Wayne State University, Detroit Medical Center, MI, United States
Ahmad Abu-Heija, MBBS, Thomas E. Kelly, MD Wayne State University, Detroit Medical Center, Detroit, MI
Introduction: Hyperemesis Gravidarum (HG) is an uncommon, yet serious condition diagnosed in up to 3% of pregnant females during the first-trimester of pregnancy. The condition is characterized by intractable, dehydrating vomiting, associated with weight loss, and necessitating hospitalization for intravenous fluid (IV) hydration. The condition is usually self-limited, terminating spontaneously by week 20 of gestation. Upwards of 50% of patients with HG can suffer from some degree of liver injury characterized by mild elevations in aminotransferases.
Case Description/Methods: 22-year-old primigravida-nulliparous female in week 15 of gestation presented with intractable vomiting for 4 weeks with associated loss of 8% of her pre-gestational body weight. Laboratory studies on admission revealed evidence of severe liver injury with prolonged prothrombin time at 20 seconds, albumin of 3.0 gm/dL, total bilirubin of 2.9 mg/dL, aspartate aminotransferase of 244 U/L, and alanine aminotransferase of 944 U/L. She received supportive therapy with IV fluids and anti-emetics with symptom resolution. Work up to identify etiology of liver injury including a liver ultrasound with duplex of the hepatic vein was normal. Serological studies including acetaminophen levels, immunoglobulin M to hepatitis A, hepatitis B surface antigen, hepatitis B e antigen, immunoglobulin M to hepatitis B core antigen, anti-hepatitis C virus antibody, hepatitis C RNA PCR, immunoglobulin M to hepatitis E, immunoglobulin M to Ebstein-Barr virus, anti-nuclear antibody, anti-smooth-muscle antibody, anti-mitochondrial antibody, liver-kidney microsomal antibody were all negative. On day 3 of admission, patient suffered from fetal demise followed by successful abortion induction. Follow up laboratory studies showed continuous improvement in prothrombin time, albumin, bilirubin, and aminotransferases, Figure 1, and she was discharged on Day 4. On follow up, after 10 days, patient was asymptomatic and had normalization of all laboratory studies.
Discussion: Early pregnancy liver injury should be approached with the same clinical intuition as non-pregnant patients, aiming at identifying common etiologies such as viral hepatitis, DILI, gallstones, and Budd-Chiari syndrome. Nevertheless, gastroenterologists should be aware of early pregnancy liver complications of a common disease affecting 3% of pregnant females, and in the right setting, include acute liver failure secondary to HG in the differential diagnosis.
Figure: Figure 1. Change in liver enzymes/INR over patient's hospitalization and on follow-up after discharge.
Ahmad Abu-Heija indicated no relevant financial relationships.
Thomas Kelly indicated no relevant financial relationships.
Ahmad Abu-Heija, MBBS, Thomas E. Kelly, MD. P1887 - Hyperemesis Gravidarum: Rare Cause of Severe Liver Injury in Pregnancy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.