Delayed Treatment Of Hepatitis Causes Death Of Pregnant Patient And Infant

This case involves a 36-year-old female with an estimated gestational age of 33 weeks who presented with cramping, nausea, and vomiting. Her vitals were normal, the fetal heart rate was normal, and her cervix was closed, so the patient was discharged. However, she continued to experience the same symptoms and returned to the hospital the next day. Labs showed elevated AST and ALT levels and the patient was admitted to the antepartum unit with a diagnosis of viral infection. Within hours, the patient became febrile. The following day, the patient’s AST and ALT levels were incredibly high and she began to deteriorate. Infectious disease was consulted, however, the patient’s diagnosis remained unknown. An ultrasound showed normal findings and an emergent delivery was done. The patient continued to decline postpartum and it was decided that a regimen of IV antivirals should be administered empirically for HSV. The patient developed a condition affecting her ability to clot and required embolization of the uterine artery. The procedure was unsuccessful and the patient succumbed to her complications. It was determined that HSV was the cause of patient’s demise. This information was not communicated to the NICU, however. The infant was extubated post-delivery but developed respiratory distress and required re-intubation. Antivirals were administered however, the infant eventually expired. The hospital determined that disseminated herpes infection likely contributed to infant’s death.

Question(s) For Expert Witness

1. Under what circumstances would HSV be included in a differential diagnosis?

2. If it is included, what would the recommended treatment be?

3. Is this a common infection/outcome seen in patients of advanced maternal age? Please explain.

Expert Witness Response E-028332

I have given talks to residents and medical students about sexually transmitted diseases and HSV hepatitis and pregnancy risks have been discussed. Fulminant hepatitis due to HSV is very rare. Unfortunately when this does occur death is common. Patients who are at increased risk of developing HSV hepatitis include those who are immunocompromised and pregnant women fall into this category. I would have included HSV in my differential once the AST or ALT was approaching 1,000 and even earlier depending on the patient's physical exam and history (reported history of HSV 1 or 2 or evidence of active cutaneous lesions). I am also aware, however, that many cases of HSV hepatitis are not accompanied by cutaneous lesions. If this would have been included in the differential then Acyclovir would be the empiric therapy. HSV associated fulminant hepatitis is not common in any pregnant patient -- even if she is of advanced maternal age. HSV-1 or HSV-2 recurrent oral or labial infections are more common in pregnant patients due to their immunocompromised state. The development of hepatitis even in the presence of a recurrent or primary outbreak of oral or labial lesions would be rare in a pregnant patient regardless of their age.