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BMJ Case Rep. 2010; 2010: bcr08.2009.2179.
Published online Feb 19, 2010. doi:  10.1136/bcr.08.2009.2179
PMCID: PMC3027416
New disease
Two cases of abnormal liver function associated with H1N1 infection in pregnancy
Debra Penney, Dhanuson Dharmasena, Alison Wright, and Rezan Abdul-Kadir
Royal Free Hospital, Obstetrics & Gynaecology, Pond Street, London NW3 2QG, UK
Correspondence to Debra Penney, debrapenney/at/yahoo.com
Abstract
Two patients with recent H1N1 virus infection in pregnancy were found to have raised transaminases. They have both had a mild illness and have recovered with no adverse effects, and one has delivered a healthy baby while the other is still pregnant. We suggest that the deranged transaminase concentrations were directly linked to the viral infection in the first patient as the abnormal blood results predated treatment. The second case is less clear.
Background
The effects of the new H1N1 virus on pregnant women are not known. Our patients were found to have raised transaminases which has not been reported in any other case study of pregnant women with H1N1.
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 tables 1 and and2.2. 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.
Table 1
Table 1
Blood results for patient 1
Table 2
Table 2
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) (table 3). 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 (table 3).
Table 3
Table 3
Blood results for patient 2
Investigations
The following tests were negative in patient 1:
  • Hepatitis A IgM
  • Hepatitis B surface antigen
  • Hepatitis C IgG
  • Hepatitis E total antibody
  • Hepatitis E IgM
  • Cytomegalovirus IgG
  • Epstein–Barr virus EBNA 1 IgG
  • Epstein–Barr virus EBNA 1 IgM
  • Epstein–Barr virus VCA IgG
  • Epstein–Barr virus VCA IgM
  • Rubella IgM
  • Parvovirus B19 IgG
  • Parvovirus B19 IgM
  • Respiratory syncytial virus RNA.
The cytomegalovirus IgM was equivocal and of uncertain significance.
The liver ultrasound scan showed a normal liver with smooth outline and no focal lesions. There was normal flow in hepatic veins, artery and portal vein.
Outcome and follow-up
Both patients have delivered healthy babies and transaminase values have returned to normal.
H1N1 is a new influenza virus to which the general population has no immunity. Pregnancy has been reported to increase the risk of a more severe illness and death in patients who have the virus.1 Pregnant women are therefore more likely to need hospitalisation and develop complications following infection. There are limited data available regarding the effect of the virus specifically in pregnancy. In two previous case reports patients have had a mild illness and the pregnancy has progressed normally, but in the third report, the patient became unwell, required early delivery, developed acute respiratory distress syndrome (ARDS) and died despite antiviral treatment.2 There was no report of raised transaminases in any of these cases but influenza infection is known to cause a transient transaminitis.3
In both our cases the patients responded to antiviral medication. Currently many cases of H1N1 infection are treated without hospital admission and blood tests. Patient 1 had liver function tests as part of a sepsis screen and patient 2 required testing as she had symptoms of obstetric cholestasis. In both patients the transaminases were significantly raised without a rise in bilirubin. In patient 1, as she was an inpatient and had serial blood tests, we were able to see that the concentrations dropped while on antiviral medication but then increased again. This transient transaminase rise did not seem to have an adverse effect on the patient and caused no problems for the fetus, but did lead to early induction of labour. In patient 2, the rise was thought to be due to obstetric cholestasis as the bile acids were also slightly raised; however, the repeat value was normal and the transaminase concentrations returned to normal following delivery.
We will need to observe extra caution in pregnant patients who present with flu like symptoms and commence antiviral treatment early to reduce severity of symptoms. We also need to consider whether monitoring of liver function should be done routinely in pregnant women who contract the H1N1 virus.
Learning points
  • The effects of H1N1 in pregnancy are not known.
  • It is important to commence antiviral treatment early in the disease.
  • Monitoring of liver function should be considered in pregnant women with H1N1 infection.
  • If there are raised transaminase values, patients should have repeat tests until the concentrations have returned to normal.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
REFERENCES
1. Rasmussen SA, Jamieson DJ, Bresee JS. Pandemic influenza and pregnant women. Emerg Infect Dis 2008; 14: 95–100. [PMC free article] [PubMed]
2. Control Centres for Diseases, Prevention Novel influenza A (H1N1) virus infections in three pregnant women, United States, April-May 2009. MMWR Morb Mortal Wkly Rep 2009; 58: 497–500. [PubMed]
3. Polakos NK, Cornejo JC, Murray DA, et al. Kupffer cell hepatitis occurs during influenza infection. Am J Pathol 2006; 168: 1169–78. [PubMed]
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