title: Acute hepatic decompensation precipitated by pregnancy-related catabolic stress: a rare mimic of acute liver failure.
abstract: BACKGROUND
  Abnormal liver function tests are common in pregnancy; however, liver failure is rare. Pregnancy is a catabolic state that can precipitate illness in patients with underlying metabolic disorders.
  
  
  METHODS
  A 19-year-old woman presented at 14 weeks of gestation with an alanine transaminase of 2,252 international units/L (less than 30), an international normalized ratio of 6.9 (0.9-1.2), and an ammonia of 58 micromole/L (11-51 micromole/L). No cause was identified on routine investigations including liver biopsy. Biochemical and clinical deterioration prompted investigation for a metabolic disorder. Urinary orotic acid was elevated, consistent with the urea cycle disorder type 1 citrullinemia. Appropriate management (arginine supplementation and dietary protein restriction) led to rapid improvement and later delivery of a healthy neonate.
  
  
  CONCLUSIONS
  This is an unusual presentation that reminds us of the importance of considering metabolic disorders during the catabolic stress of pregnancy.
authors.affiliation: Liver Transplant Unit Victoria, Austin Health, Heidelberg, Victoria, Australia.
authors.forename: Marie
authors.initials: M
authors.lastname: Sinclair
authors.forename: Shara
authors.initials: S
authors.lastname: Ket
authors.forename: Adam
authors.initials: A
authors.lastname: Testro
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Gow
authors.forename: Peter W
authors.initials: PW
authors.lastname: Angus
mesh_terms: D020159:Citrullinemia / Q000150:complications* / Q000175:diagnosis*; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D017114:Liver Failure, Acute / Q000175:diagnosis*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis*; D055815:Young Adult