2481 Severe Transaminitis in Intrahepatic Cholestasis of Pregnancy: An Atypical Presentation

Abstract

INTRODUCTION: Intrahepatic cholestasis of pregnancy (ICP) is a self-resolving hepatic condition noted during the second and third trimesters of pregnancy. ICP is a relatively benign condition. However in severe cases ICP can influence fetal outcomes resulting in prematurity and rarely intrauterine fetal demise. Diagnosis of ICP is clinical and suspected when pregnant patients present with moderate to severe pruritus and concomitant elevation in serum aminotransferases and/or bile acids. Total bile acid levels can rise by 10- to 25-fold, however aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels do not characteristically increase more than two times the upper limit of normal. The mainstay of treatment, ursodeoxycholic acid (UDCA) offers symptomatic relief of pruritus and may benefit fetal outcomes. Delivery of the fetus is followed by resolution of pruritus and normalization of transaminases and bile acids. Our case describes a rare presentation of ICP with marked 10-fold increase in AST and nearly 30-fold increase in ALT. CASE DESCRIPTION/METHODS: A 31-year-old female at 28 weeks gestation was admitted for two-day history of generalized pruritus and abnormal transaminases on surveillance testing. Past histories remarkable cholecystectomy following gallstone pancreatitis. Physical examination was benign and was without scleral icterus or jaundice. Investigations were remarkable for: alkaline phosphatase (ALK) 172, gamma glutamyl transferase (GGT) 20, AST 465, ALT 1023, and total bile acids 48.7. Further evaluations revealed negative hepatitis serologies and chronic liver disease work-up, liver doppler ultrasound without occlusion, MRCP without choledocholithiasis or other features of pancreaticobiliary pathology. The patient was started on UDCA and continued follow-up with Gastroenterology and Obstetric Clinics. Shortly after initiation of UDCA, transaminases began a steady down trend. After delivery of a healthy fetus, the patient's transaminases returned to baseline levels. DISCUSSION: Classically ICP presents with mild AST and ALT elevations no more than two times the upper limit of normal. In cases of ICP presenting with marked transaminitis it is important to exclude other causes of cholestasis and hepatic disease including viral hepatitis, gallstones, preeclampsia, and HELLP syndrome. With close multi-disciplinary monitoring, even severe cases of ICP can lead to favorable fetal and maternal outcomes including complete resolution of transaminitis and uncomplicated fetal delivery.