Acute fatty liver of pregnancy; three cases and discussion of analgesia and anaesthesia

Acute fatty liver of pregnancy - A short review

Acute fatty liver of pregnancy (AFLP) is a rare but dramatic condition associated with a high maternal and fetal morbidity and mortality. We present a short review of AFLP management, illustrated by a case report. We conducted a systematic literature search for 'acute fatty liver of pregnancy', concerning its management. We found initially 11 studies, and three of them met the selection criteria. Prompt diagnosis, maternal stabilisation and rapid delivery are mandatory. This illustrative AFLP case fulfilled nine out of 14 Swansea criteria. Caesarean section is often required (as illustrated in this case), reducing maternal and perinatal mortality rates.

Acute Fatty Liver of Pregnancy: Pathophysiology, Anesthetic Implications, and Obstetrical Management

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.

Preeclampsia Induced Liver Dysfunction Complicated by Disseminated Intravascular Coagulopathy and Placental Abruption: A Case Report and Review of the Literature

A 33-year-old primigravida at 32-week gestation was admitted to labor and delivery complaining of severe right upper quadrant pain and worsening coagulopathy. We report the anesthetic and obstetrical management of a complex case of a parturient with a mixed picture of hemolysis, elevated liver enzymes and low platelets who was delivered under general anesthesia further complicated by Disseminated Intravascular Coagulopathy (DIC) and placental abruption.

Transversus Abdominis Plane Block With Ilioinguinal-Iliohypogastric Nerve a Viable Alternative to Provide Surgical Anesthesia for Cesarean Delivery: A Case Report

Acute fatty liver of pregnancy is one of the most common causes of fulminant hepatic failure. A 28-year-old G3P1L1A1 presented at 37 weeks with diagnosis of acute fatty liver of pregnancy with grade 3 hepatic encephalopathy. Laboratory findings were suggestive of coagulopathy, metabolic acidosis, and liver and renal dysfunction. Ultrasound-guided transversus abdominis plane block with ilioinguinal-iliohypogastric nerve block is widely used for postoperative analgesia. We applied these blocks, supplemented with intravenous ketamine for breakthrough visceral pain, to conduct cesarean delivery with a favorable outcome. Thus, transversus abdominis plane with ilioinguinal-iliohypogastric is a viable alternative in patients where general and neuraxial anesthesia is unsafe.

Acute liver failure in pregnancy: Challenges and management

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.

Acute fatty liver of pregnancy: Over six months follow-up study of twenty-five patients

AIM: To evaluate the prognosis of patients with acute fatty liver of pregnancy (AFLP) 6 mo or longer after discharge.

METHODS: The records of pregnant patients diagnosed with AFLP at Beijing Ditan Hospital over a 16-year period were reviewed in November 2012. Patients were monitored using abdominal ultrasound, liver and kidney functions, and routine blood examination.

RESULTS: A total of 42 patients were diagnosed with AFLP during the study period, and 25 were followed. The mean follow-up duration was 54.5 mo (range: 6.5-181 mo). All patients were in good physical condition, but one patient had gestational diabetes. The renal and liver functions normalized in all patients after recovery, including in those with pre-existing liver or kidney failure. The ultrasound findings were normal in 12 patients, an increasingly coarsened echo-pattern and increased echogenicity of the liver in 10 patients, and mild to moderate fatty liver infiltration in 3 patients. Cirrhosis or liver nodules were not observed in any patient.

CONCLUSION: Acute liver failure and acute renal failure in AFLP patients is reversible. Patients do not require any specific long-term follow-up after recovery from AFLP if their liver function tests have normalized and they remain well.

Retrospective analysis of acute fatty liver of pregnancy: twenty-eight cases and discussion of anesthesia

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.