What is the management for a 38-week pregnant patient with significantly elevated Alanine Transaminase (ALT) levels?

Management of 38-Week Pregnant Patient with ALT 1251 U/L

This patient requires urgent evaluation for acute fatty liver of pregnancy (AFLP) or HELLP syndrome, immediate intensive care admission if encephalopathy or metabolic derangements are present, and expedited delivery once maternal coagulopathy and severe hypertension are corrected. 1, 2

Immediate Diagnostic Workup

Obtain the following laboratory tests urgently to differentiate between pregnancy-specific liver emergencies:

• Complete liver panel: AST, bilirubin, GGT, alkaline phosphatase, and platelets 1, 3
• Coagulation studies: PT, INR, and fibrinogen to assess for AFLP or HELLP 3
• Metabolic markers: Serum lactate, glucose, ammonia, and creatinine 2
• Blood pressure measurement: To evaluate for preeclampsia/HELLP syndrome 2
• Total serum bile acids: To exclude intrahepatic cholestasis of pregnancy, though less likely with this degree of ALT elevation 1, 3

Critical Differential Diagnosis at 38 Weeks

At this gestational age with ALT >1200 U/L, the most likely diagnoses are:

HELLP Syndrome (Most Common)

• Look for hemolysis (elevated LDH, decreased haptoglobin, schistocytes), elevated liver enzymes (already present), and low platelets (<100,000/μL) 2
• Associated with severe hypertension (≥160/110 mmHg) and right upper quadrant pain 2
• Occurs in 31% of third-trimester cases with abnormal liver function tests 4

Acute Fatty Liver of Pregnancy

• Evaluate for encephalopathy, elevated serum lactate, or high Swansea criteria score (≥6 points) 2
• Check for hypoglycemia, elevated ammonia, prolonged PT, and low fibrinogen 3
• Has high mortality if unrecognized and requires intensive care admission 3

Viral Hepatitis Flare

• Obtain HBsAg, anti-HCV, HAV IgM, and HEV serologies to exclude viral hepatitis 3
• Hepatitis B flare is a significant cause of maternal mortality, particularly in chronic carriers 4
• Two maternal deaths from hepatitis B flare were reported in a Singapore cohort 4

Immediate Management Algorithm

Step 1: Assess Maternal Stability

• If encephalopathy, elevated lactate, or coagulopathy present: Admit to intensive care immediately 2
• If severe hypertension present (≥160/110): Administer intravenous labetalol, nifedipine, or methyldopa 2
• Administer magnesium sulfate to prevent eclamptic seizures if severe hypertension confirmed 2

Step 2: Correct Coagulopathy and Metabolic Derangements

• Transfuse fresh frozen plasma, cryoprecipitate, or platelets as needed to correct coagulopathy 2
• Treat hypoglycemia with intravenous dextrose if present 3
• Correct metabolic acidosis and support hemodynamics 2

Step 3: Expedite Delivery

• Deliver promptly once maternal coagulopathy and severe hypertension are corrected 2
• Do not delay delivery for complete laboratory confirmation if patient is unstable 3
• Expect rapid improvement postpartum with ALT dropping 50% within 3 days for pregnancy-related causes 4

Key Pitfalls to Avoid

• Do not assume normal alkaline phosphatase rules out liver disease, as it increases to 133-418 IU/L in normal third trimester 3
• Do not delay delivery for laboratory confirmation in unstable patients with third-trimester liver dysfunction 3
• Do not miss hepatitis B flare in chronic carriers who deteriorate postpartum, as this causes maternal mortality 4
• Do not attribute all liver dysfunction to pregnancy-related causes without excluding viral hepatitis and autoimmune hepatitis 3

Expected Postpartum Course

For pregnancy-related causes (HELLP, AFLP, ICP):

• ALT should drop 50% within 3 days of delivery 4
• Monitor liver function tests until normalization within 3 months postpartum 2
• If abnormalities persist beyond 3 months, refer to hepatology for evaluation of underlying chronic liver disease 1, 3

For hepatitis B flare:

• Patients may deteriorate postpartum despite delivery 4
• Consider antiviral therapy if hepatitis B flare confirmed 5