2251 An Atypical Case of Recurrent Intrahepatic Cholestasis of Pregnancy

Abstract

INTRODUCTION: Intrahepatic cholestasis of pregnancy (ICP) usually manifests in the second to third trimester with pruritus, jaundice and abnormal liver tests. It can increase risks of preterm birth, respiratory distress syndrome, and stillbirth. Timely diagnosis and planned delivery are crucial. We hereby describe an atypical case of recurrent ICP. CASE DESCRIPTION/METHODS: Patient is a 31-year-old Chinese female who presented to hepatology clinic at week-13 of her second pregnancy. During her first pregnancy 4 years ago, she experienced pruritus associated with significant elevation of bile acids and serum aminotransferases at about 20-week gestation. Diagnosis of ICP was made and she was promptly started on ursodeoxycholic acid (URSO) [Figure 1]. Bile acids improved and pruritus resolved but she had a preterm delivery at 30-week gestation. URSO was discontinued after delivery and bile acids were completely normal by 6 weeks postpartum. The ALT levels, however, increased to >200 U/L and remained abnormal for 10 months post-partum [Figure 1]. Other common causes of liver diseases such as viral hepatitis, autoimmune and drug-related liver diseases were ruled out. Her liver biopsy reported only non-specific resolving inflammation. For her second pregnancy, bile acids were checked at 14-week gestation and were mildly elevated at 14.7umol/L; they increased to 20.8 umol/L by 26 weeks. At that time, she experienced mild pruritus. URSO was initiated at 28-week gestation for recurrent ICP. Despite being on URSO for 3 weeks, ALT normalized but bile acid increased further to 53.5 umol/L without worsening of pruritus. Induced labor was planned at week-37 and the delivery was uneventful.URSO was subsequently discontinued. At week-3 postpartum, URSO was reinitiated for her ALT significantly elevated at 259 U/L even though bile acids continued to decrease. About 1 week after starting URSO, ALT decreased to 62 U/L and bile acids completely normalized. DISCUSSION: ICP usually resolves after delivery and URSO can be discontinued. Our case was atypical for her serum aminotransferases actually markedly increased during early postpartum in both pregnancies despite improvement of the bile acid levels. URSO was promptly reinitiated postpartum that resulted in reduction of ALT. For patients with elevated liver tests associated with ICP, physicians need to be vigilant in monitoring the patient closely during postpartum period and consider continuing URSO therapy until both serum aminotransferases and bile acids return to normal range.