S2626 Very Early Presentation of Intra-Hepatic Cholestasis of Pregnancy with Onset Before the Visualization of Gestational Sac

Introduction: Intra-hepatic Cholestasis of pregnancy is common in the second and third trimester.1 - Few case reports have been in the literature about the early presentation in the pregnancy, and not before the visualization of the gestational sac.2,3 Case Description/Methods: 30 year old female came into the ED with severe progressive generalized pruritus and few episodes of vomiting for 4 days, associated with dark yellow urine. Her last menstrual period was 6 weeks ago. Urine pregnancy test was positive. Initial pelvic ultrasound couldnot localize the pregnancy, with repeat Ultrasound after 3 days showed gestational sac inside the uterus. She did not have any history of alcohol use, blood transfusion, high risk behaviors, herbal, any other over the counter or any illicit drug use, joint pain, or abdominal pain. Her Blood pressure was 122/69 mmHg, liver or spleen were not palpable. Initial labs were Total.bilirubin: 11 mg/gl, Direct.bilirubin: 8 mg/dl, AST/ALT 900/1100 IU/L, ALP: 160 IU/l, INR 1.2. Random urine protein was 24 mg/dl . Ultrasound abdomen showed normal liver of 15.7 cm, with no ascites, and abdomino-pelvic vascular Doppler study revealed patent hepatic vasculature. Ursodeoxy cholic acid was started and subsequently she experienced improvement in the pruritus. Next day, Total bilirubin: 10 mg/dl , Direct Bilirubin: 7 mg/dl, AST/ALT(IU/L): 798/1056, and INR 1.1. Total bile acid level came back as 227 mcmol/l. Other relevants lab tests Salicylate levels, Acetaminophen levels, Anti-mitochondrial antibody, alpha1 antitrypsin, Iron profile, Hepatitis A/B/C/E panel, EBV and CMV serology,, anti- LKM, Anti smooth muscle antibody, ANA and leptospira antibodies were negative. She was discharged from the hospital and followed up the gastroenterologist with complete normalization of the hepatic function test in 2 weeks. Discussion: Although in the most common scenario, intrahepatic cholestasis of pregnancy happens in the second and third trimester, it is occasionally reported in the first trimester as well as in our case. Our case report is unique in reporting it in a case of intrahepatic cholestasis as early in pregnancy as 5 weeks, even before the gestational sac was identified in the ultrasound. It might be important to rule out pregnancy in a female of reproductive age who present with jaundice, to minimize the iatrogenic risks to the fetus.