INS and cholestasis: Some patients experience hypoglycemia due to a large quantity of insulin delivery bypassing hepatic first pass metabolism and shunting into systemic circulation, resulting in hyperinsulinism.4,9 Altered fetal vascular hemodynamics have been found to cause hepatic hypoperfusion, cholestasis, and fetal intrauterine growth restrictions in the absence of other biochemical, genetic, or infectious processes.10