, another test will be needed later to confirm whether the abnormal antibodies are still present.

Medical assessment

If blood tests confirm you have APS, your medical history will be carefully assessed to check whether you have experienced any previous symptoms that may be caused by APS.

A diagnosis of APS can usually be confirmed if you have had 1 or more confirmed blood clots and, if applicable:

• 1 or more unexplained late miscarriages at or after week 10 of your pregnancy

• 1 or more premature birth at or before week 34 of your pregnancy

• 3 or more unexplained early miscarriages before week 10 of your pregnancy

Causes, Symptoms and treatment

Most people respond well to treatment and can lead normal, healthy lives. But a small number of people with APS continue to experience blood clots despite extensive treatment. This means people with APS are more likely to develop blood clots in their veins and arteries, which can cause serious or life-threatening health problems.

These include:

-High blood pressure

-DVT (deep vein thrombosis)

-A stroke or a transient ischaemic attack (TIA) ("mini-stroke")

-Heart attacks

-Pulmonary embolism (a blockage in one of the blood vessels in the lungs)

People with APS may also experience any of the following symptoms:

-Balance and mobility problems

-Vision problems, such as double vision

-Speech and memory problems

-A tingling sensation or pins and needles in your arms or legs

-Fatigue (extreme tiredness)

-Repeated headaches or migraines

-Pregnancy problems

Recurrent (3 or more) early miscarriages, usually during the first 10 weeks of pregnancy

1 or more later miscarriages, usually after week 10 of pregnancy

Premature birth, usually at or before week 34 of pregnancy, which may be caused by pre-eclampsia (where a woman develops high blood pressure during pregnancy)

It's not clear why these abnormal antibodies are produced, or why many people have antiphospholipid antibodies but don't develop blood clots. A combination of genetic and environmental factors is thought to be responsible.

Antiphospholipid antibodies

Antibodies are proteins produced by the immune system to help fight off infection and illness.

In APS, the immune system produces abnormal antibodies that rather than attacking bacteria and viruses, mistakenly attack proteins found on the outside of cells in the blood and blood vessels. It's not known how this causes the blood to clot more easily. But most experts believe that keeping your blood at the correct consistency (not too runny and not too sticky) is a delicate balancing act that relies on different types of proteins and fats working together.

This balance may be disrupted by abnormal antibodies in people with APS.

Genetic factors

Research into the genetics around APS is still at an early stage, but it seems the genes you inherit from your parents may play a role in the development of abnormal antiphospholipid antibodies.

APS isn't passed down directly from parents to children in the same way as other conditions, such as haemophilia and sickle cell anaemia. But having a family member with antiphospholipid antibodies increases the chance of your immune system also producing them. Studies have shown that some people with APS have a faulty gene that plays a role in other autoimmune conditions, such as lupus. This may explain why some people develop APS alongside another immune system condition.

Environmental factors

It's thought that one or more environmental triggers may be needed to start APS in some people.

These include:

-Viral infections, such as the cytomegalovirus (CMV) or slapped cheek syndrome (parvovirus B19)

-Bacterial infections, such as E. coli (a bacteria often associated with food poisoning) or leptospirosis (an infection usually spread by certain animals)

-Certain medications, such as anti-epileptic medicine or the oral contraceptive pill

Another theory is that many people with abnormal antiphospholipid antibodies only go on to develop APS if they have a higher risk of developing blood clots.

For example, if they:

• Eat an unhealthy diet, leading to high cholesterol levels in the blood

• Don't do enough exercise #

• Take the contraceptive pill or hormone replacement therapy (HRT)

• Smoke

• Are obese

But this doesn't explain why some children and adults who don't have any of these risk factors still develop APS.

How antiphospholipid syndrome is treated

• As part of your treatment, you'll be prescribed anticoagulant medicine such as warfarin, or an antiplatelet medication such as low-dose aspirin. These work by interrupting the process of blood clot formation. This means blood clots are less likely to form when they're not needed. If blood tests show you have abnormal antiphospholipid antibodies, but you don't have a history of blood clots, low-dose aspirin tablets are usually recommended.

• If you can't take aspirin, you may be prescribed an alternative antiplatelet tablet called clopidogrel.

• Warfarin tablets are usually recommended if you have APS and a history of blood clots, such as previously having DVT (deep vein thrombosis) or a stroke.

This needs to be changed for women who become pregnant or are planning a pregnancy. Tell your doctor if this is the case.

• If you develop a blood clot or your symptoms suddenly become severe, injections of an anticoagulant called heparin may be needed. These injections may be given in hospital, or you may be trained to give them yourself.

Side effects

Side effects of these medications are uncommon and generally mild, such as indigestion or feeling sick (nausea). But there's a risk that the disruption to the blood's ability to clot can cause excessive bleeding (a haemorrhage).

Symptoms of excessive bleeding can include: blood in your urine or stool, black stool, severe bruising, prolonged nosebleeds (lasting longer than 10 minutes) ,blood in your vomit , or coughing up blood.

Contact your GP immediately if you have any of these symptoms while taking an anticoagulant.

If this isn't possible, call your local out-of-hours service or NHS 111.

Treatment during pregnancy

Women diagnosed with APS are strongly advised to plan for any future pregnancy. This is because treatment to improve the outcome of a pregnancy is most effective when it begins as soon as possible after an attempt to conceive.

Some medications used to treat APS can also harm an unborn baby.

If you don't plan your pregnancy, it may be several weeks before you realise you're pregnant. This may increase the risk of treatment to safeguard the pregnancy being unsuccessful.

Treatment during pregnancy involves taking daily doses of aspirin or heparin, or a combination of both. This depends on whether you have a history of blood clots and previous complications during pregnancy.

Warfarin isn't recommended during pregnancy because it carries a small risk of causing birth defects.

Treatment with aspirin or heparin, or both, is usually started at the beginning of the pregnancy and may continue for 1 to 6 weeks after you have given birth.

If you do want to have a baby, you should talk to the doctor in charge of your treatment for APS.

Lifestyle changes

If you're diagnosed with APS, it's important to take all possible steps to reduce your risk of developing blood clots.

Effective ways of achieving this include:

• Quitting smoking

• Eating a healthy, balanced diet – low in fat and sugar and containing plenty of fruit and vegetables

• Taking regular exercise

• Maintaining a healthy weight and losing weight if you're obese (have a body mass index of 30 or more)

It is recommended that you wear a medical alert bracelet or similar. This is because it is important for medical staff to know you have a blood clotting disorder in case of an accident.

Reference- https://www.nhs.uk/conditions/antiphospholipid-syndrome/

If you have Inflammatory Bowel Disease (IBD) and are thinking of having a baby, you may be concerned about how your condition might affect your pregnancy. You may also be worrying about whether having a baby could affect your IBD. Most women with Ulcerative Colitis (UC) or Crohn’s Disease can expect a normal pregnancy and a healthy baby. Also, for most women, having a baby does not make their IBD worse.

However, it is important to discuss your pregnancy with your IBD team. You may need to take special care with some aspects of your pregnancy – or perhaps change your treatment slightly.

How might IBD affect my fertility (Female)?

If you have inactive IBD, whether Ulcerative Colitis or Crohn’s Disease, your chances of conceiving are unlikely to be affected by the disease.

If you have active IBD, especially Crohn’s, you may have a slightly lower chance of conceiving, particularly if you are underweight and eating poorly. Also, severe inflammation in the small intestine can affect the fallopian tubes and make it more difficult to get pregnant.

You may find it harder to get pregnant during a flare-up, but fertility should return to normal in between.

Surgery for IBD, especially ‘pouch surgery’ (an ileo pouch-anal anastomosis operation), can affect fertility, so if you are planning a pregnancy you may wish to discuss this with your specialist. You may also be advised to wait a year after other types of IBD surgery to give your body more time to recover.

Most of the drugs prescribed for IBD do not affect fertility, but there are a few exceptions that can be harmful. If you are trying to conceive or are pregnant it is imperative to discuss your medication with your doctor and take guidance on changing or withdraw medication.

Is it better to conceive while my IBD is under control?

Definitely. If you are well when your pregnancy begins, you are more likely to have an uncomplicated pregnancy. If you remain in remission your chances of a normal pregnancy and of delivering a healthy baby are about the same as those for a woman without IBD. You are also more likely to remain well yourself during your pregnancy if your symptoms are under control when you conceive.

This is why most doctors will advise women with IBD who are thinking of getting pregnant to try and get their IBD under control first.

What if I have a flare-up while I am pregnant?

If your disease is active when you conceive, or you have flares during your pregnancy, you may be more likely to give birth early or have a baby with a low birth weight. Your doctor should be able to help you bring your symptoms under control – and many women who conceived while their IBD was in an active phase have gone on to have successful pregnancies and healthy babies.

Severe active Crohn’s Disease or a very severe flare-up of Ulcerative Colitis may put the baby at greater risk. So, if your IBD symptoms begin to get worse, consult your doctor or IBD team as soon as possible.

Should I keep taking my medicines while I am pregnant?

In general, the evidence suggests that active Crohn’s or UC may do more harm to the growing baby than most IBD medicines. So most women will be advised to continue taking their IBD medication during pregnancy. This is particularly important if you have had a recent flare-up and are trying to get it under control.

However, a small number of the drugs used for IBD are not recommended or should not be used at all by pregnant women. This means that if you are, or are planning to be, pregnant, it is important to check with your IBD team whether you need to change your drug treatment before you become pregnant.

What about nutritional therapy?

Some people with Crohn’s use an elemental or polymeric diet (the two main types of liquid feed) as part of their treatment. Both diets may be safely used during pregnancy to treat a flare up of disease or as a nutritional supplement.

What investigations or tests can I have during pregnancy?

As someone with UC or Crohn’s Disease, you may need to have an investigation or test to check on your IBD, especially if you have a flare-up. Make sure your doctor and IBD team know you are, or may be, pregnant. Some types of investigation may need to be delayed until after you have the baby.

MRI and ultrasound tests are safe to have while pregnant. Sigmoidoscopy and colonoscopy are also usually considered safe in pregnancy, although guidelines suggest that these types of tests should only be carried out when they are clearly necessary.

Investigations which involve x-rays and radiation should normally be avoided by pregnant women unless essential. This includes CT scans, PET scans, and barium X-ray tests.

What about surgery while I am pregnant?

Surgery for IBD is unlikely to be suggested while you are pregnant – unless it is felt that it would be riskier not to have the surgery. Studies have suggested that if you do have IBD surgery when pregnant, the risk is lowest if the surgery is carried out during the middle trimester (months 4-6) or if this is not possible, towards the end of the pregnancy.

How can I increase the likelihood of having a healthy baby?

For women with IBD it is worth keeping in mind that if your disease is under control while you are pregnant then the baby is more likely to be healthy. It is therefore important to follow your treatment plan and to ensure that you are as fit as possible before and during your pregnancy. Talk to your doctor or IBD team if you have any worries about how to manage your IBD while pregnant. Tell your doctor if you have a flare up of your IBD or are failing to gain weight as expected.

• Diet - For any pregnant woman, a balanced and varied diet with sufficient calories, vitamins and minerals is important for the growth of their baby. Having IBD, the increased nutritional needs of pregnancy may mean you need to supplement your diet, especially if you are underweight or have active disease. You may find it helpful to talk to a dietitian or your IBD team about this.

  Extra folic acid might be suggested. All pregnant women are now recommended to take a folic acid supplement for the first 12 weeks of pregnancy to help reduce the risk of the baby having problems such as spina bifida. The usual recommendation is 400 micrograms a day. This can be particularly important for women with Crohn’s of the small intestine, as this condition can make it more difficult to absorb folic acid. Sulphasalazine also reduces folic acid absorption. If you are on sulphasalazine or if you have had surgery to remove part of the small intestine, it may be suggested that you increase your folic acid supplement to 2 mg (2000 micrograms) a day. Check with your doctor what level of folic acid would suit you. If you take steroids, calcium and vitamin D supplements can be useful to help prevent bone loss.

  Iron deficiency is quite common in IBD, and extra iron may be needed to meet the increased demands of pregnancy. Your doctor will be able to recommend a suitable supplement. Some iron tablets can cause constipation. You may find a liquid iron supplement avoids this problem.

If you have Crohn’s Disease and have had surgery to remove the terminal ileum (the end of the small intestine), you may also need regular Vitamin B12 supplements to prevent anaemia.

• Alcohol - Drinking alcohol during pregnancy can seriously harm your baby’s development. The Department of Health recommends that you do not drink any alcohol while pregnant, especially during the first three months as it may increase the risk of miscarriage.

• Exercise - Regular moderate exercise can help to keep you healthy and is important in pregnancy. Gentle exercises such as walking, yoga and swimming can be particularly valuable.

• Smoking - Smoking when pregnant is known to harm the baby. It leads to low birth weight with a higher risk of deformity and miscarriage. It can also increase the likelihood of blood clots during pregnancy. For women with Crohn’s Disease, smoking can be especially risky. Research has shown that smoking may make Crohn’s symptoms worse and increase the chance of a flare up.

If you have Ulcerative Colitis, the likely effect of smoking on your own health is less clear. There is some evidence that people with UC who smoke tend to have milder symptoms. However, this does not mean that smoking will necessarily improve your UC – and it could cause the same direct damage to the baby as in any non-IBD pregnancy. The consensus among health professionals is that whatever type of IBD you have smoking is not recommended.

Will pregnancy make my Ulcerative Colitis or Crohn’s Disease worse?

For most women, having a baby does not lead to a worsening of their IBD. Some research has even suggested that it may have a positive effect on the disease process in the longer term. For example, several studies have found that women with IBD had fewer relapses per year after having children than before they got pregnant.

How your IBD is likely to behave while you are pregnant appears to depend at least partly on how active your disease was when you started the pregnancy.

If you conceive when your IBD is in remission (inactive) you have a good chance of staying in remission. Studies have shown that about one in three women with UC who conceive while their disease is inactive will have a flare up during their pregnancy. This is a very similar rate of relapse to that for non-pregnant women with UC over nine months. The rates for women with Crohn’s Disease are also very similar. If you conceive while your disease is active, you may find that your symptoms remain troublesome during your pregnancy. For some women, flare ups may become more acute, especially during the first three months. Others may find that their symptoms improve as their pregnancy progresses.

What will happen in future pregnancies is also difficult to predict. If your IBD becomes active during a pregnancy, there is no evidence to suggest that it will do so again in future pregnancies. Similarly, if you do not have a flare up during your pregnancy, unfortunately this is no assurance that the disease will remain inactive in later pregnancies.

What sort of delivery should I have?

In most cases, a normal vaginal delivery should be possible. However, a caesarean section may be recommended by your medical team if you have severe or perianal Crohn’s Disease.

You may also be advised to have a caesarean if you have an ileo-anal pouch. This is because there is some evidence that a vaginal delivery may lead to an increased risk of faecal incontinence, although other studies suggest this risk may be lower than previously thought.

If you do opt for a vaginal delivery but also have scar tissue around your anus, your doctor may advise an episiotomy (a cut at the opening of the vagina) to prevent tearing.

Talk to your gastroenterologist or obstetrician about your own preferences and about any worries you may have.

What about my ileostomy?

Many women with ileostomies have a normal pregnancy and delivery. Your stoma may change shape and become larger as your abdomen expands. It will usually return to normal after the delivery. Occasionally the enlarging uterus can temporarily block the stoma. A change of diet may help – your stoma nurse should be able to advise you on this. You may also find there is an increase in output from your stoma during the third trimester of pregnancy. This too should resolve itself after the birth.

Most women with a stoma should be able to have a vaginal birth, but sometimes a caesarean section may be necessary.

I want to breastfeed. Will my medicines do any harm to the baby?

Breastfeeding is important for the development of a healthy immune system and is generally recommended. There is no evidence that many of the drugs used to treat IBD are harmful to a breastfed baby, although very few are licensed for use while breastfeeding. This may be because little is known about the drug’s long-term effect, or because the drug companies are cautious about conducting trials with breastfeeding mothers. So, they prefer to advise against any use of their medications while breastfeeding.

If you would like to breastfeed, talk to your doctor and your IBD team about any possible problems from your medication.

Based on experience, the 5-ASA drugs such as mesalazine and sulphasalazine are considered by doctors to be safe while breastfeeding. Research has shown that they are transferred into the breast milk, but in very low concentrations.

Steroids such as prednisolone also appear in low concentrations in breast milk. Again they are generally considered safe, although if you are taking large doses of steroids (over 40mg a day) breastfeeding is not recommended. You can reduce the effects of steroids by waiting for 4 hours after taking a dose before starting to breastfeed.

Some doctors would not advise breastfeeding by mothers on azathioprine or mercaptopurine, but very little of the active drug is secreted into breast milk. Also, there is no evidence of harm in children of mothers who have breastfed while on these drugs. Thus, the benefits of breastfeeding may outweigh any small potential risk.

Recent studies have suggested that infliximab does not pass into breast milk and that it may be safe to breastfeed while taking this drug. Evidence about adalimumab’s safety is still very limited. The long-term effects of these drugs on a child’s developing immune system are also still unknown. Most doctors still recommend that you do not breastfeed during treatment with these medicines or for six months after your last dose.

Breastfeeding is not advisable if you are taking ciclosporin, methotrexate, mycophenolate mofetil, or tacrolimus. It is also better not to breastfeed while you are on antibiotics such as ciproflaxacin or metronidazole, or the anti-diarrhoeals, loperamide and diphenoxylate.

What are the chances of my child having IBD?

Parents with IBD are slightly more likely to have a child who develops IBD. If one parent has IBD, the risk of a child developing IBD is about 2% for Ulcerative Colitis and 5% for Crohn’s Disease, although it may be higher in some population groups. That is, for every 100 people with UC, about 2 of their children might be expected to develop IBD at some time in their lives. For every 100 people with Crohn’s, about 5 of their children might be expected to develop IBD. If both parents have IBD, the risk can rise to 35%. However, we still cannot predict exactly how IBD is passed on. Even with genetic predisposition, other additional factors are needed to trigger IBD.

Summary

On balance, there are very few concerns about male infertility in IBD. As long as the patient is otherwise in good health, is a non-smoker and exercises with a healthy diet, a patient in remission from his Crohn’s or colitis should have no greater concerns than the non-IBD male about the ability to conceive and father a child. There may be drugs that are associated with reversible sperm problems such as sulphasalazine and methotrexate, but risks of harm to the foetus with any medication used in IBD is very low.

Concerns

If you have any specific concerns, this should be raised with your GP, IBD nurse or gastroenterologist. The information provided here is an overview based on clinical guidelines and current practice, but practice may vary due to individual circumstances. Chana is here for anyone who has Crohn’s and need any support or advice.

References- https://www.jewishdigest.org/crohns-colitis/pregnancy-and-ibd/

https://crohnsandcolitis.org.uk/info-support/information-about-crohns-and-colitis/all-information-about-crohns-and-colitis/living-with-crohns-or-colitis/pregnancy-and-breastfeeding#:~:text=Most%20women%20with%20Crohn's%20or,important%20part%20in%20these%20risks.

Is infertility due to male factors more common in IBD?

In IBD, male infertility is thought to be more common than in the general population. It is not clear whether this is due to the disease itself or a reduced desire to have children associated with reduced self-confidence, self-image, abdominal pain, fear of hereditability, etc.

What are the possible explanations for male infertility in IBD?

There is evidence to show the treatments commonly used for IBD may have an adverse impact on sperm production.

If you are on medications such as Sulphasalazine or Methotrexate and are trying to conceive it is imperative to discuss your medication with your doctor and take guidance on changing or withdrawing medication.

Most of the drugs prescribed for IBD do not affect fertility, but there are a few exceptions that can be harmful and therefore must be discussed with a medical professional.

What can steroids do to male fertility and pregnancy outcomes?

This doesn’t seem to be linked to infertility, although some evidence shows steroids may decrease sperm concentration and sperm motility.

Which antibiotics may be problematic in males with IBD?

There are limited studies, but the use of Metronidazole or Ciprofloxacin (mainly for fistulising Crohns disease) may be factors contributing to male infertility.

What can be done to help patients with male infertility?

In general it is recommended to control their IBD and optimise nutritional status. Cessation of any drugs that may be associated with altered sperm quality may help. But this needs to be weighed against the health benefits derived from the medication and this should only be done under medical guidance.

Can surgery hinder chances of conceiving?

Males who undergo ileoanal pouch surgery for ulcerative colitis (UC) may experience retrograde ejaculation and erectile dysfunction. However, overall no change or even an improvement in sexual function occurs after surgery. There should not be any impact of other forms of surgery on fertility.

Concerns

If you have any specific concerns, this should be raised with your GP, IBD nurse or gastroenterologist. The information provided here is an overview based on clinical guidelines and current practice, but practice may vary due to individual circumstances. Chana is here for anyone who has Crohn’s and need any support or advice.

References- https://www.jewishdigest.org/crohns-colitis/pregnancy-and-ibd/

https://crohnsandcolitis.org.uk/info-support/information-about-crohns-and-colitis/all-information-about-crohns-and-colitis/living-with-crohns-or-colitis/pregnancy-and-breastfeeding#:~:text=Most%20women%20with%20Crohn's%20or,important%20part%20in%20these%20risks.

Non-alcoholic fatty liver disease (NAFLD) is the term for a range of conditions caused by a build-up of fat in the liver. It's usually seen in people who are overweight or obese.

Early-stage NAFLD does not usually cause any harm, but it can lead to serious liver damage, including cirrhosis, if it gets worse. Having high levels of fat in your liver is also associated with an increased risk of serious health problems, such as diabetes, high blood pressure and kidney disease. If you already have diabetes, NAFLD increases your chance of developing heart problems.

NAFLD during pregnancy

The prevalence of non-alcoholic fatty liver disease (NAFLD) in pregnancy has almost tripled over the past 10 years. Having NAFLD during pregnancy increases risks for both the mother and the baby, including hypertensive complications of pregnancy, bleeding after delivery, and pre-term birth.

Women with non-alcoholic fatty liver disease (NAFLD) should receive preconception counselling about increased maternal and infant risks, while pregnant mothers will benefit from evaluation by a high-risk obstetrics team,

If detected and managed at an early stage, it's possible to stop NAFLD getting worse and reduce the amount of fat in your liver.

Am I at risk of non-alcoholic fatty liver disease (NAFLD)?

You're at an increased risk of NAFLD if you:

• Are obese or overweight – particularly if you have a lot of fat around your waist (an "apple-like" body shape)

• Have type 2 diabetes

• Have a condition that affects how your body uses insulin

• Are insulin resistance, such as polycystic ovary syndrome

• Have an underactive thyroid

• Have high blood pressure

• Have high cholesterol

• Have metabolic syndrome (a combination of diabetes, high blood pressure and obesity)

• Are over the age of 50

• Smoke

But NAFLD has been diagnosed in people without any of these risk factors, including young children.

Although it's very similar to alcohol-related liver disease (ARLD), NAFLD is not caused by drinking too much alcohol.

Symptoms

There are not usually any symptoms of NAFLD in the early stages. You probably will not know you have it unless it's diagnosed during tests carried out for another reason.

Occasionally, people with NASH or fibrosis (more advanced stages of NAFLD) may experience:

• a dull or aching pain in the top right of the tummy (over the lower right side of the ribs)

• extreme tiredness

• unexplained weight loss

• weakness

If cirrhosis (the most advanced stage) develops, you can get more severe symptoms, such as yellowing of the skin and the whites of the eyes (jaundice), itchy skin, and swelling in the legs, ankles, feet or tummy (oedema).

See a GP urgently or call 111 if you have any of these symptoms and have a liver condition.

Diagnosis

NAFLD is often diagnosed after a blood test called a liver function test produces an abnormal result and other liver conditions, such as hepatitis, are ruled out. Blood tests do not always pick up NAFLD. The condition may also be spotted during an ultrasound scan of your tummy. This is a type of scan where sound waves are used to create an image of the inside of your body.

If you're diagnosed with NAFLD, further tests may be needed to determine which stage you have. This may involve a special blood test or having another type of ultrasound scan (Fibroscan). Some people may also need a biopsy, where a small sample of liver tissue is taken using a needle so it can be analysed in a laboratory. Other tests you may have include a CT scan or MRI scan.

Treatment

Most people with NAFLD will not develop any serious problems, but if you're diagnosed with the condition it's a good idea to take steps to stop it getting any worse. There's currently no specific medication for NAFLD, but making healthy lifestyle choices can help.

Treatment also may be recommended for associated conditions (high blood pressure, diabetes and cholesterol) or complications. You may be advised to have regular appointments with your doctor to check your liver function and look for signs of any new problems.

Medicines

There's not currently any medicine that can treat NAFLD, but various medicines can be useful in managing the problems associated with the condition. For example, your doctor may recommend medicine to treat high blood pressure, treat high cholesterol, treat type 2 diabetes and treat obesity.

Liver transplant

If you develop severe cirrhosis and your liver stops working properly, you may need to be put on the waiting list for a liver transplant. Or it may be possible to have a transplant using a section of liver removed from a living donor. As the liver can regenerate itself, both the transplanted section and the remaining section of the donor's liver are able to regrow to a normal size.

Things you can do if you have non-alcoholic fatty liver disease (NAFLD)

Adopting a healthy lifestyle is the main way of managing NAFLD:

Lose weight – you should aim for a BMI of 18.5 to 24.9 (use the BMI calculator to work out your BMI); losing more than 10% of your weight can remove some fat from the liver and improve NASH if you have it

Eat a healthy diet – try to have a balanced diet high in fruits, vegetables, protein and carbohydrates, but low in fat, sugar and salt; eating smaller portions of food can help, too

Have water instead of sweet drinks

Exercise regularly – aim to do at least 150 minutes of moderate-intensity activity, such as walking or cycling, a week; all types of exercise can help improve NAFLD, even if you do not lose weight

Stop smoking – if you smoke, stopping can help reduce your risk of problems such as heart attacks and strokes

NAFLD is not caused by alcohol, but drinking may make it worse. It's therefore advisable to cut down or stop drinking alcohol.

References- https://www.nhs.uk/conditions/non-alcoholic-fatty-liver-disease/#:~:text=Non%2Dalcoholic%20fatty%20liver%20disease%20(NAFLD)%20is%20the%20term,cirrhosis%2C%20if%20it%20gets%20worse.

https://www.elsevier.com/about/press-releases/research-and-journals/nafld-in-pregnancy-increases-risks-for-mother-and-baby

What is OHSS?

Ovarian hyperstimulation syndrome is a potentially serious complication of fertility treatment, particularly of in vitro fertilisation (IVF).

What causes OHSS?

Fertility drugs, usually gonadotrophins, are used to stimulate the ovaries during IVF treatment to make eggs grow. Sometimes there is an excessive response to these drugs, leading to OHSS. Overstimulated ovaries enlarge and release chemicals into the bloodstream. Fluid from the blood vessels leaks into your abdomen and in severe cases into the space around the heart and lungs. OHSS can affect the kidneys, liver and lungs. A very small number of deaths due to OHSS have been reported.

Who gets OHSS?

Mild OHSS is common in women having IVF treatment; affecting as many as 33 in 100 women (33%). However, just over 1 in 100 women (1%) will develop moderate or severe OHSS.

The risk is higher in women who:

• have polycystic ovaries

• are under 30 years old

• have had OHSS previously

• get pregnant in the same IVF cycle as they get their symptoms, particularly if this is a multiple pregnancy (more than one baby).

What are the symptoms of OHSS?

It is normal to have some mild discomfort after egg collection. If you are worried or develop any of the symptoms below, you should seek medical advice and contact your fertility centre.

OHSS can range from mild to severe:

Mild OHSS – mild abdominal swelling, discomfort and nausea.

Moderate OHSS – symptoms of mild OHSS, but the swelling is worse because of fluid build-up in the abdomen. This can cause abdominal pain and vomiting.

Severe OHSS – symptoms of moderate OHSS with extreme thirst and dehydration. You may only pass small amounts of urine which is dark in colour and/or you may experience difficulty breathing because of a build-up of fluid in your chest. A serious, but rare, complication is formation of a blood clot (thrombosis) in the legs or lungs. The symptoms of this are a swollen, tender leg or pain in your chest and breathlessness. You should report any unusual symptoms to your doctor.

How long does it last?

Most of your symptoms should resolve in 7-10 days. If your fertility treatment does not result in a pregnancy, OHSS usually gets better by the time your next period starts. If you become pregnant, OHSS can get worse and last up to a few weeks or longer.

What should I do if I have mild OHSS?

If you have mild OHSS, you can be looked after at home. Ensure that you drink fluids at regular intervals. If you have pain, take paracetamol or codeine (no more than the maximum dose). You should avoid anti-inflammatory drugs (aspirin or aspirin-like drugs such as ibuprofen), which can affect your kidneys. It is advisable to remain active to reduce the risk of thrombosis.

When should I call for medical help?

Call for medical help if you develop any of the symptoms of OHSS, particularly if the pain is not getting any better or if you start to vomit, have urinary problems or chest pain or have difficulty breathing.

You should have the details of your fertility unit to call for help and advice. If you are unable to contact your fertility clinic, contact:

the A&E department at your local hospital or your general practice or the NHS on 111.

What may happen at the hospital?

Your doctor will ask you to describe your symptoms and will examine you. In addition, your doctor may:

-ask about how much urine you are passing and whether it is darker than normal (concentrated)

-measure your blood pressure, pulse rate and breathing rate

-take an initial measurement of your waistline and check your weight to see whether the fluid is building up or reducing

-arrange an ultrasound scan to measure the size of your ovaries and to check whether there is any fluid build-up in your abdomen

-take blood tests to measure how concentrated your blood is and how well your kidneys are working.

A diagnosis is made based on your symptoms, the examination findings and the results of your tests. If you are well enough to go home, you may be advised to attend for regular check-ups.

When will I need to stay in hospital?

Many women can be managed as outpatients, but you may need admission if:

your pain is not helped by pain-relieving medications

you have severe nausea and vomiting

your condition is not getting better

you will be unable to attend hospital easily for monitoring and follow-up.

If you are vomiting, you may need a drip to replace the fluids you have lost. The fluid will help to keep you hydrated and may contain sugar and carbohydrates (for energy), and minerals and chemical elements (for regulating and maintaining the organs in your body).

It is important that, if you are admitted to a hospital which is not the one where you had your fertility treatment, your care is discussed and coordinated with a specialist in this condition.

What is the treatment for OHSS?

Although there is no treatment that can reverse OHSS, it will usually get better with time. Treatment is to help symptoms and prevent complications.

This includes:

• pain relief such as paracetamol or codeine

• anti-sickness drugs to help reduce nausea and vomiting

• an intravenous drip to replace fluids

• support stockings and heparin injections to prevent thrombosis (a blood clot in the leg or lungs). Heparin injections for blood thinning should be continued for 7 days from cure of your symptoms if you are not pregnant or until the end of the 12th week of your pregnancy.

If your abdomen is tense and swollen because of fluid build-up, you may be offered a procedure known as a paracentesis. This is when a thin needle or tube is inserted under ultrasound guidance into your abdomen to remove fluid. You may be offered a local anaesthetic for this procedure. This treatment helps relieve discomfort and improve kidney function and you're breathing. Rarely, advice may be sought from a more specialist team which may involve anaesthetists and/or intensive care doctors.

Are there any ongoing concerns if I have had OHSS and become pregnant?

To lower the risk of developing a blood clot in your legs or lungs, you will be advised to continue wearing support stockings and taking heparin (blood-thinning) injections until 12 weeks of your pregnancy.

You may be at increased risk of developing pre-eclampsia or giving birth to your baby prematurely. However, there are no known risks to your baby’s development because of OHSS.

Is there anything else I should know?

Your fertility clinic should provide you with full written information about your fertility treatment, including the risk of OHSS and a 24-hour help number.

If you develop OHSS, your ovaries will be enlarged and painful. You should avoid having sex or doing strenuous exercise to avoid injury to the ovaries.

A few women develop OHSS as an after-effect of other fertility treatment or even in a normal conception but this is very rare.

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/ovarian-hyperstimulation-syndrome-patient-information-leaflet/