I'm pregnant (30 weeks) and my liver enzymes blood test

Patient

Q: I'm pregnant (30 weeks) and my liver enzymes blood test results are AST 56 and ALT 52. All my other values fell in normal range. I have upper right abdominal pain but my ultrasound didn't show anything wrong in the liver and gallbladder. I already been tested for all types of hepatitis and they are all good. I'm dietitian, health coach and fitness group instructor. I workout everyday and eat a low carb diet. My IMC before pregnancy was around 19,5 and in the last 15 years my body fat percentage is lower than 15%.
With 39 years old and a healthy life style do I need to be worried about this lab values?

Doctor

A:   Hello,
Thanks for the query to ATD for an opinion,

At 30 weeks pregnancy, with recent onset deranged liver function tests and right upper quadrant pain with no hepatitis indicates a probable diagnosis of intrahepatic cholestasis of pregnancy if the remaining blood picture doesn't show any homeless or low platelet as seen in HELLP syndrome.

Intrahepatic cholestasis of pregnancy (ICP) is a reversible type of hormonally influenced cholestasis. It frequently develops in late pregnancy in individuals who are genetically predisposed.[1] It is the most common pregnancy-related liver disorder. It is characterized by generalized itching, often commencing with pruritus of the palms of the hands and soles of the feet, with no other skin manifestations. It most often presents in the late second or early third trimester of pregnancy. Pruritus associated with ICP is often worse at night and the pruritus may be so severe that it can affect the patient’s quality of life, even leading to suicidal ideation. Steatorrhea and vitamin K deficiency may also occur due to fat malabsorption. If the vitamin K deficiency is not corrected by the time of delivery, a postpartum hemorrhage may ensue.

However the liver enzymes have been moderately elevated and i believe serum direct and indirect / total bilirubin levels are present normal, this may just be the very onset of ICP. Jaundice may occur in 17-75% of cases of intrahepatic cholestasis of pregnancy (ICP) but typically develops 1-4 weeks after the onset of pruritus. Multiple laboratory abnormalities can be seen in ICP. The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic/chenodeoxycholic acid level ratio. The elevation of aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase. Hence it is suggested that serum bile acid levels should be done as well and if there is itching over the skin which may increase in next few days then diagnosis of ICP is likely.

Other differential diagnosis can be hepatitis of pregnancy, pre-eclampsia, cholelithiasis ( ruled out by USG), acute fatty liver of pregnancy. It is important to rule these out as well. Maternal outcomes for patients diagnosed with ICP are good, with few, if any, long-term sequelae; however, fetal outcomes can be devastating. Thus, early recognition, treatment, and timely delivery are imperative. If diagnosed then you may have to be started on UDCA tabs daily 300mg thrice a day till one week after delivery and the delivery should be timed by 37 weeks by elective induction of labour to prevent metal morbidity.

It is suggested that you should discuss the option with your physician and get evaluated for the same. If ruled out then you can be placed under observation and every 2 weekly liver function monitoring and can be treated on lines of hepatica of pregnancy.
I hope i have answered your query in detail,
Wishing you safe pregnancy,
Regards

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