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Moreno CC, Mittal PK, Miller FH. Nonfetal Imaging During Pregnancy: Acute Abdomen/Pelvis. Radiol Clin North Am 2019; 58:363-380. [PMID: 32044012 DOI: 10.1016/j.rcl.2019.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abdominal pain is a common occurrence in pregnant women and may have a variety of causes, including those that are specific to pregnancy (eg, round ligament pain in the first trimester) and the wide range of causes of abdominal pain that affect men and women who are not pregnant (eg, appendicitis, acute cholecystitis). Noncontrast magnetic resonance (MR) imaging is increasingly performed to evaluate pregnant women with abdominal pain, either as the first-line test or as a second test following ultrasonography. The imaging appearance of causes of abdominal pain in pregnant women are reviewed with an emphasis on noncontrast MR imaging.
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Affiliation(s)
- Courtney C Moreno
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364-A Clifton Road Northeast Suite AT-627, Atlanta, GA 30327, USA.
| | - Pardeep K Mittal
- Department of Radiology, Medical College of Georgia, 1120 15th Street, BA-1411, Augusta, GA 30912, USA
| | - Frank H Miller
- Body Imaging Section and Fellowship, MRI, Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 800, Chicago, IL 60611, USA
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Abstract
Acute liver failure is a rare and severe consequence of abrupt hepatocyte injury, and can evolve over days or weeks to a lethal outcome. A variety of insults to liver cells result in a consistent pattern of rapid-onset elevation of aminotransferases, altered mentation, and disturbed coagulation. The absence of existing liver disease distinguishes acute liver failure from decompensated cirrhosis or acute-on-chronic liver failure. Causes of acute liver failure include paracetamol toxicity, hepatic ischaemia, viral and autoimmune hepatitis, and drug-induced liver injury from prescription drugs, and herbal and dietary supplements. Diagnosis requires careful review of medications taken, and serological testing for possible viral exposure. Because of its rarity, acute liver failure has not been studied in large, randomised trials, and most treatment recommendations represent expert opinion. Improvements in management have resulted in lower mortality, although liver transplantation, used in nearly 30% of patients with acute liver failure, still provides a life-saving alternative to medical management.
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Affiliation(s)
- R Todd Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA, USA
| | - William M Lee
- Digestive and Liver Diseases Division, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
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53
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Utility of MELD scoring system for assessing the prognosis of acute fatty liver of pregnancy. Eur J Obstet Gynecol Reprod Biol 2019; 240:161-166. [DOI: 10.1016/j.ejogrb.2019.06.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/24/2019] [Indexed: 12/13/2022]
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54
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Acute fatty liver of pregnancy in a Chinese Tertiary Care Center: a retrospective study. Arch Gynecol Obstet 2019; 300:897-901. [PMID: 31435779 DOI: 10.1007/s00404-019-05259-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/06/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To describe some prenatal clinical features and laboratory findings of AFLP and provide the clinicians with potential predictors in postpartum recovery time. METHODS Forty-four cases of AFLP previously treated in the First Affiliated Hospital of Zhengzhou University were retrospectively reviewed. RESULTS The maternal and fetal mortalities after treatment were both 18.2%. The main symptoms of AFLP were nausea and vomiting (63.6%), jaundice (61.4%). Moreover, the most common maternal complication was acute renal dysfunction (79.5%), followed by DIC (47.7%) and MODS (38.6%). The level of platelets, total protein and total bilirubin were found to be correlated with postpartum recovery time (Pearson correlation coefficient 0.434, P = 0.008; 0.466, P = 0.005; 0.484, P = 0.003). CONCLUSIONS AFLP is a rare, but lethal complication in the third trimester. Termination of pregnancy should be applied once AFLP was highly suspected. Prenatal platelets, total protein and total bilirubin may be potential predictors of postpartum recovery.
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Kwong S, Meyerson C, Zheng W, Kassardjian A, Stanzione N, Zhang K, Wang HL. Acute hepatitis and acute liver failure: Pathologic diagnosis and differential diagnosis. Semin Diagn Pathol 2019; 36:404-414. [PMID: 31405537 DOI: 10.1053/j.semdp.2019.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute hepatitis and acute liver failure are severe medical conditions that require early clinical intervention. Histopathologic findings on a liver biopsy or a liver explant may help identify the underlying etiology or provide an important direction for further clinical, laboratory and radiographical investigation. This review is divided into two main portions. The first portion concentrates on various etiologies and discusses unique histologic features that can be associated with specific etiologies. The second portion describes the general morphologic features based on which the diagnosis of acute hepatitis and acute liver failure are made. Histopathologic distinction between collapse and cirrhosis and limitations of histopathologic assessment for underlying etiologies are addressed in this portion. Another focus of this review is non-necrotic acute liver failure, which typically features diffuse microvesicular steatosis secondary to various etiologies causing mitochondrial dysfunction. Molecular testing serves an increasingly important role in the diagnosis and management of this group of disorders.
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Affiliation(s)
- Stanley Kwong
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States.
| | - Cherise Meyerson
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Wei Zheng
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Ari Kassardjian
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Nicholas Stanzione
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Kuixing Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States.
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Yamamoto K, Suzuki A, Shimaoka M, Yo Y, Mandai M, Matsumura N. Severe fatty liver of pregnancy requiring an extremely large amount of blood transfusion, surgery and transarterial embolization: A case report. Case Rep Womens Health 2019; 23:e00130. [PMID: 31304096 PMCID: PMC6599870 DOI: 10.1016/j.crwh.2019.e00130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 01/16/2023] Open
Abstract
We report a case of massive bleeding due to a coagulation disorder associated with acute fatty liver of pregnancy (AFLP); the patient survived by massive transfusion. She presented at 34 weeks of gestation, met six of the Swansea criteria, and was diagnosed with severe AFLP. We performed an emergency cesarean section because termination of the pregnancy was necessary for the treatment of the AFLP. After the surgery, which led to massive bleeding in the peritoneal cavity due to the coagulation disorder, she underwent two further operations and three transarterial embolizations. She received factor VII and underwent plasma exchange, and hemostasis was achieved on day 10 after hospitalization. The total volume of blood transfused was 772 units (170 units of red cell concentrate, 212 units of fresh frozen plasma, and 390 units of platelet concentrate). To the best of our knowledge, this is the most severe case of non-fatal AFLP reported to date in terms of the transfusion volume. Acute fatty liver of pregnancy (AFLP) is a potentially fatal pregnancy complication. This is a severe case of AFLP, in which massive bleeding occurred due to marked coagulopathy. To the best of our knowledge, this is the most severe case of non-fatal AFLP reported till date. For severe cases of AFLP, continuation of active treatments such as massive blood transfusion and surgery are important.
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Affiliation(s)
- Kiko Yamamoto
- Department of Obstetrics and Gynecology, Kindai University, Faculty of Medicine, Japan
| | - Ayako Suzuki
- Department of Obstetrics and Gynecology, Kindai University, Faculty of Medicine, Japan
| | - Masao Shimaoka
- Department of Obstetrics and Gynecology, Osaka prefecture Saiseikai Tondabayashi Hospital, Japan
| | - Yoshie Yo
- Department of Obstetrics and Gynecology, Kindai University, Faculty of Medicine, Japan
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University, Graduate School of Medicine, Japan
| | - Noriomi Matsumura
- Department of Obstetrics and Gynecology, Kindai University, Faculty of Medicine, Japan
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Abstract
Liver diseases during pregnancy pose a unique clinical challenge because they can affect the lives of both the mother and unborn child. Although severe liver disease is rare, pregnancy-related liver disease affects approximately 3% of pregnancies and can be fatal. Timely recognition and diagnosis are essential in order to institute appropriate management strategies. This article provides an overview of liver diseases during pregnancy and is divided into 2 sections: (1) liver diseases specific to pregnancy, and (2) preexisting or coincident liver diseases during pregnancy.
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Affiliation(s)
- Karen Ma
- Section of Gastroenterology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 207, Chicago, IL 60612, USA
| | - Daniel Berger
- Section of Gastroenterology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 207, Chicago, IL 60612, USA
| | - Nancy Reau
- Section of Hepatology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 319, Chicago, IL 60612, USA.
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Wu Z, Huang P, Gong Y, Wan J, Zou W. Treating acute fatty liver of pregnancy with artificial liver support therapy: Systematic review. Medicine (Baltimore) 2018; 97:e12473. [PMID: 30235743 PMCID: PMC6160087 DOI: 10.1097/md.0000000000012473] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Acute fatty liver of pregnancy (AFLP) is a serious disease with high mortality. Recent data suggest that postpartum application of artificial liver support therapy (ALST) in AFLP management improves disease outcome. In current study, we tend to further evaluate whether the type, the timing, and the number of postpartum ALST sessions and other clinical factors including complications and liver and renal function will influence disease outcome in ALST era. METHODS Medical records of 15 AFLP patients having postpartum ALST in our hospital from 2010 to 2016 were first retrospectively reviewed. A systematic review and statistical analysis was then conducted with our cases and those having postpartum ALST reported in PubMed, Embase, Cochrane, and ClinicalTrials.gov till the end of June 2016. RESULTS Nine relevant studies were identified in the public databases. A total of 104 cases were enrolled for analysis including 15 cases from our hospital and 89 cases from the identified 9 studies. Univariate analysis revealed that 2 complications, postpartum hemorrhage and multiple organ dysfunctions (MODS), were associated with the outcome of AFLP patients undergoing postpartum ALST. Binary logistic regression analysis further indicated that MODS was the only independent factor affecting disease outcome. Surprisingly, factors including pre-ALST serum levels of total bilirubin and creatinine, the type and number of postpartum ALST sessions, time interval between delivery and ALST were unrelated to disease outcome. CONCLUSION Current data suggest that postpartum ALST improves the outcome of AFLP patients but more properly designed experiments are needed to confirm this point. Our study further indicates that occurrence of MODS carries a bad prognosis even in ALST era. Our study provides valuable information on guiding the clinical application of postpartum ALST in AFLP management.
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Affiliation(s)
- Zhenping Wu
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University
| | - Peng Huang
- Department of Epidemiology, School of Public Health, Nanchang University
| | - Yi Gong
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Junhui Wan
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Wei Zou
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University
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59
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Mikolasevic I, Filipec-Kanizaj T, Jakopcic I, Majurec I, Brncic-Fischer A, Sobocan N, Hrstic I, Stimac T, Stimac D, Milic S. Liver Disease During Pregnancy: A Challenging Clinical Issue. Med Sci Monit 2018; 24:4080-4090. [PMID: 29905165 PMCID: PMC6034557 DOI: 10.12659/msm.907723] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
One of the least studied topics in the field of obstetrics is liver disease during pregnancy, which creates a challenge for both gynecologists and hepatologists. Approximately 3% of pregnant women are affected by some form of liver disease during pregnancy. Some of these conditions can be fatal for both the mother and child. In addition, 3 types of liver disease need to be differentiated during pregnancy. One type is liver disease directly related to pregnancy, which can occur at a specific time during pregnancy. Another type is liver disease not related to pregnancy, which can occur at any time, such as viral- or drug-induced hepatitis. Furthermore, pregnancy can occur in women with pre-existing liver disease. It is essential that the clinicians are familiar with this disorder so they can respond promptly and appropriately in all of these situations, especially when emergency delivery is needed and must not be postponed.
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Affiliation(s)
- Ivana Mikolasevic
- Department of Gastroenterology, University Hospital Center (UHC) Rijeka, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Tajana Filipec-Kanizaj
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Jakopcic
- Department of Gastroenterology, University Hospital Center (UHC) Rijeka, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Iva Majurec
- Department of Anesthesiology and Intensive Care Unit, University Hospital Merkur, Zagreb, Croatia
| | - Alemka Brncic-Fischer
- Department of Obstetrics and Gynecology, University Hospital Center (UHC) Rijeka, Rijeka, Croatia
| | - Nikola Sobocan
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Irena Hrstic
- Department of Internal Medicine, General Hospital Pula, Pula, Croatia
| | - Tea Stimac
- Department of Obstetrics and Gynecology, University Hospital Center (UHC) Rijeka, Rijeka, Croatia
| | - Davor Stimac
- Department of Gastroenterology, University Hospital Center (UHC) Rijeka, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Sandra Milic
- Department of Gastroenterology, University Hospital Center (UHC) Rijeka, School of Medicine, University of Rijeka, Rijeka, Croatia
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60
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Al-Husban N, Al-Kuran O, Al Helou A. Postpartum acute fatty liver of pregnancy: a case report. J Med Case Rep 2018; 12:67. [PMID: 29855383 PMCID: PMC5984337 DOI: 10.1186/s13256-018-1593-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/27/2018] [Indexed: 12/27/2022] Open
Abstract
Background Acute fatty liver of pregnancy can be a very dramatic clinical event with significant risk of mortality to healthy women. The pathogenesis is still unknown. It usually occurs in the third trimester or in the immediate postpartum period. The clinical presentation is very variable. Medical staff have to be very cautious even regarding a minor complaint of feeling unwell. Skin rash has not been reported as one of the initial presentations of acute fatty liver of pregnancy. It is best treated in a center with a multidisciplinary approach. Admission to the intensive care unit is recommended. Case presentation We report a case of a 20-year-old Middle Eastern Arabic woman who developed an acute fatty liver of pregnancy. She was not known to have any medical disease. She had had two previous uncomplicated deliveries. She developed acute fatty liver of pregnancy on the first day after an uncomplicated normal vaginal delivery of a healthy male newborn. She started to have nonitchy skin rash over her abdomen and upper limbs. Then she started to feel unwell. Twelve hours later, she developed epigastric and right upper quadrant abdominal pain, followed by jaundice, nausea, and vomiting. She developed recurrent hypoglycemic attacks, hemolytic anemia, coagulopathy, and hepatorenal syndrome. Conclusions The clinical presentation of acute fatty liver of pregnancy is very variable and nonspecific. Skin rash can be a new presenting symptom of acute fatty liver of pregnancy. Immediate suspicion of the diagnosis, appropriate investigations, and urgent initiation of therapy in an intensive care unit and by a multidisciplinary team resulted in a good outcome with no adverse health consequences for our patient.
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Affiliation(s)
- Naser Al-Husban
- Obstetrics & Gynecology Department, Faculty of Medicine, University of Jordan and Jordan University Hospital, P.O. Box 2194, Amman, 11941, Jordan.
| | - Oqba Al-Kuran
- Obstetrics & Gynecology Department, Faculty of Medicine, University of Jordan and Jordan University Hospital, P.O. Box 2194, Amman, 11941, Jordan
| | - Amal Al Helou
- Obstetrics & Gynecology Department, Faculty of Medicine, University of Jordan and Jordan University Hospital, P.O. Box 2194, Amman, 11941, Jordan
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Abstract
Acute liver failure (ALF) is a rare but highly fatal condition. The most common causes include drug-induced and viral hepatitis, but other less common etiologies, especially autoimmune hepatitis, Budd-Chiari syndrome, and Wilson disease, need to be considered. Because diagnosis is frequently tied to potential for reversibility of ALF and prognosis, early identification in a timely manner is crucial. Other causes of ALF are more easily recognizable based on specific circumstances, such as ALF in pregnancy or ischemic hepatitis. Ultimately, maintaining a wide differential diagnosis in patients with ALF is essential to identifying the proper treatment and prognosis.
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Affiliation(s)
- Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
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Morton A, Laurie J. Physiological changes of pregnancy and the Swansea criteria in diagnosing acute fatty liver of pregnancy. Obstet Med 2018; 11:126-131. [PMID: 30214478 DOI: 10.1177/1753495x18759353] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/16/2018] [Indexed: 12/18/2022] Open
Abstract
The Swansea criteria are used to assess the likelihood of acute fatty liver of pregnancy. There are significant physiological changes in normal pregnancy in several of the pathology parameters used in the Swansea criteria. This may impact the sensitivity and specificity of the Swansea criteria. Five of the 11 case series reporting laboratory values in acute fatty liver of pregnancy used values divergent from the Swansea criteria. When using the Swansea criteria for diagnosis of acute fatty liver of pregnancy, using pregnancy-specific and/or laboratory-specific reference intervals is recommended. Simpler diagnostic criteria using parameters of hepatocellular damage and hepatic synthetic dysfunction may be an alternative to the Swansea criteria, and further studies investigating the sensitivity and specificity of these parameters would be useful.
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Affiliation(s)
- Adam Morton
- Mater Health, University of Queensland, Brisbane, Australia
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63
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Rao S, Jim B. Acute Kidney Injury in Pregnancy: The Changing Landscape for the 21st Century. Kidney Int Rep 2018; 3:247-257. [PMID: 29725629 PMCID: PMC5932309 DOI: 10.1016/j.ekir.2018.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 01/26/2018] [Accepted: 01/28/2018] [Indexed: 12/27/2022] Open
Abstract
Pregnancy-related acute kidney injury (Pr-AKI) remains a large public health problem, with decreasing incidences in developing countries but seemingly increasing incidences in the United States and Canada. These epidemiologic changes are reflective of the advances in medical and obstetric care, as well as changes in underlying maternal risk factors. The risk factors associated with advanced maternal age, such as hypertension, diabetes, chronic kidney disease, and those associated with reproductive technologies such as multiple gestations, are increasing. Traditional causes of Pr-AKI, such as septic abortions and puerperal sepsis, have been replaced by hypertensive diseases, such as preeclampsia and thrombotic microangiopathies comprising thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). In this review, we discuss the global impact of Pr-AKI on maternal and fetal outcomes, the predominant etiologies, and key clinical features to distinguish diagnoses, such as preeclampsia/hemolysis elevated liver function test and low platelet (HELLP) syndrome, acute fatty liver disease of pregnancy (AFLP), and other thrombotic microangiopathies. New insights into the pathogenesis of preeclampsia, TTP/aHUS, and AFLP that have unearthed possible therapeutic targets are summarized. We also delve into special consideration needed to give to pyelonephritis and postobstructive causes of Pr-AKI. With each diagnosis, we offer the latest treatment recommendations, such as the positive reports from the use of eculizumab to treat aHUS. In the end, we hope to arm the clinician with the best tools to understand and address this morbid problem that does not seem to be disappearing.
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Affiliation(s)
- Swati Rao
- Division of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Belinda Jim
- Division of Nephrology, Department of Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, New York, USA
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Gao Q, Qu X, Chen X, Zhang J, Liu F, Tian S, Wang C. Outcomes and risk factors of patients with acute fatty liver of pregnancy: a multicentre retrospective study. Singapore Med J 2018; 59:425-430. [PMID: 29297090 DOI: 10.11622/smedj.2018001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Acute fatty liver of pregnancy (AFLP) frequently causes liver failure in pregnant women. A better understanding of the clinical characteristics, management, outcomes and risk factors of AFLP is required, given its relatively high mortality rate. We aimed to describe the characteristics of AFLP, and further assess its outcomes and potential risk factors from the perspectives of the mother and fetus. METHODS This was a retrospective cohort study of 133 patients with AFLP hospitalised at four tertiary hospitals in China between January 2009 and April 2014. RESULTS Among 133 patients, AFLP was diagnosed in the postpartum period for 13 (9.8%) patients. Potential factors influencing adverse maternal outcome were male fetus (p = 0.04), postpartum diagnosis of AFLP (p < 0.01), intrauterine fetal death (p = 0.04), disseminated intravascular coagulation (p < 0.01), prothrombin time (p < 0.01) and activated partial thromboplastin time (p = 0.04). The frequency of fetal distress (p = 0.03) and activated partial thromboplastin time (p < 0.05) were significantly higher in pregnancies with dead fetuses than in those where the fetuses survived. Independent risk factors for perinatal maternal mortality were history of legal termination of pregnancy (odds ratio [OR] 1.958, 95% confidence interval [CI] 1.133-3.385), total bilirubin (OR 1.009, 95% CI 1.003-1.014) and serum creatinine (OR 1.010, 95% CI 1.003-1.017). CONCLUSION Compared with total bilirubin and serum creatinine, history of legal termination of pregnancy appeared to be a greater risk factor for maternal mortality among patients with AFLP.
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Affiliation(s)
- Qiang Gao
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xin Qu
- Department of Neurosurgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Xiukai Chen
- Center for Critical Care Nephrology, University of Pittsburgh, School of Medicine, Pittsburgh, USA.,Department of Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jicheng Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Suochen Tian
- Department of Critical Care Medicine, Liaocheng People's Hospital, Liaocheng, China
| | - Chunting Wang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
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65
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Ilham Aldika Akbar M, Mayang Sari I, Aditiawarman, Gumilar Dachlan E, Dekker G. Clinical characteristics of acute fatty liver of pregnancy in a tertiary Indonesian hospital. J Matern Fetal Neonatal Med 2017; 32:1-191. [PMID: 29034746 DOI: 10.1080/14767058.2017.1393067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 10/12/2017] [Accepted: 10/12/2017] [Indexed: 01/16/2023]
Abstract
Acute fatty liver of pregnancy (AFLP) is a rare, often autosomal recessive disorder with a major risk for maternal and perinatal mortality and morbidity. In order to achieve a more favorable outcome, awareness of its clinical signs and symptoms and early recognition are of pivotal importance. Over a 5-year period 18 patients were diagnosed with AFLP (one twin, 19 babies). The most common sign and symptoms were jaundice, hypoglycemia, nausea and vomiting, encephalopathy, and hypertension. Abnormal laboratory test results included: elevated total/ conjugated (direct) bilirubin, AST, ALT, PT, APTT, creatinine, leukocyte count, and hypoalbuminemia. Maternal and fetal mortality rate was high: 66.7% resulted in a maternal death and 57.9% in an intrauterine fetal demise (IUFD). The number of complications was found to correlate with maternal death (p = 0.042). Surviving AFLP patients had ≤ 3 complications, while patients with > 3 complications on presentation had a high risk of maternal death (OR = 5.0; 95% CI: 0.55-45.4). The presence of hypertension significantly increased the risk of maternal death (OR: 24.5; 95% CI: 1.1-542.8; p = 0.01). The risk of IUFD was primarily related to gestational age at delivery and birth weight. The high rate of jaundice as presenting symptom of AFLP suggests that Indonesian primary maternity care providers may often miss its important earlier signs and symptoms, in particular de-novo onset of nausea and vomiting in late pregnancy.
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Affiliation(s)
| | - Indah Mayang Sari
- a Department Obstetrics & Gynaecology , Universitas Airlangga , RSUD dr. Soetomo , Surabaya , Indonesia
| | - Aditiawarman
- a Department Obstetrics & Gynaecology , Universitas Airlangga , RSUD dr. Soetomo , Surabaya , Indonesia
| | - Erry Gumilar Dachlan
- a Department Obstetrics & Gynaecology , Universitas Airlangga , RSUD dr. Soetomo , Surabaya , Indonesia
| | - Gustaaf Dekker
- a Department Obstetrics & Gynaecology , Universitas Airlangga , RSUD dr. Soetomo , Surabaya , Indonesia
- b Department Obstetrics & Gynaecology , Lyell Mc Ewin Hospital , the University of Adelaide , Adelaide , Australia
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66
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Anon B, Barbet C, Gendrot C, Labarthe F, Bacq Y. [Acute fatty liver of pregnancy and mitochondrial fatty acid oxidation. Consequences for the offspring]. Arch Pediatr 2017. [PMID: 28647472 DOI: 10.1016/j.arcped.2017.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute fatty liver of pregnancy (AFLP) is a rare liver disease unique to pregnancy that can lead to acute liver failure. The prognosis, initially often fatal for both mother and child, has been improved by prompt delivery. The diagnosis should be highly suspected if the mother presents epigastric pain, nausea and/or vomiting, or polyuria-polydipsia in the third trimester of pregnancy. AFLP has been found associated with a genetic deficiency of fatty acid beta-oxidation, which may cause sudden death in infancy. Consequently, the mother and her newborn should undergo screening for this deficiency.
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Affiliation(s)
- B Anon
- Service d'hépato-gastroentérologie, hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France.
| | - C Barbet
- Service de pédiatrie, hôpital Clocheville, CHRU de Tours, 37044 Tours cedex, France
| | - C Gendrot
- Laboratoire de biochimie et biologie moléculaire, hôpital Bretonneau, CHRU de Tours, 37044 Tours cedex, France
| | - F Labarthe
- Service de pédiatrie, hôpital Clocheville, CHRU de Tours, 37044 Tours cedex, France
| | - Y Bacq
- Service d'hépato-gastroentérologie, hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France
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Zhang YP, Kong WQ, Zhou SP, Gong YH, Zhou R. Acute Fatty Liver of Pregnancy: A Retrospective Analysis of 56 Cases. Chin Med J (Engl) 2017; 129:1208-14. [PMID: 27174330 PMCID: PMC4878167 DOI: 10.4103/0366-6999.181963] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Acute fatty liver of pregnancy (AFLP) is a rare but life-threatening complication occurring in the third trimester. It is often fatal to both mother and fetus. The complicated clinical manifestations as well as an insufficient understanding of the disease make the precise diagnosis and effective treatment of AFLP challenging. A full understanding of the risk factors, clinical features, and test findings of AFLP is critical for its timely diagnosis and treatment. Methods: We performed a retrospective study of 56 patients with AFLP between June 2008 and July 2013. We analyzed the clinical features, laboratory results, perioperative management, and patient outcomes. Results: The initial symptoms varied considerably, with nausea and vomiting (13/56, 23%) being the most common. Liver-function indexes were remarkable, including elevated levels of serum alanine aminotransferase (262.16 ± 281.71 U/L), aspartate aminotransferase (260.98 ± 237.91 U/L), lactic dehydrogenase (1011.76 ± 530.34 U/L), and direct bilirubin (85.59 ± 90.02 μmol/L). Coagulation disorders were indicated by abnormal levels of fibrinogen (245.95 ± 186.11 mg/dL), D-dimer (2.46 ± 4.01 mg/L), and fibrin degradation products (43.62 ± 48.71 mg/L). The main maternal complications were hypoproteinemia (75%), coagulopathy (54%), and acute renal failure (39%). Multivariate logistic regression analysis identified prothrombin time (PT; odds ratio [OR] = 1.558, 95% confidence interval [CI] =1.248–1.946, P = 0.016) and international normalized ratio (INR; OR = 40.034, 95% CI = 2.517–636.693, P = 0.009) as risk factors. The perinatal infant death rate was related to gestational age at delivery (OR = 1.298, 95% CI = 1.040–1.618, P = 0.021), direct bilirubin (OR = 1.05, 95% CI = 1.008–1.094, P = 0.020), and fibrin degradation products (OR = 0.973, 95% CI = 0.950–0.996, P = 0.021). Conclusions: Nausea and vomiting may be the most common symptoms of AFLP. Indexes of liver dysfunction and coagulation disorders should also be considered. PT and INR are risk factors for fatal complications in patients with AFLP, and perinatal mortality is linked to the level of fibrin degradation products. Timely delivery is crucial to controlling the development of AFLP.
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Affiliation(s)
- Yan-Ping Zhang
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Wei-Qi Kong
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Sheng-Ping Zhou
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yun-Hui Gong
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Rong Zhou
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Wang S, Li SL, Cao YX, Li YP, Meng JL, Wang XT. Noninvasive Swansea criteria are valuable alternatives for diagnosing acute fatty liver of pregnancy in a Chinese population. J Matern Fetal Neonatal Med 2017; 30:2951-2955. [PMID: 27923319 DOI: 10.1080/14767058.2016.1269316] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This study aims to assess the diagnostic and prognostic value of Swansea criteria in diagnosing acute fatty liver of pregnancy (AFLP) in a Chinese population. METHODS A retrospective study was conducted on 52 Chinese women diagnosed with AFLP. All selected cases were reassessed using the Swansea criteria with special focus on the noninvasive criteria, since performing a liver biopsy for this indication is rare in a Chinese population. RESULTS Ninety point four percent of patients fulfilled five or more of the Swansea criteria. Thirty-one cases were positive for six or more Swansea criteria, but there were no significance differences between patients when using a cutoff criteria <6 or >6. When patients were positive for less than seven criteria, frequency of stillbirth, continuous blood purification (CBP) treatment, hysterectomy, and postpartum hemorrhage were not increased. However, patients who were positive for seven or more criteria had a significantly higher risk of stillbirth and a higher rate of CBP treatment (p < 0.05). Areas under the receiver operating characteristic (ROC) curve of postpartum hemorrhage was 0.670, which reached a statistical significance (p = 0.040). We observed a significantly elevated postpartum hemorrhage along with positivity of the Swansea criteria (p = 0.040). CONCLUSIONS Swansea criteria without liver biopsy are good screening tools for AFLP diagnosis, and may be useful for assessing disease severity.
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Affiliation(s)
- Shan Wang
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
| | - Shan-Ling Li
- b Department of Obstetrics and Gynecology , Shandong Provincial Maternity and Childcare Hospital , Jinan , China
| | - Yan-Xia Cao
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
| | - Yan-Ping Li
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
| | - Jin-Lai Meng
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
| | - Xie-Tong Wang
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
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Gunaydin B, Tuna AT. Anesthetic considerations for liver diseases unique to pregnancy. World J Anesthesiol 2016; 5:54-61. [DOI: 10.5313/wja.v5.i3.54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/01/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Liver diseases that are most unique to pregnancy consist of hyperemesis gravidarum, acute fatty liver of pregnancy, intrahepatic cholestasis of pregnancy, and hemolysis, elevated liver enzymes and low platelets syndrome. In this review, risk factors, etiology, symptoms, diagnosis, prognosis and treatment of each entity followed by principles of anesthetic management based on the case reports or retrospective records will be addressed.
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Abstract
Acute liver failure is life threatening liver injury with coagulopathy and hepatic encephalopathy within 26 weeks and generally, in the absence of preexisting liver disease. Fulminant liver failure occurs when hepatic encephalopathy occurs within 8 weeks of jaundice. The majority of patients with ALF are women with the median age of 38 years. In the United States, drug induced liver injury including acetaminophen causes the majority of ALF cases. The etiology of ALF should be determined, if possible, because many causes have a specific treatment. The mainstay for ALF is supportive care and liver transplantation, if necessary. There are multiple prognostic criteria available. Prognosis can be poor and patients should be referred to a liver transplantation center as soon as possible.
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Affiliation(s)
- Carmi S Punzalan
- 1 Department of Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Curtis T Barry
- 1 Department of Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
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71
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Immunology of hepatic diseases during pregnancy. Semin Immunopathol 2016; 38:669-685. [PMID: 27324237 DOI: 10.1007/s00281-016-0573-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 05/18/2016] [Indexed: 02/06/2023]
Abstract
The mother's immune system has to adapt to pregnancy accepting the semi-allograft fetus and preventing harmful effects to the developing child. Aberrations in feto-maternal immune adaptation may result in disease of the mother, such as liver injury. Five pregnancy-associated liver disorders have been described so far, however, little is known concerning immune alterations promoting the respective disease. These liver disorders are pre-eclampsia, hemolysis, elevated liver enzymes, low platelet count (HELLP), acute fatty liver, hyperemesis gravidarum, and intrahepatic cholestasis of pregnancy. On the other hand, pre-existing autoimmune liver injury of the mother can be affected by pregnancy. This review intends to summarize current knowledge linking feto-maternal immunology and liver inflammation with a special emphasis on novel potential biomarkers.
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Abstract
Disseminated intravascular coagulation (DIC) is a syndrome that can be initiated by a myriad of medical, surgical, and obstetric disorders. Also known as consumptive coagulopathy, DIC is a common contributor to maternal morbidity and mortality and is associated with up to 25% of maternal deaths. The etiopathogenesis of DIC is complex and currently thought to be initiated by tissue factor or thromboplastin, which is released from trophoblastic or fetal tissue, or maternal decidua or endothelium. Tissue factor activates the coagulation sequence to cause fibrin clotting and its dissolution by the fibrinolysin system. The result of this process can range from mild, clinically insignificant laboratory derangements to marked coagulopathy with bleeding at sites of minimal trauma. Although clinical recognition varies by disease severity, several organizations have attempted to standardize the diagnosis through development of scoring systems. Several important--albeit not necessarily common--obstetric disorders associated with DIC include placental abruption, amniotic fluid embolism, sepsis syndrome, and acute fatty liver of pregnancy. More common disorders include severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and massive obstetric hemorrhage. Importantly, many of these disorders either cause or are associated with substantive obstetric hemorrhage. Treatment of DIC is centered on two principles. The first is identification and treatment of the underlying disorder. Because many women with consumptive coagulopathy also have massive hemorrhage, the second tenet of treatment is that obstetric complications such as uterine atony or lacerations must be controlled simultaneously with prompt blood and component replacement for a salutary outcome.
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AISF position paper on liver disease and pregnancy. Dig Liver Dis 2016; 48:120-37. [PMID: 26747754 DOI: 10.1016/j.dld.2015.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/29/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
Abstract
The relationship between liver disease and pregnancy is of great clinical impact. Severe liver disease in pregnancy is rare; however, pregnancy-related liver disease is the most frequent cause of liver dysfunction during pregnancy and represents a severe threat to foetal and maternal survival. A rapid differential diagnosis between liver disease related or unrelated to pregnancy is required in women who present with liver dysfunction during pregnancy. This report summarizes the recommendation of an expert panel established by the Italian Association for the Study of the Liver (AISF) on the management of liver disease during pregnancy. The article provides an overview of liver disease occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and an assessment of the available treatment options. The report contains in three sections: (1) specific liver diseases of pregnancy; (2) liver disease occurring during pregnancy; and (3) pregnancy in patients with pre-existing chronic liver disease. Each topic is discussed considering the most relevant data available in literature; the final statements are formulated according to both scientific evidence and clinical expertise of the involved physicians, and the AISF expert panel recommendations are reported.
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Châtel P, Ronot M, Roux O, Bedossa P, Vilgrain V, Bernuau J, Luton D. Transient excess of liver fat detected by magnetic resonance imaging in women with acute fatty liver of pregnancy. Am J Obstet Gynecol 2016; 214:127-9. [PMID: 26408081 DOI: 10.1016/j.ajog.2015.09.067] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 09/11/2015] [Accepted: 09/14/2015] [Indexed: 12/17/2022]
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Bergmann F, Rath W. The Differential Diagnosis of Thrombocytopenia in Pregnancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:795-802. [PMID: 26634939 PMCID: PMC4678382 DOI: 10.3238/arztebl.2015.0795] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/16/2015] [Accepted: 07/16/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Thrombocytopenia is, after anemia, the second most common abnormality of the complete blood count in pregnancy, with a reported frequency of 6.6% to 11.2%. It has many causes. Thrombocytopenia should be diagnostically evaluated as early as possible in pregnancy, so that the obstetrical management can be accordingly planned to minimize harm to the mother and child. As the various underlying diseases share clinical features and laboratory findings, the differential diagnosis is often a difficult interdisciplinary challenge. METHODS In this article, we review pertinent literature (2000-January 2015) retrieved by a selective search in PubMed. RESULTS Gestational thrombocytopenia is the most common type, accounting for 75% of cases, followed by severe pre-eclampsia/HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) in 15-22% and autoimmune thrombocytopenia (ITP) in 1-4%. Gestational thrombocytopenia and ITP differ in the bleeding history, the severity of thrombocytopenia, the frequency of neo - natal thrombocytopenia, and the rate of normalization of the platelet count after delivery. The HELLP syndrome and rarer microangiopathic hemolytic anemias (e.g., thrombotic thrombocytopenic purpura) can be differentiated on the basis of their main clinical features, such as hypertension/proteinuria and upper abdominal pain, the severity of hemolysis and thrombocytopenia, the degree of transaminase elevation, and the rapidity of postpartum remission of the clinical and laboratory findings. A stepwise diagnostic procedure should be followed to distinguish further causes, e.g., to differentiate thrombocytopenia due to infection, autoimmune disease, or drugs from thrombocytopenia due to a rare hereditary disease. CONCLUSION The early interdisciplinary evaluation of thrombocytopenia in pregnancy is a prerequisite for the optimal care of the mother and child. The development of evidence-based recommendations for interdisciplinary management should be a goal for the near future.
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Affiliation(s)
| | - Werner Rath
- Faculty of Medicine, Gynecology and Obstetrics, University Hospital RWTH Aachen
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Meng J, Wang S, Gu Y, Lv H, Jiang J, Wang X. Prenatal predictors in postpartum recovery for acute fatty liver of pregnancy: experiences at a tertiary referral center. Arch Gynecol Obstet 2015; 293:1185-91. [DOI: 10.1007/s00404-015-3941-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 10/23/2015] [Indexed: 12/19/2022]
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Arya S, Richardson CJ, Jain S, Swischuck LE. Early Vitamin K Deficiency Bleeding in a Neonate Associated with Maternal Acute Fatty Liver of Pregnancy. AJP Rep 2015; 5:e193-5. [PMID: 26495183 PMCID: PMC4603847 DOI: 10.1055/s-0035-1557107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 05/28/2015] [Indexed: 11/15/2022] Open
Abstract
Introduction Acute fatty liver of pregnancy (AFLP) is a rare but potentially fatal condition occurring in the third trimester or early postpartum period. It is characterized by microvesicular fatty infiltration of the liver. Clinically, the three most prominent derangements in women with AFLP are hepatic dysfunction, renal insufficiency, and impaired coagulation. AFLP is associated with an increased incidence of morbidity and mortality in neonates, though the exact cause for this remains unclear. Deficiency of vitamin K in patients with liver disease has been widely reported. Case Description We present a unique case of severe intracranial bleeding because of the early vitamin K deficiency in a neonate whose mother had AFLP along with accompanying renal insufficiency. Conclusion We suggest that monitoring infants born to mothers with AFLP, for vitamin K deficiency bleeding will help reduce morbidity and mortality in these infants.
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Affiliation(s)
- Shreyas Arya
- Department of Pediatrics, University of Texas Medical Branch Galveston, Galveston, Texas
| | - Carol J Richardson
- Department of Pediatrics, Division of Neonatology, University of Texas Medical Branch Galveston, Galveston, Texas
| | - Sunil Jain
- Department of Pediatrics, Division of Neonatology, University of Texas Medical Branch Galveston, Galveston, Texas
| | - Leonard E Swischuck
- Department of Radiology, University of Texas Medical Branch Galveston, Galveston, Texas
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Maruyama S, Sato Y, Nakaki A, Satake Y, Emoto I, Kim T. Postpartum duodenal perforation after acute fatty liver of pregnancy. J OBSTET GYNAECOL 2015; 36:58-9. [PMID: 26421743 DOI: 10.3109/01443615.2015.1036412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- S Maruyama
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Shiga , Japan
| | - Y Sato
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Shiga , Japan
| | - A Nakaki
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Shiga , Japan
| | - Y Satake
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Shiga , Japan
| | - I Emoto
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Shiga , Japan
| | - T Kim
- a Department of Obstetrics and Gynecology , Otsu Red Cross Hospital , Shiga , Japan
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Marsicano E, Vuong GM, Prather CM. Gastrointestinal causes of abdominal pain. Obstet Gynecol Clin North Am 2015; 41:465-89. [PMID: 25155126 DOI: 10.1016/j.ogc.2014.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Gastrointestinal causes of abdominal pain are numerous. These causes are reviewed in brief here, divided into 2 categories: acute abdominal pain and chronic abdominal pain. They are further subcategorized by location of pain as it pertains to the abdomen.
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Affiliation(s)
- Elizabeth Marsicano
- Division of Gastroenterology and Hepatology, Saint Louis University, 3635 Vista Avenue, St Louis, MO 63110, USA.
| | - Giao Michael Vuong
- Division of Gastroenterology and Hepatology, Saint Louis University, 3635 Vista Avenue, St Louis, MO 63110, USA
| | - Charlene M Prather
- Division of Gastroenterology and Hepatology, Saint Louis University, 3635 Vista Avenue, St Louis, MO 63110, USA.
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Abstract
Acute fatty liver of pregnancy, although rare, is usually a third trimester of pregnancy occurrence that may be life threatening for both the pregnant woman and the fetus. Often, the onset resembles gastroenteritis or cholecystitis and correct diagnosis is delayed. Because it can also present with preeclampsia and eclampsia, it may be mistakenly diagnosed as hemolysis, elevated liver enzymes, low platelet syndrome. This article presents diagnostic differences between liver conditions that can complicate pregnancy and management strategies for treating and maintaining the well-being of pregnant women, fetuses, and infants who are affected by acute fatty liver of pregnancy. Early recognition and rapid intervention from antepartum diagnosis through delivery and the postpartum period are required by the nursing team and medical providers to reduce maternal and neonatal morbidity and mortality.
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Affiliation(s)
- Laurel Hartwell
- Division of Gastroenterology and Hepatology, Department of Medicine, 1 University of New Mexico, MSC10-5550, Albuquerque, NM, 87131, USA,
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Abstract
OBJECTIVE To estimate the frequency of disseminated intravascular coagulation (DIC); elucidate the genesis of hemostatic dysfunction; and characterize associated hemolysis in women with acute fatty liver of pregnancy. METHODS Hemostatic function was measured in 51 women. Disseminated intravascular coagulation was assessed using the International Society of Thrombosis and Haemostasis DIC score. Hepatic and hemostatic function was quantified with measurement of fibrinogen, fibrin-fibrinogen split products, cholesterol, and coagulation testing. As a comparison of fibrinogen synthesis, these women were compared with 25 women with placental abruption. Hemolysis was assessed indirectly by quantification of reticulocytosis and nucleated red blood cells with determination of erythrocyte morphotypes. RESULTS Eighty-percent of women were classified as having unequivocal DIC (mean score 5.9±1.8) at delivery, which persisted 4-5 days postpartum. Fibrinogen regeneration with placental abruption was rapid, whereas it remained depressed for 4-5 days with acute fatty liver of pregnancy; fibrin-fibrinogen split products were also cleared more rapidly after abruption than women with acute fatty liver (P<.001 for interaction for both using random effects modeling). Kaplan-Meier survival analysis of fibrinogen recovery to a set point of 280 mg/dL after delivery was also different between the two cohorts (median 1.7 compared with 4.2 days, P=.046). Continuing hepatic dysfunction with acute fatty liver of pregnancy was exemplified by diminished procoagulant production. Reticulocytosis, nucleated red blood cells, and elevated serum bilirubin levels reflected ongoing hemolysis. CONCLUSIONS Hemostatic dysfunction with acute fatty liver of pregnancy persists 4-5 days postpartum and results from substantive ongoing DIC in concert with reduced procoagulant synthesis and clinically significant hemolysis. LEVEL OF EVIDENCE : III.
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Kane SC, Dennis A, da Silva Costa F, Kornman L, Brennecke S. Contemporary clinical management of the cerebral complications of preeclampsia. Obstet Gynecol Int 2013; 2013:985606. [PMID: 24489551 PMCID: PMC3893864 DOI: 10.1155/2013/985606] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 12/07/2013] [Indexed: 12/17/2022] Open
Abstract
The neurological complications of preeclampsia and eclampsia are responsible for a major proportion of the morbidity and mortality arising from these conditions, for women and their infants alike. This paper outlines the evidence base for contemporary management principles pertaining to the neurological sequelae of preeclampsia, primarily from the maternal perspective, but with consideration of fetal and neonatal aspects as well. It concludes with a discussion regarding future directions in the management of this potentially lethal condition.
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Affiliation(s)
- Stefan C. Kane
- Department of Perinatal Medicine, The Royal Women's Hospital, Cnr Grattan Street and Flemington Road, Parkville, VIC 3052, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Alicia Dennis
- Department of Anaesthetics, The Royal Women's Hospital, Cnr Grattan Street and Flemington Road, Parkville, VIC 3052, Australia
- Department of Obstetrics and Gynaecology and Department of Pharmacology, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Fabricio da Silva Costa
- Department of Perinatal Medicine, The Royal Women's Hospital, Cnr Grattan Street and Flemington Road, Parkville, VIC 3052, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC 3010, Australia
- Monash Ultrasound for Women, 15 Murray Street, Clayton, VIC 3170, Australia
| | - Louise Kornman
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC 3010, Australia
- Ultrasound Department, The Royal Women's Hospital, Cnr Grattan Street and Flemington Road, Parkville, VIC 3052, Australia
| | - Shaun Brennecke
- Department of Perinatal Medicine, The Royal Women's Hospital, Cnr Grattan Street and Flemington Road, Parkville, VIC 3052, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC 3010, Australia
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