S2425 Pregnancy and Transaminitis in the COVID-19 Era

Abstract

INTRODUCTION: Liver complications associated with the novel corona virus, COVID-19 (SARS-CoV-2) are well-described phenomena occurring in approximately 60% of infected patients. The degree and extent in the level of transaminitis is not yet well defined. In the evaluation of transaminitis in pregnant patients, consideration of the differential diagnoses is important in order to provide appropriate timely treatment and management. Determining the exact etiology for transaminitis in the pregnant patient with COVID-19 is particularly challenging given other competing diagnosis in this patient population. We present a case of a pregnant woman with acute liver enzyme elevation in the setting of COVID-19 infection. CASE DESCRIPTION/METHODS: A 34 year old female with COVID-19 presented at 33 weeks twin gestation with right upper quadrant pain, vomiting for 2 days and acute respiratory distress which improved with supplemental oxygen. Initial labs showed elevated inflammatory markers, mildly elevated liver enzymes (AST 102, ALT 53 IU/L), low platelets (139 K/uL), lactate dehydrogenase was 375 IU/L, and INR was 1.0. Total bilirubin was normal. An abdominal ultrasound demonstrated cholelithiasis without evidence of cholecystitis, patent portal and hepatic veins, and no biliary ductal dilation. The next day, her liver enzymes increased (ALT; 119 IU/L and AST; 228 IU/L), and LDH rose to 750 IU/L while vital signs were unchanged. She was treated with N-acetyl-cysteine (non-acetaminophen-induced liver failure protocol) without improvement. The next day her liver enzymes peaked (ALT; 307 IU/L and AST; 641 IU/L). Due to rising liver enzymes, increased abdominal pain she underwent an emergency c-section to minimize maternal and fetal risk. Post-operatively, her ALT and AST down trended. On post-op day 4, aminotransferases markedly improved (AST of 20 IU/L, ALT of 49 IU/L), patients symptoms improved and patient was discharged home. DISCUSSION: Clinical presentation and associated liver complications of COVID-19 infection are not well described. Due to the rapid global spread of COVID-19, prompt identification of associated liver test abnormalities from other causes especially in pregnant patients is vital. It is also important to consider that COVID-19 may cause severe acute viral hepatitis rather than a mild elevation in liver enzymes in pregnant patients, possibly exacerbating underlying conditions such as pre-eclampsia or HELLP syndrome.Figure 1.: Graph Trending AST, ALT, LDH throughout Hospital Stay.Table 1.: Chart of Common Hepatic Complications in Pregnancy.