Endgames Case Report

Acute painless hepatitis in pregnancy—a cause for concern?

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7686 (Published 30 December 2014) Cite this as: BMJ 2014;349:g7686
  1. Michael Ankcorn, specialist registrar in infectious diseases and virology12,
  2. Cariad Evans, specialist registrar in infectious diseases and virology12,
  3. Stephen Thomas Green, professor of infectious diseases1
  1. 1Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield S10 2JF, UK
  2. 2Northern General Hospital, Sheffield Teaching Hospitals, Sheffield S5 7AU, UK
  1. Correspondence to: M Ankcorn mjankcorn{at}gmail.com

A 26 year old woman, who was 19 weeks’ pregnant, was referred by her general practitioner with acute onset hepatitis and painless jaundice. She described a four week history of lethargy and palpitations on exertion. She also reported febrile episodes over the past three days, with no other clinical features on systems inquiry.

Her medical history included pre-eclampsia in her first pregnancy, which resulted in induction at 40+1 weeks and a caesarean section. She was taking aspirin at presentation but no other drugs. She had a history of allergy to penicillin and latex, which both caused a rash. She was married with a 2 year old son and worked as a pharmacy dispenser. She reported no recent travel outside the UK, no unusual hobbies, no risk factors for acquiring blood borne viruses, and no contacts with similar symptoms.

Baseline bloods tests showed alanine aminotransferase 1779 U/L (reference range 0-41; 1 U/L=0.02 µkat/L), total bilirubin 65 µmol/L (0-21), albumin 33 g/L (35-50), and prothrombin time of 11.4 s (9.7-11.5). Her full blood count was normal. During admission her transaminases rose and her prothrombin time increased.

Questions

  • 1. What are the viral causes of hepatitis in pregnancy and which are of greatest concern?

  • 2. What are the tests for an acute viral hepatitis?

  • 3. How might this patient have acquired this condition?

  • 4. What infection control measures should be taken?

  • 5. How would you manage this patient?

Answers

1. What are the viral causes of hepatitis in pregnancy and which are of greatest concern?

Short answer

Viral causes include hepatitis A, B, C, D, and E, as well as cytomegalovirus and Epstein-Barr virus. These infections can occur during any trimester. Cytomegalovirus is associated with congenital infection and hepatitis E virus is associated with fulminant hepatitis in pregnancy. In rare cases herpes simplex and varicella zoster viruses can cause hepatitis and are associated with congenital and perinatal infection.

Long answer

Common causes of acute viral …

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