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Alexander V, Benjamin SJ, Subramani K, Sathyendra S, Goel A. Acute liver failure in pregnancy. Indian J Gastroenterol 2024; 43:325-337. [PMID: 38691240 DOI: 10.1007/s12664-024-01571-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 03/09/2024] [Indexed: 05/03/2024]
Abstract
Liver function abnormalities are noted in a minority of pregnancies with multiple causes for the same. A small proportion of these develop severe liver injury and progress to acute liver failure (ALF). There is a discrete set of etiology for ALF in pregnancy and comprehensive understanding will help in urgent evaluation. Certain diseases such as acute fatty liver of pregnancy, hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome and pre-eclampsia are secondary to pregnant state and can present as ALF. Quick and targeted evaluation with urgent institution of etiology-specific management, especially urgent delivery in patients with pregnancy-associated liver diseases, is the key to avoiding maternal deaths. Pregnancy, as also the fetal life, imparts a further layer of complication in assessment, prognosis and management of these sick patients with ALF. Optimal management often requires a multidisciplinary approach in a well-equipped centre. In this review, we discuss evaluation, assessment and management of pregnant patients with ALF, focussing on approach to pregnancy-associated liver diseases.
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Affiliation(s)
- Vijay Alexander
- Department of Hepatology, Christian Medical College, Vellore 632 004, India
| | - Santosh J Benjamin
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore 632 004, India
| | - Kandasamy Subramani
- Division of Critical Care, Christian Medical College, Vellore 632 004, India
| | - Sowmya Sathyendra
- Department of Obstetric Medicine, Christian Medical College, Vellore 632 004, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore 632 004, India.
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2
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Khuroo MS. Hepatitis E and Pregnancy: An Unholy Alliance Unmasked from Kashmir, India. Viruses 2021; 13:1329. [PMID: 34372535 PMCID: PMC8310059 DOI: 10.3390/v13071329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/22/2021] [Accepted: 07/05/2021] [Indexed: 12/23/2022] Open
Abstract
The adverse relationship between viral hepatitis and pregnancy in developing countries had been interpreted as a reflection of retrospectively biased hospital-based data collection by the West. However, the discovery of hepatitis E virus (HEV) as the etiological agent of an epidemic of non-A, non-B hepatitis in Kashmir, and the documenting of the increased incidence and severity of hepatitis E in pregnancy via a house-to-house survey, unmasked this unholy alliance. In the Hepeviridae family, HEV-genotype (gt)1 from genus Orthohepevirus A has a unique open reading frame (ORF)4-encoded protein which enhances viral polymerase activity and viral replication. The epidemics caused by HEV-gt1, but not any other Orthohepevirus A genotype, show an adverse relationship with pregnancy in humans. The pathogenesis of the association is complex and at present not well understood. Possibly multiple factors play a role in causing severe liver disease in the pregnant women including infection and damage to the maternal-fetal interface by HEV-gt1; vertical transmission of HEV to fetus causing severe fetal/neonatal hepatitis; and combined viral and hormone related immune dysfunction of diverse nature in the pregnant women, promoting viral replication. Management is multidisciplinary and needs a close watch for the development and management of acute liver failure. (ALF). Preliminary data suggest beneficial maternal outcomes by early termination of pregnancy in patients with lower grades of encephalopathy.
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Affiliation(s)
- Mohammad Sultan Khuroo
- Digestive Diseases Centre, Dr. Khuroo's Medical Clinic, Srinagar, Jammu and Kashmir 190010, India
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3
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Two Fatty Liver Conditions Masquerading as Autoimmune Hepatitis. Case Reports Hepatol 2021; 2021:8820350. [PMID: 33763269 PMCID: PMC7964110 DOI: 10.1155/2021/8820350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 01/28/2021] [Accepted: 03/02/2021] [Indexed: 11/17/2022] Open
Abstract
Acute fatty liver of pregnancy (AFLP) is a rare obstetric condition that classically presents in the third trimester or early postpartum period and can lead to liver failure and death. Only six second trimester AFLP cases have been reported in the English literature. We present the earliest case of AFLP at 15 weeks of gestation confounded by a high titer anti-nuclear antibody (ANA >1 : 1280) and concern for autoimmune hepatitis. Our patient had intrauterine fetal demise with prompt dilation and evacuation. Sepsis and multisystem organ failure ensued, and she was transferred to a liver transplant center where she expired without further intervention.
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Ziogas IA, Hayat MH, Tsoulfas G. Obstetrical and gynecologic challenges in the liver transplant patient. World J Transplant 2020; 10:320-329. [PMID: 33312893 PMCID: PMC7708880 DOI: 10.5500/wjt.v10.i11.320] [Citation(s) in RCA: 1] [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: 07/26/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
An increasing number of childbearing agewomen undergo liver transplantation (LT) in the United States. Transplantation in this patient subgroup poses a significant challenge regarding the plans for future fertility, particularly in terms of immunosuppression and optimal timing of conception. Intrapartum LT is only rarely performed as the outcome is commonly dismal for the mother or more commonly the fetus. On the other hand, the outcomes of pregnancy in LT recipients are favorable, and children born to LT recipients are relatively healthy. Counseling on pregnancy should start before LT and continue after LT up until pregnancy, while all pregnant LT recipients must be managed by amultidisciplinary team, including both an obstetrician and a transplant hepatologist. Additionally, an interval of at least 1-2 years after successful LT is recommended before considering pregnancy. Pregnancy-induced hypertension, pre-eclampsia, and gestational diabetes mellitus are reported more commonly during the pregnancies of LT recipients than in the pregnancies of non-transplant patients. As adverse fetal outcomes, such asmiscarriage, abortion, stillbirth, or ectopic pregnancy, may occur more often than in the non-transplant population, early planning or delivery either through a planned induction of labor or cesarean section is critical to minimize the risk of complications. No significant long-term physical or phycological abnormalities have been reported in children born to LT recipients.
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Affiliation(s)
- Ioannis A Ziogas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Muhammad H Hayat
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Georgios Tsoulfas
- Department of Surgery, Papageorgiou University Hospital, Aristotle University of Thessaloniki, Thessaloniki 54622, Greece
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Acute Fatty Liver of Pregnancy: Pathophysiology, Anesthetic Implications, and Obstetrical Management. Anesthesiology 2020; 130:446-461. [PMID: 30707120 DOI: 10.1097/aln.0000000000002597] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A narrative review of the pathophysiology, diagnosis, management, delivery implications, obstetric anesthesia care, and potential critical care needs in patients presenting with acute fatty liver of pregnancy.
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Abstract
Liver disease in pregnancy may present as a disorder that is unique to pregnancy or as an acute or chronic liver disease occurring coincidentally in pregnancy. Hepatic diseases that are unique to pregnancy include hyperemesis gravidarum; preeclampsia/eclampsia; the syndrome of hemolysis, elevated liver enzymes, and low platelets; intrahepatic cholestasis of pregnancy; and acute fatty liver of pregnancy. Acute and chronic forms of primary hepatic disorders that are seen in pregnancy include viral hepatitis, autoimmune hepatitis, nonalcoholic fatty liver disease, and cirrhosis. Because of the need to consider both maternal and fetal health, there are special considerations for the implementation of diagnostic strategies and pharmacologic therapies for liver disease that occurs in pregnancy. An understanding of the pathogenesis and expression of liver diseases in pregnancy has been evolving, and various diagnostic and prognostic tools have been studied in order to determine noninvasive approaches to identifying and staging of such diseases. Investigations have also been underway to evaluate the safety and utility of existing and new therapeutic agents that previously were thought to not be compatible with pregnancy. This review will explore updates in the epidemiology, diagnosis, and management of various liver diseases seen in pregnancy.
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Affiliation(s)
- Carla W Brady
- Division of Gastroenterology Duke University Medical Center Durham NC
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7
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Bang YS, Ko D, Lee S, Lee S, Park C. Hepatic failure caused by acute fatty liver of pregnancy treated by orthotopic liver transplantation - A case report -. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.2.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Yun-Sic Bang
- Department of Aneshesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Daeun Ko
- Department of Aneshesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sunyoung Lee
- Department of Aneshesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Seunghoon Lee
- Department of Aneshesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Chunghyun Park
- Department of Aneshesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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8
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Babu R, Kanianchalil K, Sahadevan S, Nambiar R, Kumar A. Liver transplantation for acute liver failure due to hepatitis E in a pregnant patient. Indian J Anaesth 2018; 62:908-910. [PMID: 30532332 PMCID: PMC6236778 DOI: 10.4103/ija.ija_149_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Rakesh Babu
- Department of Anaesthesiology and Liver Transplant, Aster MIMS Hospital, Calicut, Kerala, India
| | - Kishore Kanianchalil
- Department of Anaesthesiology and Liver Transplant, Aster MIMS Hospital, Calicut, Kerala, India
| | - Sajeesh Sahadevan
- Department of Anaesthesiology and Liver Transplant, Aster MIMS Hospital, Calicut, Kerala, India
| | - Rajesh Nambiar
- Department of Anaesthesiology and Liver Transplant, Aster MIMS Hospital, Calicut, Kerala, India
| | - Anish Kumar
- Head of Medical Gastroenterology, Aster MIMS, Calicut, Kerala, India
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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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10
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White H, Peters M. Severe Liver Disease in Pregnancy. J Intensive Care Med 2016. [DOI: 10.1177/088506669000500303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Liver disease is uncommon in pregnant women. It can be divided into disorders that occur only during preg nancy and those that can occur during pregnancy, but are not related directly to pregnancy. Jaundice during pregnancy is relatively rare, occurring in 1 in 1,500 pregnancies [ 1 ]. In this review we briefly discuss normal changes in hepatic physiology during pregnancy and then outline the liver disorders of pregnancy, emphasiz ing those that can be severe and result in admission to intensive care units.
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Affiliation(s)
- Heather White
- Gastroenterology Division, Washington University School of Medicine, St. Louis, MO
| | - Marion Peters
- Gastroenterology Division, Washington University School of Medicine, St. Louis, MO
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Abstract
Pregnancy associated liver diseases affect up to 3% of pregnant women and are the most frequent cause of liver dysfunction in pregnancy. When severe, they are associated with significant morbidity and mortality for both mother and infant. A rapid evaluation to distinguish them from non-pregnancy related liver dysfunction is essential, in order to facilitate appropriate management. Liver disease unrelated to pregnancy can present de novo in pregnancy, or pregnancy can occur in women with preexisting liver pathology (Table 1). Research and subsequent advances in medical care have resulted in improved but still not satisfactory maternal and fetal outcomes. In this review we provide an overview of the liver diseases specific to the pregnant state and an update on their pathogenesis, treatment and outcomes. The risks of pregnancy in women with pre-existent liver pathology is detailed and recent advances in our understanding of specific risks and outcomes are discussed.
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12
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Tran TT, Ahn J, Reau NS. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol 2016; 111:176-94; quiz 196. [PMID: 26832651 DOI: 10.1038/ajg.2015.430] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/01/2015] [Indexed: 12/11/2022]
Abstract
Consultation for liver disease in pregnant women is a common and oftentimes vexing clinical consultation for the gastroenterologist. The challenge lies in the need to consider the safety of both the expectant mother and the unborn fetus in the clinical management decisions. This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women.
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Affiliation(s)
- Tram T Tran
- Department of Medicine, Liver Transplant, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Ahn
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nancy S Reau
- Department of Medicine, Rush University, Chicago, Illinois, USA
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13
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Ringers J, Bloemenkamp K, Francisco N, Blok JJ, Arbous MS, van Hoek B. Auxiliary or orthotopic liver transplantation for acute fatty liver of pregnancy: case series and review of the literature. BJOG 2015; 123:1394-1398. [PMID: 26449726 DOI: 10.1111/1471-0528.13707] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2015] [Indexed: 12/17/2022]
Affiliation(s)
- J Ringers
- Department of Transplant Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Kwm Bloemenkamp
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - N Francisco
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J J Blok
- Department of Transplant Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - M S Arbous
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - B van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
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Pandey CK, Karna ST, Pandey VK, Tandon M. Acute liver failure in pregnancy: Challenges and management. Indian J Anaesth 2015; 59:144-9. [PMID: 25838585 PMCID: PMC4378074 DOI: 10.4103/0019-5049.153035] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Acute liver failure (ALF) in pregnancy negatively affects both maternal and foetal outcome. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver functions leading to significant morbidity and even mortality. In this comprehensive review, we searched articles published as review articles, clinical trials, and case series in the Medline from 1970 to 2012. The overall outcome of ALF in pregnancy depends on the aetiology, timely diagnosis, prompt management, and early referral to a centre equipped in managing medical or obstetric complication. The foetal outcome is affected by the stage of pregnancy in which the mother has a deterioration of the liver function, with a worst prognosis associated with first or second-trimester liver failure. When ALF complicates pregnancy, liver transplantation is the one of the viable options. Management protocols need to be individualised for each case keeping in mind the risk versus benefit to both the mother and the foetus.
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Affiliation(s)
- Chandra Kant Pandey
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Sunaina Tejpal Karna
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Vijay Kant Pandey
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Manish Tandon
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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de Oliveira CV, Moreira A, Baima JP, Franzoni LDC, Lima TB, Yamashiro FDS, Coelho KYR, Sassaki LY, Caramori CA, Romeiro FG, Silva GF. Acute fatty liver of pregnancy associated with severe acute pancreatitis: A case report. World J Hepatol 2014; 6:527-531. [PMID: 25068005 PMCID: PMC4110545 DOI: 10.4254/wjh.v6.i7.527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 05/20/2014] [Accepted: 06/11/2014] [Indexed: 02/06/2023] Open
Abstract
Acute fatty liver of pregnancy is a rare disease that affects women in the third trimester of pregnancy. Although infrequent, the disease can cause maternal mortality. The diagnosis is not always clear until the pregnancy is terminated, and significant complications, such as acute pancreatitis, can occur. Pancreatic involvement typically only occurs in severe cases after the development of hepatic and renal impairment. To date, little knowledge is available regarding how the disease causes pancreatitis. Treatment involves supportive measures and pregnancy interruption. In this report, we describe a case of a previously healthy 26-year-old woman at a gestational age of 27 wk and 6 d who was admitted with severe abdominal pain and vomiting. This case illustrates the clinical and laboratory overlap between acute fatty liver of pregnancy and pancreatitis, highlighting the difficulties in differentiating each disease. Furthermore, the hypothesis for this overlapping is presented, and the therapeutic options are discussed.
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Acute Liver Failure Occurring during the First Trimester of Pregnancy Successfully Treated with Living Donor Liver Transplantation. Case Rep Transplant 2013; 2013:309545. [PMID: 24368963 PMCID: PMC3867862 DOI: 10.1155/2013/309545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/13/2013] [Indexed: 02/02/2023] Open
Abstract
Acute liver failure (ALF) during pregnancy remains difficult to treat, and despite advances in treatment, liver transplantation must be selected as treatment option in certain cases. We report a 30-year-old woman with ALF of unknown etiology, occurring during the first trimester of pregnancy. Her condition was complicated by consciousness disturbance and coagulopathy due to ALF, but she was successfully treated with living donor liver transplantation 7 days after dilatation and curettage. At 9-month followup, she was in good medical condition. Liver transplantation has been reported as one of the treatment options for ALF during pregnancy with the prognosis varying depending on the trimester, from living donor or deceased donor liver transplantation. Of importance is that clinicians always think of emergent liver transplantation as a therapeutic option in ALF even in the first trimester of pregnancy.
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18
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Zhou G, Zhang X, Ge S. Retrospective analysis of acute fatty liver of pregnancy: twenty-eight cases and discussion of anesthesia. Gynecol Obstet Invest 2013; 76:83-9. [PMID: 23796980 DOI: 10.1159/000351565] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 04/23/2013] [Indexed: 12/15/2022]
Abstract
AIMS To summarize the clinical features, perioperative management and maternal and neonatal outcomes of patients with acute fatty liver of pregnancy (AFLP) and to discuss the management of anesthesia in these patients. METHODS This study was a retrospective review over a period of 5 years and 9 months; 28 cases from the Shanghai Public Health Clinical Center were included. Records were reviewed for symptoms, signs, laboratory findings, clinical courses, perioperative management and maternal and neonatal outcomes. RESULTS Of the AFLP cases analyzed in the present study, 75.0% occurred in primipara and 63.3% occurred with male fetuses. Prodromic symptoms included the sudden onset of fatigue, nausea, vomiting, anorexia and jaundice. Laboratory results indicated liver function abnormalities, coagulopathy, hypoglycemia, leukocytosis and negative urine bilirubin. There were 2 maternal deaths (7.1%) without fetal deaths. Cesarean sections were performed in 16 cases under neuraxial anesthesia and in 12 cases under general anesthesia with rapid-sequence induction. CONCLUSION Early diagnosis, prompt delivery and intensive supportive treatment are critical for improving the prognosis of AFLP. Anesthesia selection should be individualized and general anesthesia with rapid-sequence induction may be the best choice for patients with severe coagulopathy.
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Affiliation(s)
- GuoXia Zhou
- Department of Anesthesia, Zhongshan Hospital and Department of Anesthesiology, Shanghai Medical College, Fudan University, Shanghai, China
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19
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Lima TB, Villar CR, Rodrigues MAM, Baima JP, Yamashiro FDS, Franzoni LC, Caramori CA, Silva GF, Romeiro FG, Sassaki LY. Liver biopsy for visceral leishmaniasis diagnosis in pregnancy: report of 2 cases. World J Clin Infect Dis 2013; 3:20-24. [DOI: 10.5495/wjcid.v3.i2.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Revised: 04/18/2013] [Accepted: 04/29/2013] [Indexed: 02/06/2023] Open
Abstract
Visceral leishmaniasis (VL) or kala-azar is a zoonosis caused by intracellular protozoa of the Leishmania genus and is transmitted to humans by the bite of phlebotomine sandflies. It particularly affects cells in the phagocytic mononuclear system, accompanied by disturbances of cellular and humoral immunity. VL is potentially fatal and is characterized by fever, hepatosplenomegaly, diarrhea, epistaxis, jaundice, anemia, leucopenia, thrombocytopenia, hypoalbuminemia and hyperglobulinemia. Diagnostic suspicion is based on epidemiological, clinical and laboratory data and is confirmed by detecting the parasite in infected tissue. Splenic aspiration is the most sensitive method, followed by bone marrow aspiration (BMA) by sternal puncture, liver biopsy and lymph node aspiration; but, due to safety concerns, BMA is the most recommended method. VL is included as a target disease by players in drug research and development. Severe liver dysfunction associated with VL is uncommon. We report two VL cases in pregnant women from Bauru, Sao Paulo state, Brazil, considered an endemic area. The first of them developed hepatic failure due to fulminant hepatitis. In both cases, BMA was unable to find the protozoan; thus, liver biopsy was the only means of making the diagnosis.
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Successful living donor liver transplantation for fulminant hepatic failure that manifested immediately after cesarean delivery. ASAIO J 2012; 58:174-6. [PMID: 22370690 DOI: 10.1097/mat.0b013e3182444ed4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A 31-year-old pregnant woman was diagnosed as having acute hepatitis of unknown etiology and conservatively treated. An emergency cesarean delivery was performed 5 days later at 33 weeks and 3 days of gestation because of a gradual deterioration in liver function. Two days after the cesarean delivery, she lost consciousness in the evening (Glasgow coma scale [GCS] = 9) because of hepatic encephalopathy and was diagnosed as having fulminant hepatic failure (FHF). Five days after the cesarean delivery, the patient (blood type B) underwent a successful left lobe with caudate lobe (S1+2+3+4) liver transplantation from her father (blood type AB), an ABO-incompatible donor. At 1 year follow-up, she and her baby are in good medical condition. The drastic deterioration in hepatic function, despite intensive plasmapheresis and continuous hemodiafiltration, during the early postpartum period suggested a possible causative association between the termination of pregnancy and progression of FHF from acute hepatitis of unknown etiology.
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Simsek Y, Isik B, Karaer A, Celik O, Kutlu R, Aydin NE, Yilmaz S. Fulminant hepatitis A infection in second trimester of pregnancy requiring living-donor liver transplantation. J Obstet Gynaecol Res 2012; 38:745-8. [PMID: 22379955 DOI: 10.1111/j.1447-0756.2011.01757.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We present an 18-year-old pregnant woman who was referred to our emergency clinic as a case of acute hepatic failure and hepatic encephalopathy. Laboratory tests showed abnormal liver function tests and serological workup was consistent with acute hepatitis A infection. Ultrasonography revealed a single live fetus with fetal biometry compatible with 18 gestational weeks. The patient underwent a highly urgent liver transplantation using a right lobe graft from her husband. Histological examination of the explanted liver showed acute, lymphocyte-rich, diffuse necrotizing hepatitis, consistent with acute necrotizing hepatitis A. After the operation her allograft function gradually recovered. Her follow-up obstetrics ultrasound revealed a male fetus with severely decreased amniotic fluid. The patient was informed about the poor prognosis of her pregnancy and the pregnancy was terminated by vaginal misoprostol induction. She has maintained a good general condition and liver function for 4 months postoperatively, up to the present time.
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Affiliation(s)
- Yavuz Simsek
- Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, Malatya, Turkey.
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Tang W, Huang Z, Wang Y, Bo H, Fu P. Effect of Plasma Exchange on Hepatocyte Oxidative Stress, Mitochondria Function, and Apoptosis in Patients With Acute Fatty Liver of Pregnancy. Artif Organs 2012; 36:E39-47. [DOI: 10.1111/j.1525-1594.2011.01417.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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Collyer T, Holbrook S, Lyons G. Anaesthetic management of the pregnant patient with liver disease. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2011. [DOI: 10.1016/j.tacc.2011.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bacq Y. Liver diseases unique to pregnancy: a 2010 update. Clin Res Hepatol Gastroenterol 2011; 35:182-93. [PMID: 21310683 DOI: 10.1016/j.clinre.2010.11.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 11/19/2010] [Accepted: 11/23/2010] [Indexed: 02/08/2023]
Abstract
Liver disorders occurring during pregnancy may be specifically pregnancy-related, or may be due to an intercurrent or chronic liver disease, which may present in anyone, pregnant or not. This review focuses on the liver diseases unique to pregnancy. Hyperemesis gravidarum, which occurs during early pregnancy, may be associated with liver dysfunction. Intrahepatic cholestasis of pregnancy typically occurs during the second or third trimester. Pruritus and the associated biological signs of cholestasis improve rapidly after delivery. Mutations in gene encoding biliary transporters, especially ABCB4 encoding the multidrug resistance 3 protein, have been found to be associated with this complex disease. Ursodeoxycholic acid is currently the most effective medical treatment in improving pruritus and liver tests. Pre-eclampsia, which presents in late pregnancy frequently involves the liver, and HELLP syndrome (Hemolysis-Elevated Liver enzymes-Low Platelets) is a life-threatening complication. Prognosis of acute fatty liver of pregnancy has been radically transformed by early delivery, and clinicians must have a high index of suspicion for this condition when a woman presents nausea or vomiting, epigastric pain, jaundice, or polyuria-polydipsia during the third trimester. Acute fatty liver of pregnancy has been found to be associated with a defect of long-chain 3-hydroxyacyl coenzyme A dehydrogenase in the fetus, and mothers and their offspring should undergo DNA testing at least for the main associated genetic mutation (c.1528G>C).
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Affiliation(s)
- Yannick Bacq
- Service d'hépatogastro-entérologie, hôpital Trousseau, Tours cedex, France.
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Westbrook RH, Yeoman AD, Joshi D, Heaton ND, Quaglia A, O'Grady JG, Auzinger G, Bernal W, Heneghan MA, Wendon JA. Outcomes of severe pregnancy-related liver disease: refining the role of transplantation. Am J Transplant 2010; 10:2520-6. [PMID: 20977643 DOI: 10.1111/j.1600-6143.2010.03301.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Severe liver disease in pregnancy is generally considered to have a favorable prognosis. The limited data available have not yielded disease-specific prognostic criteria or guidance on who should undergo liver transplantation (LT). We retrospectively evaluated 54 admissions with pregnancy-related liver disease to (1) evaluate if any admission parameters were associated with death and/or transplantation and (2) identify maternal complications. Eighteen had acute fatty liver of pregnancy and 32 had hypertension/eclampsia related disease. Seven patients (13%) died and four (7%) underwent LT. Survival rates were 43/48 if not listed for LT and 4/6 if listed. Of the four transplanted, three survived. Patients who died and/or underwent LT were more likely to have encephalopathy (p = 0.04) and hyperlactaemia (p = 0.03). Serum lactate was the best discriminant (ROC AUC 0.84). An admission lactate greater than 2.8mg/dL had 73% sensitivity and 75% specificity for predicting death or LT. The addition of encephalopathy to this parameter increased sensitivity and specificity to 90% and 86%, respectively. The King's College criteria were not effective in predicting outcome. This study confirms the overall favorable prognosis in pregnancy-related liver failure but indicates that elevated lactate levels in the presence of encephalopathy best identify patients at greatest risk of death or LT.
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Affiliation(s)
- R H Westbrook
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
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Craig DGN, Lee A, Hayes PC, Simpson KJ. Review article: the current management of acute liver failure. Aliment Pharmacol Ther 2010; 31:345-58. [PMID: 19845566 DOI: 10.1111/j.1365-2036.2009.04175.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute liver failure is a devastating clinical syndrome with a persistently high mortality rate despite critical care advances. Orthotopic liver transplantation (OLT) is a life-saving treatment in selected cases, but effective use of this limited resource requires accurate prognostication because of surgical risks and the requirement for subsequent life-long immunosuppression. AIM To review the aetiology of acute liver failure, discuss the evidence behind critical care management strategies and examine potential treatment alternatives to OLT. METHODS Literature review using Ovid, PubMed and recent conference abstracts. RESULTS Paracetamol remains the most common aetiology of acute liver failure in developed countries, whereas acute viral aetiologies predominate elsewhere. Cerebral oedema is a major cause of death, and its prevention and prompt recognition are vital components of critical care support, which strives to provide multiorgan support and 'buy time' to permit either organ regeneration or psychological and physical assessment prior to acquisition of a donor organ. Artificial liver support systems do not improve mortality in acute liver failure, whilst most other interventions have limited evidence bases to support their use. CONCLUSION Acute liver failure remains a truly challenging condition to manage, and requires early recognition and transfer of patients to specialist centres providing intensive, multidisciplinary input and, in some cases, OLT.
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Affiliation(s)
- D G N Craig
- Scottish Liver Transplantation Unit, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, UK
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Abstract
Liver diseases in pregnancy may be categorized into liver disorders that occur only in the setting of pregnancy and liver diseases that occur coincidentally with pregnancy. Hyperemesis gravidarum, preeclampsia/eclampsia, syndrome of hemolysis, elevated liver tests and low platelets (HELLP), acute fatty liver of pregnancy, and intrahepatic cholestasis of pregnancy are pregnancy-specific disorders that may cause elevations in liver tests and hepatic dysfunction. Chronic liver diseases, including cholestatic liver disease, autoimmune hepatitis, Wilson disease, and viral hepatitis may also be seen in pregnancy. Management of liver disease in pregnancy requires collaboration between obstetricians and gastroenterologists/hepatologists. Treatment of pregnancy-specific liver disorders usually involves delivery of the fetus and supportive care, whereas management of chronic liver disease in pregnancy is directed toward optimizing control of the liver disorder. Cirrhosis in the setting of pregnancy is less commonly observed but offers unique challenges for patients and practitioners. This article reviews the epidemiology, pathophysiology, diagnosis, and management of liver diseases seen in pregnancy.
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Hepburn IS, Schade RR. Pregnancy-associated liver disorders. Dig Dis Sci 2008; 53:2334-58. [PMID: 18256934 DOI: 10.1007/s10620-007-0167-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 11/26/2007] [Indexed: 12/14/2022]
Abstract
Liver disorders associated with pregnancy include hyperemesis gravidarum (HG), intrahepatic cholestasis of pregnancy (ICP), preeclampsia, syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP), and acute fatty liver of pregnancy (AFLP). These conditions are relatively common and unique to pregnancy and are more likely to occur at certain terms of gestation specific to each condition. They can be associated with significant maternal and fetal morbidity and mortality. Although managing such patients may be very challenging, spontaneous resolution of the disease occurs shortly after termination of the pregnancy, usually without hepatic sequellae. Early diagnosis and timely treatment is a key to therapeutic success. This article explores the clinical features, pathophysiology, and management of these disorders.
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Affiliation(s)
- Iryna S Hepburn
- Department of Medicine, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912, USA.
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Acute and chronic liver insufficiency. HEPATOLOGY TEXTBOOK AND ATLAS 2008. [PMCID: PMC7121136 DOI: 10.1007/978-3-540-76839-5_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The term “liver insufficiency” denotes a break down in the functions of the liver. The syndrome of functional liver failure covers a wide spectrum of clinical, biochemical and neurophysiological changes. In principle, liver insufficiency can occur without previous liver damage as well as with already existing liver disease. It is characterized by a deterioration in the synthesizing, regulatory and detoxifying function of the liver. This final stage of liver disease terminates in hepatic coma.
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Oleszczuk A, Spannbauer M, Tannapfel A, Blüher M, Hengstler J, Pietsch UC, Schuhmacher A, Wittekind C, Hauss JP, Schön MR. Regenerative capacity differs between micro- and macrovesicular hepatic steatosis. ACTA ACUST UNITED AC 2007; 59:205-13. [PMID: 17869075 DOI: 10.1016/j.etp.2007.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 05/30/2007] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Independent of etiology, the hepatic microvesicular steatosis has a worse prognosis compared with macrovesicular steatosis. Proliferation compensates for apoptosis and reflects regenerative mechanisms following liver injury. It is unknown whether these two types of fatty liver have differences in regenerative capacity and apoptosis, which could have an impact on their prognosis. METHODS Two groups of pigs were studied for 72 days under a protein-deficient diet. One group received only protein-deficient diet (n=6), the other was treated in addition to the diet with 6g ethanol/kg/day by means of a percutaneous intragastric catheter (n=6). The rate of proliferating and apoptotic hepatocytes was determined, respectively, by proliferation cell nuclear antigen (PCNA) and ISEL/TUNEL staining for apoptosis in liver biopsies with similar steatosis grade in pigs with micro- or macrovesicular fatty liver. RESULTS The ethanol-treated group developed microvesicular steatosis, the other group developed macrovesicular steatosis. Proliferation index was significantly increased in macrovesicular in comparison with microvesicular steatosis (p<0.05). Apoptosis rate was similar in both groups. CONCLUSIONS Regeneration, but not apoptosis rate differs between micro- and macrovesicular steatosis. The reduced regenerative capacity in microvesicular steatosis may contribute to the worse prognosis of this subtype of fatty liver disease.
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Affiliation(s)
- Agnieszka Oleszczuk
- Department of Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Germany
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Ko HH, Yoshida E. Acute fatty liver of pregnancy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2006; 20:25-30. [PMID: 16432556 PMCID: PMC2538964 DOI: 10.1155/2006/638131] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute fatty liver of pregnancy (AFLP) is a rare, potentially fatal complication that occurs in the third trimester or early postpartum period. Although the exact pathogenesis is unknown, this disease has been linked to an abnormality in fetal fatty acid metabolism. Early diagnosis of AFLP sometimes can be difficult because it shares features with other common conditions such as pre-eclampsia, viral hepatitis and cholestasis of pregnancy. However, a careful history and physical examination, in conjunction with compatible laboratory and imaging results, are often sufficient to make the diagnosis, and liver biopsy is rarely indicated. Supportive care and expeditious delivery are essential to optimal maternal-fetal outcomes and remain as the mainstay treatment for AFLP.
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Affiliation(s)
| | - Eric Yoshida
- Correspondence: Dr Eric M Yoshida, Vancouver General Hospital, Division of Gastroenterology, 100-2647 Willow Street, Vancouver, British Columbia V5Z 3P1. Telephone 604-875-5371, fax 604-875-5447, e-mail
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32
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Acute and chronic liver insufficiency. HEPATOLOGY PRINCIPLES AND PRACTICE 2006. [PMCID: PMC7120693 DOI: 10.1007/3-540-28977-1_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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MacLean AA, Almeida Z, Lopez P. Complications of acute fatty liver of pregnancy treated with activated protein C. Arch Gynecol Obstet 2005; 273:119-21. [PMID: 16091940 DOI: 10.1007/s00404-004-0716-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2004] [Accepted: 11/26/2004] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Acute fatty liver (AFL) of pregnancy is a difficult and challenging diagnosis. The treatment plan is usually supportive. CASE REPORT We present a case of a patient with AFL of pregnancy and Gram-negative endomyometritis and sepsis. Our treatment plan included the use of activated protein C (APC). CONCLUSION This is the first case report of the use of APC in a post-partum patient with AFL and sepsis.
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Affiliation(s)
- Alexandra A MacLean
- Division of Trauma and Critical Care, DeWitt Department of Surgery, University of Miami, PO Box 016960 (D-40), Miami, FL 33101, USA
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Affiliation(s)
- David A Sass
- University of Pittsburgh Medical Center (UPMC) Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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Affiliation(s)
- Julie Polson
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical School Department, Dallas, Texas 75390-9151, USA.
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Abstract
Determining the cause of liver disease in pregnancy can present a difficult challenge for clinicians. Minor elevations in aminotransferases may be a harbinger of life-threatening processes, such as acute fatty liver of pregnancy (AFLP) or hemolysis, elevated liver enzyme levels, low platelet count (HELLP) syndrome. Preeclampsia, HELLP syndrome, and AFLP form a spectrum of disease that ranges from involving mild symptoms to severe life-threatening multiorgan system dysfunction. They have been shown to be the primary causes of severe hepatic dysfunction during pregnancy. This article attempts to define the clinical and diagnostic features, pathophysiology, and treatment options of these diseases.
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Affiliation(s)
- Jay S Steingrub
- Department of Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA.
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37
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Abstract
Liver disease is an uncommon complication of pregnancy, although one that must be recognized early because of its potential for grave consequences for mother and child. Because of increased awareness and rapid triage of patients, maternal and fetal outcomes have improved significantly over the last 30 years.
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Affiliation(s)
- Sheeten Doshi
- Division of Digestive Diseases, University of Cincinnati, 231 Albert B. Sabin Way, M.L. 0595, Cincinnati, OH 45267-0595, USA
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38
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Abstract
FHF is a devastating illness of varied causes, carrying considerable mortality and affecting patients with previously healthy livers. The clinical presentation varies widely but encephalopathy is the defining criterion. Management requires a multidisciplinary approach, including rapid triage, monitoring, and referral to a transplantation center for further evaluation. Early prognostication and timely availability of donor livers are essential for a successful outcome. A donor shortage, however, continues to pose problems for both hepatologists and surgeons. Effective liver support devices may greatly prolong the window of opportunity to provide a donor liver, or alternatively to allow the native liver to regenerate. Despite decades of great progress in the field of liver support systems, the ideal system is still a long-cherished goal in hepatology. Hybrid systems have garnered most of the recent attention, but the quest for improved synthetic function has not yet been realized. It is hoped that rapid conceptual and technologic developments with respect to hybrid systems, hepatocyte transplantation, and xenografting will yield a safe and accessible tool for managing these critically ill patients. Controlled, multicenter trials in well-defined patient groups and with standard outcome measures are essential to evaluate the clinical value of these devices. A better understanding of mechanisms responsible for liver cell death and multiorgan failure, and the development of strategies to enhance liver regeneration, may allow a more targeted approach to therapy.
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Affiliation(s)
- David A Sass
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, PUH, Mezzanine Level, C-Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Abstract
Liver disease has an impact on women's health during pregnancy because of the complex interactions between the physiologic changes induced by pregnancy and the pathophysiologic changes of liver disease. In particular, liver diseases that predominantly afflict females, such as primary biliary cirrhosis and autoimmune hepatitis, pose a special problem for conception and management of pregnancy. Pregnancy, moreover, specifically is associated with several potentially life-threatening liver diseases. This article reviews comprehensively the impact of liver diseases on pregnancy and of pregnancy on liver function and liver disease.
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Affiliation(s)
- Bimaljit S Sandhu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA,
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40
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Abstract
Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, 760 Broadway Avenue, Brooklyn, NY 11206, USA
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Abstract
Anatomic and physiologic adaptations within the renal system during pregnancy are significant. Alterations are seen in renal blood flow and glomerular filtration, resulting in changes in normal renal laboratory values. When these normal renal adaptations are coupled with pregnancy-induced complications or preexisting renal dysfunction, the woman may demonstrate a reduction of renal function leading to an increased risk of perinatal morbidity and mortality. This article will review normal pregnancy adaptations of the renal system and discuss common pregnancy-related renal complications.
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Affiliation(s)
- Martha S Thorsen
- La Casa De Buena Salud, Family Practice Medicine, Portales, New Mexico, USA
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Affiliation(s)
- D G Fong
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
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Morillas R, Forteza-Vila J, Bechini J. [Severe liver failure and lesions located in liver space in a 33-year-old patient]. Med Clin (Barc) 2000; 114:349-53. [PMID: 10786337 DOI: 10.1016/s0025-7753(00)71289-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- R Morillas
- Servicio de Digestivo, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona
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Affiliation(s)
- I Tein
- Department of Pediatrics, The University of Toronto, Ontario, Canada
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Castro MA, Fassett MJ, Reynolds TB, Shaw KJ, Goodwin TM. Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. Am J Obstet Gynecol 1999; 181:389-95. [PMID: 10454689 DOI: 10.1016/s0002-9378(99)70567-3] [Citation(s) in RCA: 182] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We sought to describe our experience with the clinical diagnosis, management, and course of patients with acute fatty liver of pregnancy. STUDY DESIGN Twenty-eight cases of acute fatty liver of pregnancy at the Los Angeles County and University of Southern California Medical Center from 1982 to June 1997 were identified, and presenting symptoms, clinical course, laboratory values, maternal complications, and neonatal outcomes were studied. RESULTS The incidence of acute fatty liver of pregnancy was 1 in 6659 births. There were no maternal deaths. Initial presentation was at an average of 37 weeks of gestation with a characteristic prodrome of malaise, nausea, vomiting, and abdominal pain. No patient was admitted with the diagnosis of acute fatty liver of pregnancy. The condition was diagnosed most commonly on the second hospital day after laboratory results indicated coagulopathy, renal insufficiency, and liver function abnormalities. One patient underwent liver biopsy at cesarean delivery. Radiologic studies did not aid with the diagnosis. Twenty-one patients were admitted in spontaneous labor, and 16 labors were complicated by abnormal fetal heart rate patterns or meconium. There was 1 stillbirth and 1 neonatal death as a result of perinatal asphyxia. Maternal morbidity consisted of hypoglycemia, infection, renal insufficiency, coagulopathy, encephalopathy, and wound complications. All patients had evidence of disseminated intravascular coagulopathy with profoundly decreased antithrombin levels. All patients recovered normal liver function post partum. CONCLUSIONS Reversible peripartum liver failure may be diagnosed and managed on the basis of clinical and laboratory criteria. With adequate support, these patients may have full recovery of hepatic function.
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Affiliation(s)
- M A Castro
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Massachusetts General Hospital, Boston, USA
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Affiliation(s)
- C A Riely
- Division of Gastroenterology, University of Tennessee, Memphis, 38163, USA
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Abstract
Acute renal failure (ARF) during pregnancy is a rare event. However, the care of the woman diagnosed with ARF is a challenge for the perinatal care team. The physiologic hydronephrosis and hydroureter of pregnancy alters clinical parameters for assessing the woman diagnosed with ARF. Urinary stasis and enhanced filtration predisposes to alterations in 24-hour urine evaluations, increased urinary creatinine excretion, and lower BUN and serum creatinine values. If the renal system becomes compromised, the woman is at risk for acidemia, fluid and electrolyte imbalances, and pregnancy compromise. The perinatal nurse must have an understanding of normal pregnancy physiology and an appreciation for how pregnancy physiology may alter renal assessments. Furthermore, the nurse must know the impact that ARF can have on maternal status and fetal well-being. Astute, continuous assessments of maternal and fetal status are required to detect subtle changes. While maternal status is the primary concern, it must not be forgotten that a change in fetal status may be the first indication of underlying maternal compromise.
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Affiliation(s)
- J H Poole
- Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina 28277-8896, USA.
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Abstract
Acute liver failure (ALF) is a relatively uncommon but dramatic clinical syndrome with high mortality rates, in which a previously normal liver fails within days or weeks. Paracetamol overdose remains the major cause of ALF in the UK, while viral hepatitis is the commonest cause world-wide. Cerebral oedema is the leading cause of death in patients with ALF. Despite advances in intensive care and the development of new treatment modalities, ALF remains a condition of high mortality best managed in specialist centres. Orthotopic liver transplantation is the only new treatment modality that has made a significant impact in improving outcome. Bioartificial liver support systems and hepatocyte transplantation are new promising treatment options that may change the management of ALF in the future.
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Affiliation(s)
- J N Plevris
- University Department of Medicine, The Royal Infirmary of Edinburgh, Scotland, UK
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50
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Abstract
Acute fatty liver of pregnancy is a rare clinical entity unique to pregnancy that occurs during the third trimester. The obstetric team must be familiar with this disease because early diagnosis and prompt delivery have dramatically improved prognosis, which was often fatal for both mother and child. Clinicians must have a high index of suspicion for this condition when a woman has nausea or vomiting, abdominal pain (particularly epigastric), jaundice, polyuria-polydipsia (without diabetes), increased serum transaminase activity or thrombocytopenia in late pregnancy. The disease rarely recurs during a subsequent pregnancy. The cause is unknown, but some cases of acute fatty liver of pregnancy have been associated with a genetic deficiency of fatty acid beta-oxidation. Because of the possibility of this congenital deficiency, infants of affected mothers should undergo close follow-up from birth.
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Affiliation(s)
- Y Bacq
- Service d'hepatogastroentérologie, Hôpital Trousseau, Tours, France
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