What is considered a clinically relevant increase in Alanine Transaminase (ALT) and Aspartate Transaminase (AST) in a pregnant patient without other signs of Hemolysis, Elevated Liver enzymes, and Low Platelet count (HELLP) syndrome?

From the Guidelines

In pregnant patients without other signs of HELLP syndrome, a clinically relevant increase in ALT and AST is typically considered to be 2-3 times the upper limit of normal, with values exceeding 70-100 U/L for ALT or AST warranting clinical attention and further evaluation, as stated in the most recent guidelines 1.

Key Considerations

• The interpretation of liver enzyme elevations should always consider the gestational age and clinical context, taking into account the physiological changes that occur during pregnancy 1.
• Mild elevations (less than twice the upper limit of normal) are relatively common in pregnancy due to these physiological changes and may not indicate pathology, but progressive increases in transaminases, even if modest, are more concerning than stable values 1.
• Early detection of significant liver enzyme elevations is crucial because they may precede the development of full HELLP syndrome, a serious complication of preeclampsia that requires prompt intervention to prevent maternal and fetal morbidity and mortality 1.

Evaluation and Management

• A comprehensive assessment should be prompted by significant liver enzyme elevations, including additional laboratory tests (complete blood count, platelets, bilirubin, and coagulation studies), blood pressure monitoring, and evaluation for proteinuria 1.
• The management of liver diseases in pregnancy should be guided by the most recent clinical practice guidelines, which emphasize the importance of pre-pregnancy counseling, optimization of health and disease management prior to pregnancy, and prompt investigation and management of gestational liver disorders 1.

Clinical Context

• The clinical context, including the presence of other signs or symptoms of liver disease or preeclampsia, should be carefully considered when interpreting liver enzyme elevations in pregnant patients, as the risk of maternal and fetal morbidity and mortality is significant if left untreated 1.

From the Research

Definition of Clinically Relevant Increase in ALT and AST

• A clinically relevant increase in ALT and AST in a pregnant patient without other signs of HELLP syndrome is not explicitly defined in the provided studies.
• However, according to the Tennessee Classification System, diagnostic criteria for HELLP syndrome include AST (>or= 70 U/L) 2.
• It is essential to note that the provided studies focus on the diagnosis and management of HELLP syndrome, rather than defining a clinically relevant increase in ALT and AST in the absence of other symptoms.

Diagnostic Criteria for HELLP Syndrome

• The Tennessee Classification System diagnostic criteria for HELLP syndrome include haemolysis with increased LDH (> 600 U/L), AST (>or= 70 U/L), and platelets < 100 x 10(9)/L 2.
• The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts 2.
• These criteria can be used to diagnose HELLP syndrome, but may not be directly applicable to defining a clinically relevant increase in ALT and AST in the absence of other symptoms.

Management of HELLP Syndrome

• Delivery is indicated if the HELLP syndrome occurs after the 34th week or the fetal and/or maternal conditions deteriorate 3, 2, 4.
• Vaginal delivery is preferable, and standard corticosteroid treatment is of uncertain clinical value in maternal HELLP syndrome 3, 2, 4.
• Close surveillance of the mother should be continued for at least 48 hours after delivery 3, 2.