S3286 Challenging the Diagnosis of ICP: A Pregnant Patient With Transient Cholestasis and COVID-19 Exposure

Introduction: Intrahepatic cholestasis of pregnancy (ICP) is a gestation specific liver disorder and presents during third trimester of pregnancy. Very rarely an ICP can occur early in pregnancy and usually associated with in vitro fertilization pregnancies. Case Description/Methods: Patient was a 39-year-old gravida 3 para 2 (G3P2) woman with no significant past medical history who was referred to our tertiary care centre by her Obstetrician at 8 weeks' gestation for deranged liver associated enzymes (LAEs) in the setting of pregnancy. Two weeks prior this presentation, she was seen by her primary care physician for fever, generalized weakness, vomiting, and diarrhea and found to be positive for SARS-CoV-2. She was managed symptomatically with acetaminophen. Ten days later, she presented to her Obstetrician for nausea, vomiting, jaundice, icterus and pruritus. Laboratory results showed elevated LAEs, INR 1.3 and bile acid 522 μmol/L. Upon admission, vitals unremarkable and physical exam was notable for generalized jaundice, scleral icterus and erythematous rash of chest and back with sparing of palms and soles. Investigations were significant for AST 895 IU/L, ALT 697 IU/L, ALP 288 IU/L, T.Bili 10.8 mg/dl, D.Bili 6.7 mg/dl. INR 1.13 and Bile acid 138.8 μmol/L. Additionally, Viral etiology for HBsAg, hepatitis C, A, and E virus, HIV, cytomegalovirus, Epstein-Barr virus, herpes simplex virus 1, herpes simplex virus 2 were negative. Toxoplasma gondii and Immunological analysis (antinuclear antibody and AMA) were negative too. Ceruloplasmin and IgG were within the reference values. SARS-CoV-2 negative. Serum acetaminophen level was <0.2. Abdominal ultrasound demonstrate normal sized liver with increased echogenicity. No visible gallstones and no biliary distension reported. Patient’s symptoms eventually improved and LAEs continued to downtrend without any pharmacological intervention (Ursodeoxycholine acid). She was discharged home with outpatient follow up with Obstetrician. Two months later, repeat hepatic panel was within normal limit. Patient had induction of labour with spontaneous vaginal delivery at 37 weeks of gestation due to preeclampsia. Improvement in BA mirrored resolution of coronavirus disease 2019 (COVID-19) symptoms without any pharmacological intervention. Thus, patient’ presentation was thought to be secondary to COVID-19 associated hepatic impairment. Discussion: BA can also be elevated in COVID-19 due to hepatocyte injury in a similar manner as seen in acute viral hepatitis. Physicians should be cognizant of the association of hepatic cholestasis and COVID-19 while evaluating the pregnant patients who present with elevated BA.