Lessons from practice

MANY PREGNANCY-SPECIFIC liver disorders occur in the third trimester; thus, an aetiological diagnosis of liver diseases can be difficult. Common liver disorders in pregnancy are intrahepatic cholestasis of pregnancy, HELLP syndrome (haemolysis, elevated liver enzymes and low platelets), and acute fatty liver of pregnancy. The commonest cause of jaundice in pregnancy is acute viral hepatitis, which can result from primary infections with hepatitis viruses A to E or as part of a systemic infection with viruses such as cytomegalovirus, Epstein–Barr virus, vari-cella zoster virus and herpes simplex virus (HSV). 1 Except when caused by hepatitis E virus or HSV, viral hepatitis does not usually increase maternal or fetal mortality. 2 Hepatitis due to HSV infection is a rare but frequently fulminant disease. Most reports have been in immunocom-promised patients 3 or newborns. 4 Fulminant HSV hepatitis has been reported in immunocompetent adults, 5-7 mostly pregnant women. 8-10 Two per cent of susceptible women acquire HSV infection during pregnancy, and seroconver-sion can be asymptomatic. 6 Fulminant hepatic failure from herpes simplex in pregnancy Clinical Record A 30-year-old woman in the 30th week of pregnancy was admitted with a two-day history of fever, malaise, dysuria, frequent micturition and mild lower abdominal pain. Slight lower abdominal tenderness was the only clinical abnormality. Results of urine microscopy were white blood cell (WBC) count, 33 ϫ 10 6 /L (normal range, 0–10); red blood cell count, 15 ϫ 10 6 /L (normal range, 0–12); epithelial cell count, 21 ϫ 10 6 / L (normal range, 0–5); and culture was sterile. Full blood count revealed haemoglobin, 113 g/L (normal range, 100– 180); WBC count, 11.6 ϫ 10 9 /L (normal range, 5–18); platelet count, 215 ϫ 10 9 /L (normal range, 150–450); and lymphocyte count, 0.23 ϫ 10 9 /L (normal range, 2–8). Liver function tests were mildly abnormal at presentation (Table). The patient was treated with empirical ampicillin and gentamicin, with resolution of her symptoms. However, her liver function tests worsened. Leptospiral serology was negative and blood cultures were sterile. Hepatitis A, B and C, flavivirus, Ross River virus, cytomegalovirus, Epstein–Barr virus, HIV, parvovirus and toxoplasmosis were all excluded. Negative antinuclear, mitochondrial and smooth muscle antibodies and normal immunoglobulin levels indicated that autoimmune hepatitis was unlikely. From the fifth day after admission, her condition deteriorated, with marked upper abdominal pain and worsening liver function tests (Table). On admission to the intensive care unit she was …