Acute painless hepatitis in pregnancy—a cause for concern?

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.