Acute fatty liver of pregnancy

Background

  • Rare, potentially fatal complication that presents in second half of pregnancy or (less commonly) early postpartum
  • Exact etiology unclear, but thought to involve abnormal fetal fatty acid metabolism
  • Fat vesicles accumulate within hepatocytes, interfering with liver function

Clinical Features

  • Usually presents in 3rd trimester, but may occur any time in 2nd half of pregnancy to early postpartum
  • Nausea/vomiting (commonly severe)
  • Jaundice
  • Findings consistent with preeclampsia in some women:
  • Hypoglycemia
  • Often, signs/symptoms of DIC
  • +/- encephalopathy, ascites

Differential Diagnosis

  • Often initially misdiagnosed as preeclampsia/HELLP
    • Hypoglycemia, jaundice, ascites, hypofibrinogenemia all more common in AFLP

3rd Trimester/Postpartum Emergencies

Indirect Hyperbilirubinemia

Direct (Conjugated) Hyperbilirubinemia

Hepatocellular damage

Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase

Additional Differential Diagnosis

Evaluation

  • LFTs
    • ALT/AST usually in 300-500 range, alk phos usually elevated in pregnancy
    • Hyperbilirubinemia- more pronounced than in preeclampsia
  • BMP
  • DIC labs
    • Low fibrinogen, coagulopathy
    • DIC present in as many as 70% of patients[1]
  • CBC
  • UA

Management

  • Emergent Ob/Gyn consult
    • Delivery typically results in rapid hepatic recovery
  • Dextrose for hypoglycemia
  • FFP, cryoprecipitate, and/or platelets for coagulopathy (see DIC)

Disposition

  • Admit ICU or transfer to center with Ob

See Also



References

  1. Ko H, Yoshida EM (2006). Acute fatty liver of pregnancy. Canadian Journal of Gastroenterology. 20 (1): 25–30
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