Kelly Zucker, DO1, Brian M. Fung, MD1, Nael Haddad, MD2, Shivang Mehta, MD1 1University of Arizona College of Medicine, Phoenix, AZ; 2University of Arizona, Phoenix, AZ
Introduction: Acute liver failure in pregnancy is a diagnostic challenge. Etiologies are vast, ranging from pregnancy specific causes to etiologies affecting the general population, such as drug induced liver injury (DILI). We present a 37-year-old pregnant patient presenting with acute liver injury progressing to acute liver failure.
Case Description/Methods: A 37-year- old female with hypertension and chronic pain presented as a transfer for abnormal LFTs at 13 weeks gestation. She initially presented with right upper quadrant pain (RUQ), bilirubin 2.8, AST 1125, ALT 1248, alkaline phosphatase 223. She underwent a laparoscopic cholecystectomy for presumed acute cholecystitis. She was transferred for rising LFTs.
At our facility, she had bilirubin 5.8, alkaline phosphatase 211, AST 1179, ALT 1545, INR 1.8. Given recent laparoscopic cholecystectomy, MRCP was completed showing a small amount of free fluid around the liver and spleen, no intra or extra hepatic biliary dilatation. She stated no new medications or supplements, and no history of liver disease. While waiting on liver biopsy results, she had an ERCP to evaluate for bile duct injury which did not show any defect. Biopsy showed acute hepatitis, predominantly portal and periportal inflammation, no significant fibrosis.
Further investigation found she had an episode of acute liver injury 7 years prior during a previous pregnancy. She had pre-eclampsia and was started on labetalol. LFTs rose, she had an inconclusive biopsy. LFTs recovered post-delivery with discontinuation of labetalol. She disclosed then she was put on lisinopril two years prior, and only recently started labetalol. Suspicion for DILI led to discontinuation labetalol. Unfortunately her LFTs, bilirubin, and INR rose. She became encephalopathic went into acute liver failure.
She was emergently listed and transplanted 3 days later. Explant showed massive hepatic necrosis, patchy microvesicular steatosis- consistent with DILI. Immunosuppression has been tailored for lowest risk options to the fetus.
Discussion: DILI is a diagnosis of exclusion, and was challenging in this case. There are few cases of DILI in pregnancy, and fewer related to labetalol. Only labetalol and methyldopa are reported to cause hepatoxicity in pregnancy. This case highlights a rare cause of DILI with a multi-disciplinary approach given early gestation. It is rare for a fetus to survive liver transplantation, and she will require intensive monitoring for the duration of her pregnancy in her post-transplant care.
Disclosures: Kelly Zucker indicated no relevant financial relationships. Brian Fung indicated no relevant financial relationships. Nael Haddad indicated no relevant financial relationships. Shivang Mehta indicated no relevant financial relationships.
Kelly Zucker, DO1, Brian M. Fung, MD1, Nael Haddad, MD2, Shivang Mehta, MD1. P0804 - DILI Leading to Acute Liver Failure in a Pregnant Patient, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
