A 37-year-old primigravida at 14 weeks gestation comes to the office for an initial prenatal visit. She has had some nausea but no vomiting, abdominal pain, or vaginal bleeding. The patient has type 2 diabetes mellitus and hypertension. She used to drink 1 or 2 glasses of wine a night but quit a year ago in anticipation of becoming pregnant. Temperature is 37.5 C (99.5 F), blood pressure is 138/88 mm Hg, pulse is 85/min, and respirations are 14/min. BMI is 36 kg/m². On examination, the sclerae are anicteric. Cardiopulmonary examination is normal. The abdomen is nontender, and the liver edge is palpated 3 cm below the right costal margin. Laboratory results are as follows: A right upper quadrant ultrasound reveals a hyperechoic-appearing liver, several gallstones without gallbladder wall thickening, and a normal-appearing common bile duct. Which of the following is the most likely cause of this patient's abnormal liver studies?

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11ec25c8_d271_9aa3_bc81_8f5c6226096f_MD0003_00 This patient with type 2 diabetes mellitus, obesity, and elevated aminotransferases most likely has nonalcoholic fatty liver disease (NAFLD). Risk factors for NAFLD include type 2 diabetes mellitus, obesity, dyslipidemia, and metabolic syndrome. Insulin resistance causes unregulated hepatic triglyceride synthesis, peripheral lipolysis, and free fatty acid uptake into the liver-all of which promote hepatic fat deposition (ie, hepatic steatosis). Most patients (such as this one) are asymptomatic; some may have hepatomegaly on examination or minimal right upper quadrant pain. Laboratory findings include elevated aminotransferases (usually 2-5 times the upper limit of normal) with an AST/ALT ratio <1. An ultrasound is performed to help confirm the diagnosis and usually demonstrates a hyperechoic-appearing liver, which reflects hepatic fatty infiltration. As NAFLD progresses, steatohepatitis can occur, putting patients at risk for liver fibrosis and cirrhosis. The mainstay of therapy is weight loss, which can reverse NAFLD-related liver damage. (Choices A and F) Acute fatty liver of pregnancy (AFLP) and preeclampsia with severe features are causes of elevated aminotransferases in pregnant women. However, in contrast to this patient, those with AFLP or preeclampsia typically develop acute right upper quadrant pain and associated thrombocytopenia in the third trimester. (Choice B) Alcoholic hepatitis is characterized by AST predominance (AST/ALT ratio of 2:1) and is unlikely with light to moderate alcohol intake (<15 drinks/week for men, <10 drinks/week for women). (Choice C) Gallstones commonly develop in pregnancy because elevated progesterone levels inhibit gallbladder contraction and promote gallstone formation. Although gallstone formation increases the risk for cholecystitis and ascending cholangitis, patients typically have fever, leukocytosis, abdominal pain, and gallbladder wall thickening in addition to elevated aminotransferases. (Choice D) Intrahepatic cholestasis of pregnancy can cause elevated aminotransferase levels. However, patients typically have generalized pruritus that is worse on the palms and soles in addition to elevated total bilirubin levels, making this diagnosis unlikely. Educational objective: Nonalcoholic fatty liver disease typically presents in patients with type 2 diabetes mellitus, obesity, and elevated aminotransferases with an AST/ALT ratio <1. References: The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases. (http://www.ncbi.nlm.nih.gov/pubmed/28714183)

A 37-Year-Old Primigravida at 14 Weeks Gestation Comes to the Office