Hyperemesis with Liver Dysfunction

Hyperemesis with liver dysfunction is hyperemesis gravidarum with raised liver enzymes, found in up to 50 percent of admitted women. The liver injury is mild and reversible, and is caused by starvation and raised hCG. It matters because viral hepatitis, gallstones, drug injury and other liver disease must be excluded, and the enzymes settle when vomiting stops.

• Alanine aminotransferase is usually below 300 IU/L, occasionally higher.
• Risk factors: severe vomiting, weight loss, previous hyperemesis.
• Bilirubin is usually normal or only mildly raised.

Women have severe vomiting with weight loss and dehydration, and sometimes mild jaundice or right upper quadrant discomfort.

• Dark urine may reflect dehydration.
• Itch is uncommon.
• Differential diagnosis: viral hepatitis A, B, C or E, gallstones, drug induced injury, malaria, pancreatitis, hyperthyroidism, acute fatty liver of pregnancy (later pregnancy).
• Complications: electrolyte disturbance, Wernicke encephalopathy, venous thrombosis, malnutrition, prolonged admission.

The approach is to confirm raised enzymes and exclude other liver disease.

• Alanine aminotransferase, aspartate aminotransferase, bilirubin, alkaline phosphatase, albumin and INR.
• Hepatitis B surface antigen, hepatitis A IgM, hepatitis C antibody; hepatitis E where available; malaria test.
• Electrolytes, urea, creatinine, glucose, TSH and free T4, amylase.
• Abdominal ultrasound for gallstones, biliary dilatation and liver appearance.

The principle is to treat the hyperemesis and track the enzymes, which normalise within weeks.

• Supportive: admit if dehydrated; intake and output chart; daily weight; avoid hepatotoxic drugs including high dose paracetamol; avoid alcohol.
• Pharmacological: thiamine 100 mg IV daily for 3 days before dextrose; sodium chloride 0.9 percent 1 litre IV over 1 to 2 hours, then 1 litre over 4 to 6 hours with potassium chloride 20 mmol per litre; metoclopramide 10 mg IV 8-hourly (maximum 5 days); ondansetron 4 mg IV 8-hourly if others fail; promethazine 12.5 to 25 mg IV or IM 8-hourly (maximum 100 mg daily); paracetamol 500 mg oral 6-hourly as needed (maximum 2 g in 24 hours); enoxaparin 40 mg subcutaneous daily for admission above 3 days; vitamin K 10 mg IV daily for 3 days if INR is above 1.5.
• Procedures: none.
• Special groups: women with hepatitis B receive tenofovir 300 mg oral daily from 28 weeks if viral load is above 200000 IU/mL.
• Red flags: jaundice, confusion, bleeding, INR above 1.5, alanine aminotransferase above 500 IU/L, hypoglycaemia, severe right upper quadrant pain.
• Follow-up: repeat liver enzymes weekly until normal; discharge when eating; review at 2 weeks; investigate further if enzymes fail to fall by 4 weeks.