A 20-year-old woman with abnormal liver-function test results in the third trimester of pregnancy

Abstract

A Z&year-old pregnant Hispanic woman was admitted to the hospital in the 34th week of gestation with right-sided abdominal pain and premature contractions. Her only previous pregnancy, 2 years earlier, ended with an uncomplicated normal spontaneous vaginal delivery. Before admission, this second pregnancy had also been uncomplicated. An ultrasonogram performed early in the second trimester revealed no fetal abnormalities. Results of a serum alpha-fetoprotein test were normal. Results of Hepatitis B surface antigen and antibody to hepatitis B surface antigen tests were negative in the first trimester. The patient’s abdominal pain began suddenly while she was recumbent, and she promptly came to the hospital. She localized the discomfort to approximately 7 cm to the right of the umbilicus. At admission, results of the physical examination of her abdomen were normal. Her blood pressure, pulse, and temperature were also normal. An external monitor revealed mild uterine contractions. Terbutaline was administered subcutaneously, causing relief of her symptoms. Admission laboratory tests revealed a hematocrit of 33.2%, a white blood cell count of 7,9OO/pL, platelet count of 23O,OOO/pL, normal prothrombin and partial thromboplastin times, blood urea nitrogen (BUN] concentration of 7 mg/dL, creatinine concentration of 0.5 mg/dL, normal electrolyte levels, and a glucose concentration of 73 mg/dL. Results of her liver function tests were abnormal: alanine aminotransferase (ALT) concentration was 166 IU/L (normal, 13-41 IU/L), aspartate aminotransferase (AST) concentration was 81 IU/L (normal, 8-40 IU/L), alkaline phosphatase concentration was 198 IU/L (normal, 21-130 IU/L in nonpregnant women), and total bilirubin concentration was 0.8 mg/dL (normal, O-l.5 mg/dL). Results of urine analysis were negative for glucose, protein, and ketones. The patient denied having a history of hepatitis, blood transfusions, IV drug abuse, alcohol abuse, travel outside the continental United States, and other illness or use of antibiotics during pregnancy. She had no history of pruritus. She reported living in the Boston area all her life. Her family history was notable for cirrhosis in two maternal grandparents, both of whom were alcoholics. There was no family history of diabetes, congestive heart failure, or pruritus during pregnancy. Her medications during pregnancy consisted of iron sulfate and multivitamins. She was maintained on oral terbutaline therapy for premature contractions. She reported no further abdominal pain in the first three hospital days. Results of liver function tests remained essentially the same for the first 3 days of hospitalization. Her blood pressure was normal. Her hematocrit, white blood cell count, platelet count, and urine analysis results did not significantly change. An evaluation of her blood smear showed no signs of hemolysis. An abdominal ultrasound examination obtained on the second hospital day showed no gallstones, no focal lesions in the liver, normal bile ducts, and a normal intrauterine pregnancy consistent with estimated dates. On the fourth hospital day, she had a single episode of nausea and vomiting, but otherwise felt well. Also on day 4 of her hospitalization, her liver tests revealed an ALT concentration of 281 IU/L, AST concentration of 194 IU/L, alkaline phosphatase concentration of 202 IU/L, and total bilirubin concentration of 1.1 mg/dL. A gastroenterological consultation was requested. Physical examination revealed no stigmata of chronic liver disease, an enlarged uterus with palpable fetal movement, no abdominal tenderness or masses, no hepatosplenomeg aly, and no jaundice. Her vital signs were normal with the exception of a resting tachycardia, and she had no edema. Results of heart and lung examinations were normal. Her only medication was terbutaline.