Thomas Jefferson University Hospital Philadelphia, PA, United States
Jamie Huot, BSN1, Michael Zimmerman, MS, BS1, Scott Manski, MD2, Ana Angarita, MD2, Jesse Civan, MD2 1Thomas Jefferson University School of Medicine, Philadelphia, PA; 2Thomas Jefferson University Hospital, Philadelphia, PA
Introduction: Intrahepatic cholestasis of pregnancy (ICP) is a liver disease unique to pregnancy, typically presenting in the second or third trimester. Chronic viral hepatitis, in particular hepatitis C, is a known risk factor for ICP. Here we present a case of ICP in a patient with untreated chronic viral hepatitis B (HBV) infection, and recent intramuscular progesterone administration.
Case Description/Methods: A 39-year-old G3P0020 at 19 weeks gestation presented with jaundice, pale-colored stools, dark urine, and nausea of one week duration. She endorsed diffuse pruritus beginning at 16 weeks gestation, which began two days post progesterone injection, used to prevent pre-term labor in a high-risk pregnancy. She had recently been diagnosed with chronic HBV and, with normal alanine aminotransferase (ALT) at the time, had been planned to start anti-viral therapy in her third trimester to reduce risk of maternal-fetal transmission. Her pruritus persisted despite oral diphenhydramine and corticosteroids. Laboratory testing prior to admission revealed marked transaminase elevations: aspartate aminotransferase (AST) 1,098 IU/L, ALT 1,898 IU/L, hyperbilirubinemia (total bilirubin 3.4 mg/dL) and elevated total bile acids (328 umol/L). Upper limit of normal for bile acids is >10 umol/L with severe ICP having bile acid concentrations >40 umol/L. While hospitalized, lab values peaked at AST 1,739 IU/L, ALT 2,378 IU/L, and total bilirubin 7 mg/dL. HBV viral load on admission was 1.0 * 108. Abdominal ultrasound showed a normal-appearing liver. Fetal heart tones were normal. Further workup for other causes of liver injury was unrevealing. The patient was initiated on tenofovir and ursodiol. Subsequently, labs trended downward and the pruritis resolved. The patient was discharged on ursodiol and tenofovir.
Discussion: Our case is unique in its atypical early presentation of ICP at 19 weeks gestation, and in highlighting two lesser-known risk factors. Although chronic viral hepatitis C is a more established risk factor for ICP, a 2020 meta-analysis found that HBV infection was also a risk factor. Moreover, the use of systemic progesterone may have provoked this early presentation of ICP. A case-control study showed an association between vaginal progesterone (although not specifically intra-muscular) and ICP. Our case illustrates the multifactorial etiology of ICP, reinforces the reported association with chronic viral hepatitis B, and suggests an association with intramuscular administration of progesterone.
Disclosures: Jamie Huot indicated no relevant financial relationships. Michael Zimmerman indicated no relevant financial relationships. Scott Manski indicated no relevant financial relationships. Ana Angarita indicated no relevant financial relationships. Jesse Civan indicated no relevant financial relationships.
Jamie Huot, BSN1, Michael Zimmerman, MS, BS1, Scott Manski, MD2, Ana Angarita, MD2, Jesse Civan, MD2. P2881 - A Twin Diagnosis: Intrahepatic Cholestasis of Pregnancy in a Patient with Chronic Hepatitis B and Intramuscular Progesterone Use, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.