Case Presentation: 33 yr old pregnant female with a history of choleycystectomy, presented at 17 weeks gestational age (GA) to the hospitalist service with epigastric pain, vomiting and transaminitis. She had no pruritus, jaundice or hypertension. Her medications included vitamins and Anise (as a carminative). OB consult determined that the pain was not pregnancy related. Through supportive measures, she improved and tolerated oral intake. She was discharged but had five similar presentations with hospitalizations prior to 24 weeks GA.
See Table 1.

Her early GA made HELLP unlikely but this diagnosis was entertained as her pregnancy advanced and her platelets decreased. Despite reservations expressed by the OB providers, a liver biopsy was performed at 20 weeks GA as requested by the hospitalist service which showed patchy lobular inflammation, largely mononuclear, with scattered acidophil bodies and very mild lobular collapse on reticulin stain. No specific features of pre-eclampsia seen (such as periportal necrosis or fibrin thrombi).

She subsequently developed pregnancy complications including poor growth and reduced end diastolic flow on fetal middle cerebral artery dopplers, both predictors of poor fetal outcomes. Rheumatology consultants recommended that a trial of steroids was initiated but it did not improve lab values or symptoms. Fetal chromosomal analysis was normal. High frequency monitoring eventually showed fetal distress. At 23w6d GA she was noted to have mid range blood pressures, her platelet value was 38 and magnesium was started for seizure prophylaxis. Given worsening maternal health, she underwent induction of labor at 24 weeks and delivered a non-viable fetus. Her low platelets and transaminitis resolved post delivery.

Discussion: Hepatitis with abdominal pain in pregnancy has a wide differential and requires coordination between medical and obstetrical providers. At one point, the medical providers urged the obstetrical providers to pursue a liver biopsy which is not a typical diagnostic tool in liver disease of pregnancy. HELLP is rare before 20 weeks GA and associated with underlying pregnancy complications such as molar pregnancy, triploidy or antiphospholipid syndrome. Additionally, this patient reported taking an herbal supplement (Anise) that can cause hepatitis but her symptoms and signs did not improve with cessation. Liver biopsy was not diagnostic in this case. Ultimately, it was thought that this patient had a rare, early presentation of HELLP syndrome.

Conclusions: There are multiple potential causes of transaminitis, abdominal pain and thrombocytopenia to be considered in pregnant patients. Unfortunately, poor outcomes are expected with early presentation of HELLP. Placental diseases have a wide spectrum of presentation and may not fulfill all diagnostic characteristics. Her initial presentation and liver biopsy were not suggestive of HELLP. (see Figures 1&2) This patient’s resolution of lab abnormalities following delivery suggests that this was, in fact, pregnancy-related. The hospitalist must work diligently and collaboratively to evaluate and treat medical disease in a situation where obstetrical stakes are high. Treating obstetrical patients who are hospitalized for medical illnesses presents a unique set of challenges including medication and diagnostic workup safety.

IMAGE 1: Table 1. Case Findings

IMAGE 2: Liver Biopsy