Pregnancy, pruritus and pain, oh my! A case-based approach to abnormal liver chemistries in pregnancy

25-year-old female with hyperthyroidism who is 30 weeks pregnant initially presented with costovertebral tenderness, pelvic pain and nausea. Pain resolved after passing a kidney stone, but  initial labs are concerning for abnormal liver chemistries with AST of 118 U/L, ALT of 162 U/L, alkaline phosphatase of 200 U/L, Total Bilirubin of 2.0 mg/dL and INR of 1.0.  What is the next best step?

The rise and fall of bilirubin and alkaline phosphatase

Why, after an episode of prolonged biliary obstruction, or after severe forms of acute liver injury, does the alkaline phosphatase (ALP) rise in a delayed fashion? And why do the ALP and total bilirubin often take a while to normalize? We’ve all heard (or said) this before. Today, let’s get to the bottom of why this happens!