Question of the Week # 198

198)  A 26 year old pregnant woman is evaluated in the emergency Room for severe weakness and dehydration from persistent vomiting. She is a primigravida at 9 weeks gestation. She reports that her nausea and vomiting started at 5 weeks of pregnancy and have progressively become worse. She denies any abdominal pain or vaginal bleeding. She denies any headache. Her bowel movements are normal. Her past medical history is unremarkable. Her pre-pregnancy weight was 60lbs but now she weighs about 55lbs. Physical examination reveals dry oral mucosa. Laboratory tests reveal Serum sodium 140 meq/l, potassium 3.2meq/L, Chloride 102meq/l, Bicarbonate 34meq/L. hematocrit of 52 (normal = 36 to 46%); Total bilirubin of 2mg/dl; ALT of 160U/L and AST of 140U/L. Urine is positive for ketones. Ultrasound reveals normal fetus appropriate for 9 week gestation. Which of the following explains her jaundice and elevated liver function tests:

A) Acute pancreatitis

B) Acute Fatty Liver of pregnancy

C) Cholestatis of Pregnancy

D) Hyperemesis Gravidarum

E) HELLP Syndrome

6 Responses

  1. Is this hperemesis Dr Red, as AFP/cholestasis is more common in third trimester.hyperemesis can cause altered lft

  2. D…. Acute fatty Liver of Pregnancy associated with Hypoglycemia because of damaged liver so no more gluconeogenesis & alo elevated direct bilirubin

  3. very good question ! Tricky . haha

    answer : Cholestasis of pregnancy .

    It has nothing to do with the question at all . . The vignette is describing hyperemesis graviddarum : N/V + ketones positive .

    However , none were mention about pruritus which is common in Cholestasis of pregnancy .

    there’s mild elevation of bilirubin . Since the last sentences mention jaundice = it’s definitely Cholestasis of pregnancy .

    when COP superimposed with jaundice there’s a high risk of fetal lost , fetal prematurity , fetal distress .

    Just my 2 cents .

  4. D:) Spectrum of Maternal Liver Disease in Hyperemesis Gravidarum

    The spectrum of liver disease in HG is broad. With the exception of rare cases of jaundice, the clinical presentation of HG with and without liver involvement is nearly identical. Mild aminotransferase elevation (up to 200 U/l) is the most common liver laboratory abnormality seen in HG, although increased alkaline phosphatase up to twice normal values and mild hyperbilirubinemia (mixed direct and indirect fractions) up to 4 mg/dl may also occur.15 There are rare case reports of aminotransferases elevation greater than 1600 U/l, but fulminant liver failure in HG has not been reported.16,17 The severity of nausea and vomiting in patients with HG and liver disease, as a general rule, correlates with the degree of liver enzyme elevation.18 Imaging studies of the liver in patients with HG are usually unremarkable, although abdominal ultrasounds are always advised in patients with suspected HG in order to rule out gestational trophoblastic disease and multiple gestations. Liver biopsies are rarely necessary in HG and are performed in very few patients. When liver biopsies are done, they may show the histopathologic changes of necrosis, steatosis and bile plugs.15,19 The treatment for HG with liver disease is the same as HG without liver disease and usually entails hospitalization for intravenous fluids, intravenous antiemetics, bowel rest and, rarely, parenteral nutrition. Unlike the other pregnancy-related liver diseases discussed elsewhere in the text, HG with liver involvement is almost never fatal. Liver function abnormalities usually return to normal levels within a few days of volume expansion and the cessation of vomiting. No long-term sequelae of liver dysfunction have been described in patients with pregnancies complicated by HG and liver disease.

  5. differential Diagnosis of Liver Disease in Hyperemesis Gravidarum

    HG with liver disease is a diagnosis of exclusion, and the differential diagnosis of nausea and vomiting in pregnancy with abnormal liver function tests is extensive. Before the diagnosis can be made, disease states unrelated to pregnancy such as gastrointestinal disorders (e.g., viral hepatitis and cholecystitis), metabolic disease (e.g., diabetes and hyperthyroidism), and medication effects, must be ruled out. Other pregnancy-related conditions with nausea, vomiting and liver dysfunction such as the acute fatty liver of pregnancy (AFLP) and the hemolysis elevated liver enzymes and low platelets (HELLP) syndrome typically present in the third trimester of gestation and thus are readily distinguished from HG in most cases.

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