Diagnosis and Management of Therapy for a Breastfeeding Patient with Significant Elevation of Liver Enzymes Postpartum – Interactive Case Study

A 38-year-old woman hospitalized in 2009 at 36 weeks of pregnancy at the gynecology and obstetrics clinic due to pruritus and elevated liver enzymes. This was her 4th pregnancy, with a history of pruritus and elevated liver tests during her 3rd pregnancy, which subsided after delivery.

Now, pruritus was detected again, along with a slight elevation of ALP to about 3 μkat/l, symptoms attributed to intrahepatic cholestasis of pregnancy. The concentration of total bile acids in the blood serum was determined with a practically normal finding (9 μmol/l). Treatment with ursodeoxycholic acid (UDCA) at a dose of 750 mg/day and S-adenosylmethionine (SAME) was initiated. At 40 weeks of pregnancy, she delivered a healthy child (per vias naturales).

Three weeks postpartum, pruritus reoccurred, this time severe, with a very significant elevation of liver enzymes: ALP 15 μkat/l, GGT 6 μkat/l, ALT/AST 3 μkat/l, bilirubin 50 μmol/l. Simultaneously, total cholesterol was 12 mmol/l, bile acids 250 μmol/l, with positive antimitochondrial antibodies (M2 AMAb). The ultrasound finding on the liver was unremarkable.

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The first-line treatment for patients with PBC according to European (EASL), American (AASLD), and Czech (ČHS ČLS JEP) guidelines is the administration of ursodeoxycholic acid (UDCA) at a dose of 13-15 mg/kg of body weight. This treatment was offered to the patient with the suggestion that it would be advisable to pharmacologically cease lactation before starting the treatment, which the patient declined.

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