///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Coagulopathy and Vitamin K Deficiency in a Parturient with Intrahepatic Cholestasis of Pregnancy

Abstract Number: RF2BB-182
Abstract Type: Case Report Case Series

Alexa K Ron MD1 ; Mallika Thampy MD2; Holly Ende MD3

Intrahepatic cholestasis of pregnancy (IHCP) is a well-described condition in the peripartum period and is associated with multiple adverse pregnancy outcomes including preterm delivery, meconium staining, and fetal demise (1). While it is reported in the literature, cases of significant Vitamin K deficiency and severe coagulopathy resulting from IHCP are rare (2). We report a case of a 24-year-old primigravida with a medical history of systemic lupus erythematosus, autoimmune hepatitis on chronic immunosuppressant therapy, chronic hypertension secondary to lupus nephritis, exercise-induced asthma, and alpha 1-antitrypsin deficiency heterozygosity who presented for routine prenatal check at 25+4 weeks gestational age (GA) with new symptoms of generalized pruritus. Bile acids were found to be 124 mcmol/L (ref 0-7), confirming a diagnosis of IHCP. The patient was initiated on ursodeoxycholic acid with initial improvement in symptoms. However, at 30+4 weeks GA, upon development of scleral icterus, repeat labs were significant for total bilirubin 4.2, INR 2.2, and normal transaminases. Hepatology consultation favored a diagnosis of worsening IHCP over a flare of autoimmune hepatitis. Furthermore, the patient’s normal albumin levels in addition to a recent liver biopsy without significant fibrosis made liver synthetic dysfunction unlikely. Ultimately, her clinical and laboratory findings were attributed to IHCP with resultant fat-soluble vitamin deficiency leading to elevated INR. After multidisciplinary discussions between maternal fetal medicine, hepatology, and obstetric anesthesia, a plan was made to admit the patient for IV Vitamin K infusion prior to a planned 35 week induction of labor. The patient presented to triage at 34+1 weeks GA with vaginal bleeding which ultimately resolved spontaneously, and repeat labs at that time demonstrated total bilirubin 6.3 and INR 3.6. She received 2 doses of IV Vitamin K during this hospital admission, and coagulation studies following Vitamin K infusions demonstrated normalization (PT 13.7, INR 1.1, PTT 22.6). She was discharged, but presented 3 days later with pre-term labor (34+4 weeks GA). Following confirmation of normal coagulation studies and thromboelastography, the patient received a combined spinal-epidural and had an uneventful vaginal delivery. She was discharged on postpartum day 2. In the postpartum period, MRCP and liver biopsy were performed—neither of which could demonstrate an alternate etiology for a significant coagulopathy and hyperbilirubinemia during pregnancy. This case emphasizes the importance of evaluating for severe coagulopathy in patients who present with IHCP in order to avoid serious adverse outcomes for mother or fetus.

1 Williamson et al. Intrahepatic Cholestasis of Pregnancy. Obstet Gynecol 2014

2 Maldonado et al. Intrahepatic Cholestasis of Pregnancy Leading to Severe Vitamin K Deficiency and Coagulopathy. Case Rep Obstet Gynecol 2017

SOAP 2019