Patient 1, a 30-year-old woman in her second pregnancy, presented at 35+1 weeks gestation feeling generally unwell. She complained of a day’s history of muscle ache, sore throat, coryza and reduced fetal movements overnight. She had not travelled recently and had no contacts with any ill people. She had no urinary or bowel symptoms, no itching, no vaginal bleeding or discharge, no cough, no chest pain and no dyspnoea. Her previous pregnancy resulted in a spontaneous vaginal delivery. She was known to have factor XI deficiency, Raynaud’s syndrome, livedo reticularis, and positive cardiolipin antibody. She was on low dose aspirin and had her factor XI levels monitored throughout the pregnancy.
On examination she had a temperature of 37.6°C, pulse 125 beats/min and an inflamed oropharynx. Her abdomen was soft and non-tender with no rash, and the cardiotocograph was reassuring. She was given paracetamol and her temperature and pulse returned to normal. She was sent to accident and emergency for H1N1 testing and sent home.
The following day the swab was positive for H1N1 and the patient was contacted at home. She was noted to have raised aspartate transaminase (AST) and alanine transaminase (ALT). In view of the blood results and the reduced fetal movements, she was admitted and started on nasal (inhaled) zanamivir (Relenza) which she continued for 5 days. On re-admission she had a temperature of 38.8°C and pulse of 120 beats/min. She improved clinically and was investigated for the cause of the raised transaminases.
She remained in hospital for 5 days and improved symptomatically. She was monitored as an outpatient and 13 days after initial presentation the transaminases were once again rising. The results of her investigations are shown in and . She had a normal vaginal delivery of a boy weighing 2.794 kg on day 14. Mother and baby were well and discharged the next day. She has continued to be monitored including liver function testing which has shown a return to normal of transaminases.
Blood results for patient 1 (continued)
Patient 2 was seen at the same time, complaining of itching for a week at 34+2 gestation. She was investigated and was found to have raised transaminases but also raised bile acids of 11 μmol/l (reference range 1–10 μmol/l) (). She had been treated for H1N1 infection with zanamivir 2 weeks before. She continued to have liver function testing and was managed as having obstetric cholestasis, although repeat bile acids on 10/07 was normal at 5 μmol/l. Repeat transaminases on 04/09 had returned to normal ().