Case 86

1. Presented by Dr. Kevin Toomer MD, PhD

The patient is an adult female with a 3rd trimester pregnancy presenting to Labor and Delivery. The patient was admitted for monitoring as a result of newly diagnosed intrauterine growth restriction (fetal weight below third percentile), oligohydramnios, and abnormal umbilical artery Doppler flow studies. The patient complained of abdominal pain, and was found to have elevated serum transaminases with peak ALT 356 U/L (reference range 0-31 U/L) and peak AST 351 U/L (reference range 0-31 U/L), as well as a platelet count of 138,000/mm3 (reference range 150,000-350,000/mm3) down-trending from 181,000/mm3 on admission. Bilirubin and alkaline phosphatase were wnl. Patient was normotensive, U/A negative for proteinuria. Patient was RhD-negative, however RhoGAM was not administered because the patient's partner was documented as RhD-negative. Acute hepatitis panel was ordered to investigate possible causes of transaminitis. Anti-HAV IgM, anti-HBc IgM, and anti-HCV serologies were nonreactive, and HBsAg was negative. An anti-Hepatitis E virus (HEV) ELISA was subsequently ordered and detected anti-HEV IgM. The patient was born in the United States, was up to date on immunizations, and denied travel abroad during pregnancy. CMV and toxoplasma serologies were negative. The patient's previous pregnancy resulted in the birth of a healthy infant by spontaneous vaginal delivery.

The decision was made to proceed with Caesarian section for nonreassuring fetal status. Upon delivery, it was noted the infant had no dysmorphic features and the placenta was sent for analysis in surgical pathology. Histopathological examination of the placenta was notable for accelerated maturation of the placental disc and subchorionic hemorrhage, without viral inclusions. The maternal transaminitis resolved shortly after delivery, and the patient was discharged. In the course of the patient's subsequent hepatology workup, anti-HEV IgM was detected on multiple repeat tests during the following year. Anti-HEV IgG and HEV PCR were tested during the same period and found to be negative. No liver abnormalities were detected on ultrasound.

Question: What is the most likely underlying cause for the clinical presentation of the patient and neonate?