2019 Research Forum

Simmer Kaur MD R2, Tamara Hilvers MS III, Arash Heidari MD Department of Internal Medicine, Kern Medical, Bakersfield, California HYPERBILIRUBINEMIA & TRANSAMINITIS SECONDARY TO HYPEREMESIS GRAVIDARUM

Purpose

Laboratory Data & Imaging

Treatment

Nausea and vomiting is common in pregnancy beginning in the first trimester and usually resolves spontaneously by the second trimester. Hyperemesis gravidarum occurs in up to 2% of pregnancies and is characterized by intractable nausea and vomiting. It can be associated with severe dehydration, electrolyte imbalances and liver abnormalities. However, very rarely patients do present with bilirubinemia and jaundice. Case History A 22-year-old Hispanic female presented to the hospital with an intrauterine pregnancy at 5 weeks gestation complaining of nausea and vomiting. This patient was treated with ondansetron and she showed significant clinical improvement. She was sent home with an anti-emetic and was advised to follow-up with her Obstetrician. In August 2017, this patient presented again to the emergency department at 13 and 4/7 gestation with a chief complaint of severe nausea and vomiting and a significant weight loss of 37 pounds since the last visit.

Patient was admitted for IV hydration and her nausea was controlled with IV reglan.

Hyperemesis gravidarum is a condition of intractable nausea and vomiting that occurs in up to 2% of pregnancies. Hyperemesis gravidarum can be associated with liver dysfunction and elevations in AST and ALT in 15% of these patients with a rare occurrence of jaundice with no other underlying liver disease. Management is supportive with rehydration and fasting for a short period of time. There is a resolution of liver abnormalities with the treatment of the underlying hyperemesis gravidarum. Over the hospital course, patient was able to tolerate PO intake. Liver and kidney function improved and patient was discharged home in stable condition with Zofran 4mg as needed for symptomatic control. Conclusions

Figure 1: Total and Conjugated Bilirubin levels in mg/dl over the course of hospital day admissions.

Figure 2: Liver function lab values measured in U/L over the course of hospital day admissions.

References

Allen, Alina M., et al. “The Epidemiology of Liver Diseases Unique to Pregnancy In A Community: A Population-Based Study.” Clinical Gastroenterology and Hepatology, vol. 14, no. 2, 2016. Boregowada, Geethanjali, and Hassan A Shehataq. “Gastrointestinal and Liver Disease in Pregnancy.” Best Practice & Research Clinical Obstetrics and Gynecology, 2013, pp. 835–853.

Physical Findings

Physical examination was significant for scleral icterus, moderate RUQ tenderness, and tachycardia. On neurological examination there was bilateral motor weakness in both upper and lower extremities.

Frise, C. J., and C. Williamson. “Gastrointestinal and Liver Disease in Pregnancy.” Clinical Medicine, vol. 13, no. 3, Jan. 2013, pp. 269–274.

Kia, Leila, and Mary E. Rinella. “Interpretation and Management of Hepatic Abnormalities in Pregnancy.” Clinical Gastroenterology and Hepatology, vol. 11, no. 11, 2013, pp. 1392–1398. Than, Nwe Ni, and James Neuberger. “Liver Abnormalities in Pregnancy.” Best Practice & Research Clinical Gastroenterology, vol. 27, no. 4, 2013, pp. 565–575. Pubmed, doi:10.1016/j.bpg.2013.06.015.

97