GASTROENTEROLOGY
1991;100:1123-1125
Intrahepatic Cholestasis of Pregnancy and Acute Fatty Liver of Pregnancy An Unusual
But Favorable Association?
DENIS VANJAK, RICHARD MOREAU, JACQUELINE ROCHE-SICOT, ANNEl SOULIER, and CHRISTIAN SICOT Service de RBanimation et de MBdecine d’urgence, Service de MBdecine Interne, and Service d’Anatomo-Pathologie, Centre Hospitalier Emile Roux, Eaubonne, France
During the 26th week of a first pregnancy, a 25-yearold woman presented with pruritus suggesting an intrahepatic cholestasis of pregnancy. The pruritus, however, persisted despite the premature delivery of a normal newborn at the 35th week. Moreover, aspartate aminotransferase activity increased, reaching a maximum of 36 times normal level on the 17th day after the delivery. Thus, an acute fatty liver of pregnancy was suspected and confirmed by liver biopsy. This patient appeared to have both intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy, an association not previously reported. It is suggested that intrahepatic cholestasis of pregnancy caused premature delivery, which in turn may have prevented the onset of severe maternal and fetal complications caused by acute fatty liver of pregnancy.
he association of intrahepatic nancy with acute fatty liver yet been reported. We describe whom the association of these have occurred during the same
T
cholestasis of pregof pregnancy has not a case of a patient in two syndromes might pregnancy.
Case report A 25year-old woman was admitted to the hospital because of pruritus and abnormal liver function tests during her first pregnancy. The patient was well until she began to complain of a pruritus at the 26th week of the pregnancy. No physical signs accompanied this pruritus. The patient consulted a physician during the 33rd week of pregnancy and was then transferred to this hospital. She drank no alcohol, consumed a balanced diet, and had gained 8 kg during her pregnancy. There was no history of drug addiction, nausea, vomiting, jaundice, hepatitis, blood transfusion, fever, or ingestion of tetracycline or acetaminophen. She had taken oral contraceptive steroid with no side
effects; this treatment had been stopped 1 year before the onset of the gestation. There was no family history of jaundice during pregnancy. On examination the patient was in good condition. Temperature was 37.2”C, pulse rate 84, and respirations 14. Blood pressure was 95/60 mm Hg. No jaundice, spider angiomas, rash, petechiae, ecchymoses, lymphadenopathy, or peripheral edema were found. The lungs and heart were normal. Abdominal examination showed that the uterus was firm. No sign of fetal distress was noted. The edge of the liver was percussed at the right costal margin and was smooth; the liver had a vertical span of 12 cm. Rectal examination showed no abnormality. Neurological examination had negative results; no asterixis was observed. The main laboratory values are shown in Table 1. Other findings were 5’-nucleotidase, 11 U/L (normal value, < 2 U/L); serum total protein, 71 g/L (normal range, 65-80 g/L); serum albumin, 35 g/‘L [normal range, 42-54 g/L]; a,globulin, 7 g/L (normal range, 5-10 g/L); y-globulin, 11 g/L (9-15 g/L); hemoglobin, 132 g/L; white blood cell count, 76OO/p.L; and platelet count, 289,OOO/p.L. The prothrombin and partial thromboplastin times were normal. Tests for hepatitis B surface antigen, surface antibody, and core antibody were negative. Hepatitis A antibody [Immunoglobulin M (IgM)] was negative. Tests for serology for cytomegalovirus, rubella, herpes, Epstein-Barr virus, and toxoplasmosis were negative. Tests for antibodies to mitochondria, smooth muscle, nuclei, and DNA were negative. A culture test of urine and three blood culture tests were negative. Ultrasound examination of liver and biliary tract showed no abnormality. The diagnosis of intrahepatic cholestasis of pregnancy was made. Cholestyramine was prescribed (12 g/day). During the 34th week of pregnancy, pruritus mildly improved while liver function tests worsened (Table 1). The delivery occurred spontaneously without complications during the
Abbreviation used in this paper: GGTP, y-glutamyl transpeptidase. o 1991 by the American Gastroenterological Association oom-5085/91/$3.00
GASTROENTRROLOGYVol. 100, No. 4
1124 VANJAKETAL.
Table 1. Serial Liver Biochemical Tests
Normal 2104186 2/11/88 2116186
2125186 2127188 3103186 3106186 3111186 3125186 6122187
TB (WOW
CB
GGTP
AST
(jl.mol/Ll
WlL)
(ULI
1991;100:1123-1125
Intrahepatic Cholestasis of Pregnancy and Acute Fatty Liver of Pregnancy An Unusual
But Favorable Association?
DENIS VANJAK, RICHARD MOREAU, JACQUELINE ROCHE-SICOT, ANNEl SOULIER, and CHRISTIAN SICOT Service de RBanimation et de MBdecine d’urgence, Service de MBdecine Interne, and Service d’Anatomo-Pathologie, Centre Hospitalier Emile Roux, Eaubonne, France
During the 26th week of a first pregnancy, a 25-yearold woman presented with pruritus suggesting an intrahepatic cholestasis of pregnancy. The pruritus, however, persisted despite the premature delivery of a normal newborn at the 35th week. Moreover, aspartate aminotransferase activity increased, reaching a maximum of 36 times normal level on the 17th day after the delivery. Thus, an acute fatty liver of pregnancy was suspected and confirmed by liver biopsy. This patient appeared to have both intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy, an association not previously reported. It is suggested that intrahepatic cholestasis of pregnancy caused premature delivery, which in turn may have prevented the onset of severe maternal and fetal complications caused by acute fatty liver of pregnancy.
he association of intrahepatic nancy with acute fatty liver yet been reported. We describe whom the association of these have occurred during the same
T
cholestasis of pregof pregnancy has not a case of a patient in two syndromes might pregnancy.
Case report A 25year-old woman was admitted to the hospital because of pruritus and abnormal liver function tests during her first pregnancy. The patient was well until she began to complain of a pruritus at the 26th week of the pregnancy. No physical signs accompanied this pruritus. The patient consulted a physician during the 33rd week of pregnancy and was then transferred to this hospital. She drank no alcohol, consumed a balanced diet, and had gained 8 kg during her pregnancy. There was no history of drug addiction, nausea, vomiting, jaundice, hepatitis, blood transfusion, fever, or ingestion of tetracycline or acetaminophen. She had taken oral contraceptive steroid with no side
effects; this treatment had been stopped 1 year before the onset of the gestation. There was no family history of jaundice during pregnancy. On examination the patient was in good condition. Temperature was 37.2”C, pulse rate 84, and respirations 14. Blood pressure was 95/60 mm Hg. No jaundice, spider angiomas, rash, petechiae, ecchymoses, lymphadenopathy, or peripheral edema were found. The lungs and heart were normal. Abdominal examination showed that the uterus was firm. No sign of fetal distress was noted. The edge of the liver was percussed at the right costal margin and was smooth; the liver had a vertical span of 12 cm. Rectal examination showed no abnormality. Neurological examination had negative results; no asterixis was observed. The main laboratory values are shown in Table 1. Other findings were 5’-nucleotidase, 11 U/L (normal value, < 2 U/L); serum total protein, 71 g/L (normal range, 65-80 g/L); serum albumin, 35 g/‘L [normal range, 42-54 g/L]; a,globulin, 7 g/L (normal range, 5-10 g/L); y-globulin, 11 g/L (9-15 g/L); hemoglobin, 132 g/L; white blood cell count, 76OO/p.L; and platelet count, 289,OOO/p.L. The prothrombin and partial thromboplastin times were normal. Tests for hepatitis B surface antigen, surface antibody, and core antibody were negative. Hepatitis A antibody [Immunoglobulin M (IgM)] was negative. Tests for serology for cytomegalovirus, rubella, herpes, Epstein-Barr virus, and toxoplasmosis were negative. Tests for antibodies to mitochondria, smooth muscle, nuclei, and DNA were negative. A culture test of urine and three blood culture tests were negative. Ultrasound examination of liver and biliary tract showed no abnormality. The diagnosis of intrahepatic cholestasis of pregnancy was made. Cholestyramine was prescribed (12 g/day). During the 34th week of pregnancy, pruritus mildly improved while liver function tests worsened (Table 1). The delivery occurred spontaneously without complications during the
Abbreviation used in this paper: GGTP, y-glutamyl transpeptidase. o 1991 by the American Gastroenterological Association oom-5085/91/$3.00
GASTROENTRROLOGYVol. 100, No. 4
1124 VANJAKETAL.
Table 1. Serial Liver Biochemical Tests
Normal 2104186 2/11/88 2116186
2125186 2127188 3103186 3106186 3111186 3125186 6122187
TB (WOW
CB
GGTP
AST
(jl.mol/Ll
WlL)
(ULI
