Professor Catherine Nelson-Piercy

Guy’s & St Thomas’ Hospital

Professor David Williams

University College London Hospital

Professor Alison Rodger

University College London

Dr Bhaskar Narayan

Royal Surrey NHS Foundation Trust

Dr Carol Postlethwaite

Kent, Surrey, and Sussex regions

Dr Caroline Ovadia

King's College London

Dr Cathy Head

Norfolk And Norwich University Hospital​

Dr Felicity Coad

Royal United Hospital

Dr Charlotte Frise

Queen Charlotte’s And Chelsea Hospital

Dr Fran Neuberger

North Bristol NHS Trust

Professor Helen Murphy

University of East Anglia

Dr Kate Bramham

King’s College Hospital

Jennifer Nightingale

Guys and St Thomas’ NHS Trust

Dr Kate Wiles PhD MRCP

Royal London Hospital, Barts Health NHS Trust

Dr Kate Womersley

The George Institute for Global Health

Professor Kypros Nicolaides

King’s College Hospital

Dr Lizemarie Wium

King’s College Hospital

Professor Lucy Chappell

King's College London

Dr Lucy Mackillop

Oxford University Hospitals NHS Trust

Miss Mandish Dhanjal

Queen Charlotte's and Chelsea Hospital

Dr Melanie Nana

King’s College London

Dr Michael Desborough

Oxford University Hospitals NHS Foundation Trust

Dr Oseme Etomi

Guy’s & St Thomas’ Hospital

Dr Paarul Prinja

Royal Wolverhampton NHS Trust

Dr Pooja Dassan

London NW University Healthcare NHS Trust

Dr Siara Teelucksingh

Guy’s and St. Thomas’ NHS Foundation Trust

Dr Tim Korevaar

Erasmus University Medical Center

Professor Yvonne Gilleece

University Hospitals Sussex NHS Trust

Professor Catherine Nelson-Piercy

Guy’s & St Thomas’ Hospital

Catherine Nelson-Piercy is a Consultant Obstetric Physician at Guy’s and St. Thomas’ Hospitals Trust and Queen Charlotte’s and Chelsea Hospital in London. In 2010 she was awarded the title of Professor of Obstetric Medicine at King’s College London. Her undergraduate studies were at King’s College, Cambridge University and St Bartholomew’s Hospital. She trained as a physician, and was taught Obstetric Medicine by Professor Michael de Swiet.

Professor Nelson-Piercy is past President of the International Society of Obstetric Medicine (ISOM). She was founding co-editor in chief of the journal ‘Obstetric Medicine: the medicine of pregnancy.’

Professor Nelson-Piercy has been involved in the development of several evidence-based National Guidelines notably for “Contraception in Women with Heart Disease”, BTS / SIGN “Asthma in Pregnancy” and RCOG Green top guidelines on “Reducing the risk of thromboembolism during pregnancy, birth & the puerperium” and ‘Management of nausea vomiting of pregnancy and hyperemesis gravidarum”. She has over 250 publications and has edited five books and written the successful Handbook of Obstetric Medicine, now in its sixth edition. She is also one of the central physician assessors for the UK Confidential maternal deaths enquiry.

Professor Catherine Williamson

Imperial College London

Catherine Williamson is Professor of Women’s Health at Imperial College London. She is also Consultant in Obstetric Medicine at Queen Charlotte’s, St Thomas’ and King’s College Hospitals.

She is a Fellow of the Academy of Medical Sciences and a NIHR Senior Investigator. In her clinical practice she manages women with medical disorders in pregnancy.

Her research focuses on the endocrine signals that influence alterations in bile acid, lipid and glucose homeostasis in normal and pathological pregnancies.

She also studies the maternal and fetal aetiology, outcomes and management of intrahepatic cholestasis of pregnancy, gestational diabetes mellitus, thyroid disease and severe hyperemesis gravidarum.

Professor David Williams

University College London Hospital

Professor Williams is an obstetric physician at the Institute for Women’s Health, University College London Hospital. He leads a multi-disciplinary team that provides clinical care for pregnant women with medical disorders. Originally trained as a nephrologist, he has particular expertise in kidney disease and hypertension in pregnancy.

As an obstetric physician he developed the concept that physiological changes in pregnancy lead to gestational syndromes that in turn unmask a predisposition to disease in later life. His research group investigate the pathophysiology and management of pre-eclampsia, acute fatty liver of pregnancy, paternal genetic and epigenetic factors influencing fetal growth and immune causes of recurrent pregnancy loss.

He was chairman of the UK NICE guideline on intrapartum management of medical disorders in pregnancy and is current chairman of the Wellbeing of Women Research Advisory Committee.

Professor Alison Rodger

University College London

Alison Rodger is Professor of Infectious Diseases at University College London and Consultant and Clinical Director of Infectious Diseases at the Royal Free Hospital in London. Her research interests include reducing rates of new HIV infections and improving the long-term health of people with HIV. 

Alison also works on the Baby Biome Study which describes how perinatal acquisition of gut microorganisms impacts on the infant immune response and subsequent health outcomes. She is the lead infectious diseases assessor for UK maternal deaths reviews (MBRRACE), including the recent reviews on maternal deaths from COVID-19

Dr Bhaskar Narayan

Royal Surrey NHS Foundation Trust

Dr Bhaskar Narayan is a Consultant in Intensive Care, Acute and Obstetric Medicine at Royal Surrey NHS Foundation Trust. After graduating from Cambridge University, he completed his postgraduate training in London, South East England, Greater Manchester, and Melbourne, and worked as a consultant at St Mary’s Hospital in Manchester prior to his current role. He has particular interests in pulmonary embolism and maternal critical care.

Dr Carol Postlethwaite

Sussex Maternal Medicine Networks

Carol is an Acute and Obstetric Medicine Consultant working in Kent, Surrey, and Sussex regions.

She is the lead Obstetric Physician for the Kent & Medway and Sussex Maternal Medicine Networks and works with the SE London team to deliver training and education to the region.

She is an honorary lecturer at Brighton and Sussex Medical Schools, and teaches locally, regionally and nationally to midwives, obstetricians and medics of all varieties and grades and is also the Preceptor for the Maternal Medicine Module SITM for RCOG KSS.

 

Dr Caroline Ovadia

King’s College London, Guys’ And St Thomas’ NHS Foundation Trust

Caroline is a Clinical Senior Lecturer at King’s College London and an Honorary Consultant Obstetrician at Guy’s and St Thomas’ NHS Foundation Trust, where she leads the obstetric diabetes service. Her special interests are in maternal metabolic disorders and their impact on adverse fetal outcomes. She was awarded the ROCG William Blair Bell Memorial Lecture and the Harold Malkin Prize, and received the Tommy’s charity “Star Researcher Award” for her work on intrahepatic cholestasis of pregnancy. She was a member of the former RCOG Stillbirth CSG, and is an advisor for Sands and ICP Support. Caroline is also the Integrated Academic Training Lead in Women’s Health, and a passionate clinical and academic educator.

Dr Cathy Head

Norfolk And Norwich University Hospital

Catherine Head is a consultant cardiologist and service lead for the maternal cardiology and adult congenital heart disease services at the Norfolk and Norwich University Hospital. She trained in Cambridge, London and Birmingham and undertook an MRC Clinical Training Fellowship at the University of Cambridge.

Prior to her appointment at NNUH she was a consultant at Guy’s and St Thomas’ Hospital from 2005-2019. She is President of the UK Maternal Cardiology Society (UKMCS), a cardiology assessor for the MBRRACE confidential enquiry and a contributor to NICE guidelines relating to heart disease in pregnancy.

She is the author of book chapters on cardiac disease in pregnancy and the joint UKMCS/BCS statement on COVID risk assessment of pregnant women with heart disease, disseminated as NHSE shielding guidance by the Chief Medical Officer 2020.

Dr Felicity Coad

Royal United Hospital

Felicity is a Consultant Physician, dividing her time between Obstetric medicine and Acute medicine at the Royal United Hospital (RUH) in Bath. She works closely with the SW Maternal Medicine Network team. She is a current assessor for MBBRACE-UK.

She graduated from Imperial College London in 2010, and undertook postgraduate medical training in London and the South West, during which she spent a year as the Obstetric Medicine Fellow at Guy’s and St Thomas’ hospital. She was the RCP Chief Registrar at the RUH in Bath during her final year of training. She is an enthusiastic educator and has a PG Cert in medical education.

She has formerly co-edited the RCP Clinical Medicine CME on Obstetric Medicine. She is passionate about improving care for pregnant women with medical problems.

Dr Charlotte Frise

Queen Charlotte’s And Chelsea Hospital

Charlotte Frise is a consultant Obstetric Physician and is Lead Obstetric Physician for the NW London Maternal Medicine network. 

She is a senior college lecturer in Clinical Medicine at Keble College, Oxford. She is co-editor-in-chief of the journal Obstetric Medicine. 

She has also recently authored two textbooks:  Obstetric Medicine, in the Oxford Specialist Handbooks in Obstetrics and Gynaecology series and Case Histories in Obstetric Medicine.

Dr Francesca Neuberger

MBChB FRCP (UK) | North Bristol NHS Trust

 

Fran is an Acute and Obstetric Physician at North Bristol NHS Trust and is Obstetric Physician lead for the Southwest Maternal Medicine Network, working closely with obstetric teams to deliver care for pregnant women with pre-existing medical conditions, and for those who develop medical complications in pregnancy. She has a keen interest in medical education and runs a multidisciplinary simulation course focussing on medical problems in pregnancy

Professor Helen Murphy

University of East Anglia

Dr Helen Murphy is a Professor of Medicine (Diabetes and Antenatal Care) at the University of East Anglia, and a practicing clinician (Norfolk & Norwich University Hospital NHS Trust), Norwich, UK.

She runs a diabetes pregnancy research programme which aims to support women with diabetes to achieve the pregnancy glucose targets required for optimal mother and baby health outcomes. She co-led the CONCEPTT Continuous Glucose Monitoring (CGM) trial. CONCEPTT demonstrated health benefits for mothers with type 1 diabetes (T1D), their newborn infants and the potential for substantial healthcare cost savings. In addition to scientific contributions, building research infrastructure and supporting the next generation of clinical academics, data from CONCEPTT led to international changes in clinical practice, CGM is now the recognised standard of care for pregnant women with T1D.

Her work with Professor Roman Hovorka demonstrating that hybrid closed-loop systems could transform the future clinical management of T1D during pregnancy was published in the New England Journal of Medicine. Based on these landmark studies, the CamAPS FX closed-loop system is licensed for use during T1D pregnancy and strongly endorsed by the 2023 proposed NICE guidelines for women who are pregnant or planning pregnancy.

Helen also serves as clinical lead for the National Pregnancy in Diabetes (NPID) audit, which is the largest population-based study in diabetes pregnancy. Data from NPID directly informs national healthcare policy, highlighting the urgent need to improve glycaemic management in type 2 diabetes (T2D) pregnancy.

Supported by JDRF, Diabetes UK, and the NIHR, her research is changing the management of diabetes in pregnancy. Helen serves on several research committees, the editorial board for Diabetes Care, Diabetologia, and is a regular contributor to national and international scientific meetings.

Dr Kate Bramham

King’s College Hospital

Dr Kate Bramham is a Consultant Nephrologist at King’s College Hospital and Reader at King’s College London. She is UK Deputy Lead for Rare Renal Diseases Registry, UK CKD Africa Genetics group lead and the London Kidney Network Health Inequalities scoping committee. She has authored several original manuscripts and book chapters on renal disease, pregnancy and ethnicity. She is leading several clinical studies and trials in the UK and in Zambia and Sierra Leone to improve detection of early kidney disease, using point-of-care approaches and novel treatments to protect kidney function in people of African ancestry. Kate is passionate about working closely with Black communities to change the trajectory of kidney disease.

Jennifer Nightingale
MSc NMP

Advanced Nurse Practitioner –Epilepsy

Jen has worked in the field of Epilepsy since 1999 completing a Masters in Epileptology in 2004. Jen has worked as an epilepsy CNS/ANP in many of London’s teaching hospitals including Kings, UCH, The Royal Free and Barts she is currently an Advanced Nurse Practitioner at Guys and St Thomas’ NHS Trust.

Jen has a particular interest in the diagnosis and management of first seizures and care of pregnant women with epilepsy

Dr Kate Wiles PhD MRCP

Royal London Hospital, Barts Health NHS Trust

Kate is as a consultant obstetric physician at Barts Health NHS Trust and physician-lead of the North-East London maternal medicine network. She was lead investigator for a multicentre prospective cohort study examining the implications of CKD for women’s health and pregnancy. She has published articles on pre-pregnancy counselling, gestational acute kidney injury, superimposed pre-eclampsia in women with chronic kidney disease, transplantation in pregnancy, glomerular disease in women, thyroid disease in pregnancy, and management of inflammatory bowel disease in pregnancy.

She member of both the UK expert consensus group on kidney disease in pregnancy and the international KDIGO international group examining controversies in women’s health and kidney disease. She is lead author of the first UK guideline for the management of pregnancy in women with kidney disease.

She has authored chapters on obstetric nephrology for the Oxford Textbook of Clinical Medicine, Oxford Textbook of Clinical Nephrology, Comprehensive Clinical Nephrology and Chesley’s Hypertension. She is an author of the popular Oxford Handbook of Clinical Medicine.

Dr Kate Womersley

The George Institute for Global Health

Dr Kate Womersley is Co-Principal Investigator of the MESSAGE Project (Medical Science Sex and Gender Equity) at The George Institute for Global Health at Imperial College London. She is also a psychiatry trainee based in Edinburgh. Her clinical and research interests focus on intersections between the physical and mental health of women and girls across the lifecourse.

Professor Kristel Van Calsteren

University of Leuven

Kristel Van Calsteren is feto-maternal medicine specialist and associate professor in the department of obstetrics and gynaecology at the University of Leuven, Belgium. In 2009 she defended her PhD thesis which handled different aspects of cancer and cancer treatment during pregnancy, and continued research on this topic over the last 15 year. She is a founding member of INCIP (International Network on Cancer, Infertility and Pregnancy) and ABCIP (Advisory Board on Cancer, Infertility and Pregnancy). Other research topics include the application of cfDNA analysis in pregnancy beyond screening for common fetal trisomies, and pharmacokinetics and safety of medicine use in pregnancy.

Professor Kypros Nicolaides

King’s College Hospital

Professor of Fetal Medicine and director of the Research Institute for Fetal Medicine of King’s College Hospital, London, UK. Recipient of highest awards of excellence from many international professional bodies, the Eardley Holland Gold Medal of the RCOG, Grand Cross of the Order of Makarios III from the Republic of Cyprus, Gold Cross of The Order of the Phoenix from the Republic of Greece, Honorary Doctorates in Medicine from 14 Universities across the World. Published 1,603 peer-review papers in Scientific Journals. His h-index is 195 (highest of all obstetricians and gyaecologists in the world) and his work has been cited more than 156 thousant times. Founded the UK charity Fetal Medicine Foundation, which donated more than £45,000,000 to finance the training of many doctors from all over the world and to carry out major multicentre studies.

Dr Lizemarie Wium

King’s College Hospital

Dr Lizemarie Wium is a consultant obstetric physician at King’s College Hospital NHS Foundation Trust and works cross site at King’s College Hospital and Princess Royal University Hospital sites. She completed her MB ChB at the University of the Free State, and in 2016 acquired MMed(Internal Medicine) and FCP(SA) from the University of Pretoria. Lizemarie trained in obstetric medicine at Guy’s and St Thomas’ NHS Foundation Trust in 2018.
She is the cofounder and past president of the Society of Obstetric Medicine South Africa (SOOMSA) and remains ardent about making evidence based learning accessible to clinicians in low to middle resource settings.

Professor Lucy Chappell

King’s College London

Professor Lucy Chappell is Professor in Obstetrics at King’s College London, Honorary Consultant Obstetrician at Guy’s and St Thomas’ NHS Foundation Trust and an NIHR Senior Investigator. She runs a research programme investigating prediction and prevention of adverse pregnancy outcomes, particularly in women with pre-existing co-morbidities such as chronic hypertension and chronic kidney disease, using randomised controlled trials and observational studies. She has subspecialty training in maternal-fetal medicine and a Masters in higher education, supervising higher degree students from obstetric, nephrology, general practice and midwifery backgrounds.

Dr Lucy Mackillop

Oxford University Hospitals NHS Foundation Trust

Dr Mackillop is a Consultant Obstetric Physician, Oxford University Hospitals NHS Foundation Trust; Honorary Senior Clinical Lecturer, Nuffield Department of Women’s and Reproductive Health, University of Oxford and President of the UK’s MacDonald Obstetric Medicine Society. She is also Chief Medical Officer at Sensyne Health plc, a clinical AI company.

Dr Mackillop trained in General, Renal and Obstetric Medicine in Oxford, London and Sydney before taking up her consultant post in 2008.

Dr Mackillop has published over 50 peer-reviewed articles, national and international guidelines, book chapters and e-learning resources on a wide variety of medical conditions in pregnancy; including the Royal College of Obstetricians and Gynaecologists guideline Reducing the risk of VTE in pregnancy and the puerperium. She contributed to the Royal College of Physicians curriculum for a credential in Obstetric Medicine, launched in November 2020 and is an educational supervisor and external assessor for this programme.

Her research interests include the role of telehealth solutions in women with medical problems in pregnancy and construction of evidence-based algorithms to predict acutely unwell women in pregnancy and the immediate puerperium. She has led the development and evaluation of a patient app-to-clinician digital system for the management of women with diabetes in pregnancy through to commercialisation and scale; now used in over half of maternity units in England.

Miss Mandish Dhanjal

Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust

Mandish Dhanjal is a Consultant Obstetrician, Gynaecologist and Maternal Medicine specialist at Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust. She is the Lead Obstetrician for the North West London Maternal Medicine Network, and Obstetric Representative for the UK Macdonald Obstetric Medicine Society. She is an assessor for the UK-MBRRACE maternal deaths enquiry.

She advised on standards for the NICE guideline on intrapartum management of medical disorders in pregnancy and was a committee member on the NICE guideline on adrenal insufficiency. She has written and lectured widely on obstetric medicine and co-authored the Oxford Specialist Handbook on Heart Diseases in Pregnancy. She is co-director of the UK Obstetric Neurology Course. She currently is the Senior Independent Responsible Officer for Women’s Services for NHS Cheshire and Merseyside.

Dr Melanie Nana

King’s College London

Melanie Nana is an NIHR clinical research fellow and obstetric medicine registrar and at King’s College London. She holds an endocrinology national training number in Wales but moved to London in 2020 to undertake the clinical fellowship at St. Thomas’ Hospital during which time she was taught obstetric medicine by Professor Nelson-Piercy and completed the Royal College of Physicians credential in Obstetric Medicine. She is the current RCP Trainee Committee Co-Chair.

Melanie has several publications related to obstetric medicine and is co-author of the European Guideline for Liver Disease and Pregnancy and upcoming RCOG Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum.

She was awarded an NIHR research training fellowship in 2021. Her PhD, supervised by Professor Williamson, focusses on the nutritional status of women with hyperemesis gravidarum and the neurodevelopmental and metabolic consequences for their children.

Dr Michael Desborough

Oxford University Hospitals
NHS Foundation Trust

Mike Desborough is a consultant haematologist at Oxford University Hospitals NHS Foundation Trust. He subspecialises in immunohaematology, transfusion medicine and obstetric haematology. He is the lead for the Oxford specialised thrombotic thrombocytopenic purpura (TTP) and immune thrombocytopenia (ITP) centres. He is an associate professor at the University of Oxford where his research focuses on platelets and intracerebral haemorrhage.

Dr Oseme Etomi

Guy’s and St Thomas’ Hospital and the Queen Elizabeth Hospital

Dr Oseme Etomi is a Consultant Rheumatologist and Obstetric Physician in South East London and works across 2 NHS trusts including Guy’s and St Thomas’ Hospital and the Queen Elizabeth Hospital in Woolwich.

She trained in North-East London, in some of the most prestigious centres for Rheumatology including the Royal Free Hospital (National Centre for Scleroderma and other Connective tissue disorders) and Bart’s and the Royal London (National Centre of inflammatory arthritis and SLE). In 2017, Oseme undertook a clinical fellowship at St Thomas’s Hospital under Professor Nelson Piercy.

Within the field of Obstetric Medicine, her main interest is looking after women with inflammatory diseases and immunosuppression in pregnancy. She runs a weekly inflammatory rheumatic disease and a weekly inflammatory bowel disease clinic in pregnancy.

Oseme has published abstracts and papers on Inflammatory Rheumatic Disease in pregnancy. In 2018 she was awarded the best oral presentation at the international Society of Obstetric Medicine for her work in this field. She was also instrumental in setting up the British Society of Rheumatology Specialist interest group in Pregnancy in 2019. She sits on the advisory board for the Biologics in Rheumatoid arthritis Pregnancy (BiRAP) group and was one of the organisers of the highly successful 12th Rheumapreg Symposium in September 2023 in London.

Her other interests include work on diversity, inclusion and wellbeing. She is the lead for trainee wellbeing in O&G at GSTT. A role she is extremely passionate about.

Dr Paarul Prinja

Royal Wolverhampton NHS Trust

Dr Paarul Prinja works at Royal Wolverhampton NHS Trust as both and Acute and Obstetric Physician. She is also the lead Obstetric Physician for the West Midlands Maternal Medicine Network. She is also Treasurer for the Macdonald Obstetric Medicine Society.

She has also trained in intermediate critical care and is proficient in using ultrasound and has accreditation in focussed echocardiography. Simulation training and education of the multi-disciplinary team are her particular areas of interest, and she teaches locally on ‘ObSIM’ and nationally as course director for “Enhanced maternal care” run by Babylifeline training. Most recently she is one of the co –authors of the RCP acute care toolkit 15 “Managing acute medical problems in pregnancy”

Dr Pooja Dassan

London North West University Healthcare NHS Trust

Pooja Dassan is a Consultant Neurologist, working at London North West University Healthcare NHS Trust (LNWUHT) and Imperial College Healthcare NHS Trust. She is the Associate Medical Director and Clinical Lead of Neurology at LNWUHT.

She has a specialist interest in Obstetric-Neurology and has led a joint clinic at Queen Charlotte’s and Chelsea Hospital for the last 10 years. She reviews women with a wide range of neurological issues for preconception counselling, antenatal and postnatal care.

She is an assessor for the MBRRACE confidential enquiry, reviewing maternal deaths from neurological causes across the UK.

She has co-authored the UK Consensus Guidelines on the Management of Multiple Sclerosis in Pregnancy, published in Practical Neurology in 2019.

Dr Siara Teelucksingh

Guy’s and St. Thomas’ NHS Foundation Trust

 

Dr. Siara Teelucksingh is a Consultant Acute and General Physician at Guy’s and St. Thomas’ NHS Foundation Trust and Consultant Obstetric Physician for the South West London and Surrey Heartlands Maternal Medicine Network.

Siara completed her undergraduate training at the University of the West Indies in Trinidad and Tobago and her postgraduate training in the London deanery.

Siara has a passion for acute care delivery and service design in maternity, and has led on education initiatives including multidisciplinary simulation training, hosting the PACES examination cycles and has delivered Obstetric Medicine themed lectures for the Royal College of Physicians.

Siara’s commitment extends to global health, where she has initiated a groundbreaking project to introduce Obstetric Medicine to the West Indies.

Dr Tim Korevaar

Erasmus University Medical Center

Tim Korevaar is an obstetric internist and endocrinologist at the Erasmus University Medical Center in Rotterdam, the Netherlands. His key interest is gestational and placental endocrinology including thyroid disease in fertility and pregnancy. Doctor Korevaar is the co-founder and coordinator of the Consortium on Thyroid and Pregnancy, the co-chair of the current ATA guidelines on Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum and co-chair of the European Thyroid Association Guidelines on Hypothyroidism and Thyroid Autoimmunity During Pregnancy. He has been awarded with the Dutch Royal Academy of Sciences Early Career Award and the ESE Young Investigator Award and has published more than 140 peer-reviewed articles.

Professor Yvonne Gilleece

University Hospitals Sussex NHS Trust

Yvonne Gilleece trained in Dublin and London, is an Honorary Clinical Reader and Consultant in HIV & Sexual Health at University Hospitals Sussex NHS Trust and Brighton Medical School.

She has a special interest in HIV & Women and is Vice Chair of WAVE, Chair of SWIFT, promoting research in women living with HIV, Honorary Secretary of BHIVA and Chair of the BHIVA Pregnancy Guidelines. She also specialises in HIV and Bone and HIV and Hepatitis Coinfection & Liver Dysfunction.