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Karim G, Giri D, Kushner T, Reau N. Evaluation of Liver Disease in Pregnancy. Clin Liver Dis 2023; 27:133-155. [PMID: 36400462 DOI: 10.1016/j.cld.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Liver disease in pregnancy often requires diagnostic and therapeutic considerations that are unique to pregnancy. Liver disease in pregnancy is commonly thought of as either liver disease unique to pregnancy, chronic liver disease, or liver disease coincidental to pregnancy. This review summarizes the approach to evaluation of liver disease in pregnancy.
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Affiliation(s)
- Gres Karim
- Department of Medicine, Mount Sinai Beth Israel, 350 East 17th Street, 20th Floor, New York, NY 10003, USA
| | - Dewan Giri
- Department of Medicine, Mount Sinai Beth Israel, 350 East 17th Street, 20th Floor, New York, NY 10003, USA
| | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1123, New York, NY 10023, USA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1123, New York, NY 10023, USA.
| | - Nancy Reau
- Division of Hepatology, Rush University Medical Center, 1725 West Harrison Street
- Suite 319, Chicago, IL 60612, USA
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2
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Cao W, Chen T, Jiang W, Geng Y, Xie B, Wang Q, Wang X. Timely identification and successful treatment of acute fatty liver of pregnancy without obvious clinical symptoms: Case reports. Medicine (Baltimore) 2022; 101:e28723. [PMID: 35119019 PMCID: PMC8812678 DOI: 10.1097/md.0000000000028723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/11/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Acute fatty liver of pregnancy (AFLP) is a rare and potentially fatal complication that occurs in the third trimester or early postpartum period. The diagnosis of AFLP is based on typical clinical and laboratory features and imaging examinations. PATIENT CONCERNS Case 1: a 25-year-old pregnant woman was hospitalized for threatened preterm birth at gestation of 35weeks and 2 days gestation. Laboratory tests revealed liver dysfunction, coagulopathy, hypoglycemia, hypoproteinemia, leukocytosis, and elevated creatinine and uric acid levels. Case 2: a 28-year-old (nulliparous) became pregnant after in vitro fertilization-embryo transfer at 29 weeks and 1 days' gestation and came to the obstetric ward for vaginal bleeding. At 34 weeks and 1 day, laboratory investigations showed high serum creatinine, uric acid, liver dysfunction, coagulopathy, and hypoglycemia. DIAGNOSES Two patients did not show obvious clinical symptoms, while the ultrasound findings confirmed a diagnosis of AFLP. INTERVENTIONS Immediate delivery and comprehensive supportive treatment are the most important methods for the treatment of AFLP. OUTCOMES The 2 patients and their babies were discharged from the hospital in a good condition. LESSONS Special attention should be paid to mothers with AFLP after in vitro fertilization-embryo transfer. The clinical presentation of AFLP is variable, hence laboratory features and ultrasound examination may be important methods for screening for AFLP.
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Affiliation(s)
- Weiping Cao
- Departments of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu, PR China
| | - Tingmei Chen
- Departments of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu, PR China
| | - Wen Jiang
- Department of Nursing, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, PR China
| | - Yinping Geng
- Department of Ultrasound, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu, PR China
| | - Bing Xie
- Departments of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu, PR China
| | - Qin Wang
- Departments of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu, PR China
| | - Xinzhi Wang
- New drug screening center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, PR China
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Ramadan MK, Khaza'al J, Cha'ar D, Bazzi Z, Bachnak R, Haibeh P. Second-trimester acute fatty liver disease of pregnancy: A brief review of the literature and a case report. J Obstet Gynaecol Res 2020; 47:34-43. [PMID: 33230970 DOI: 10.1111/jog.14577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 12/14/2022]
Abstract
Acute fatty liver disease of pregnancy (AFLP) is a rare life-threatening medical emergency unique to pregnancy. It is characterized by progressive microvesicular fatty infiltration of maternal hepatocytes, but the exact etiology has yet to be elucidated. AFLP typically manifests in late third trimester or immediately postpartum and seldom during second trimester. Prompt delivery, irrespective of gestational age or severity, is crucial for arresting the insult and permitting recovery. We hereby report a 21-year-old Lebanese second-gravid woman at 20 weeks' gestation diagnosed with AFLP depending on clinical features and compatible laboratory studies (score of 8 on Swansea criteria), in spite of early occurrence. A review and analysis of early AFLP (second trimester) compared to late (third trimester) was also presented. AFLP appearing during second trimester is as serious as the disease manifesting in late third trimester, with similar diagnostic difficulties, less association with hypertension, but with greater hesitation of obstetricians to affect prompt delivery and higher adverse perinatal outcome due to added effect of premature delivery in second trimester.
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Affiliation(s)
- Mohamad K Ramadan
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Makassed General Hospital, Beirut, Lebanon
| | - Janoub Khaza'al
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
| | - Dunia Cha'ar
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
| | - Zeinab Bazzi
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
| | - Ronza Bachnak
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
| | - Pierre Haibeh
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
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Wang L, Gan Q, Du S, Zhao Y, Sun G, Lin Y, Li R. Acute fatty liver of pregnancy cases in a maternal and child health hospital of China: Three case reports. Medicine (Baltimore) 2020; 99:e21110. [PMID: 32702860 PMCID: PMC7373617 DOI: 10.1097/md.0000000000021110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
RATIONALE Acute fatty liver of pregnancy (AFLP) is extremely hazardous to pregnant woman in the 3rd trimester of pregnancy. AFLP has an insidious onset and nonspecific experimental indicators, which therefore is difficult to be diagnosed. PATIENT CONCERNS Case 1 was transferred to our hospital for hypertensive disorders complicating pregnancy at gestation of 38 weeks + 3 days. Case 2 was transferred to our hospital for suspicious fetal heart monitoring response at gestation of 36 weeks + 4 days. Case 3 was transferred to our hospital for prelabor rupture of membranes at gestation of 37 weeks + 1 days. DIAGNOSIS The diagnosis of AFLP was based on the Swansea criteria. INTERVENTIONS All 3 cases were delivered by cesarean section, and they were all transferred to intensive care unit for further treatment. Cases 2 and 3 were subjected to plasma exchange and continuous renal replacement therapy. OUTCOMES In this study, all 3 patients were initially diagnosed as gastritis. In addition, case 1 was diagnosed as preeclampsia and her AFLP was misdiagnosed with postpartum hemorrhage after cesarean delivery. Case 2 was admitted to the hospital for intrahepatic cholestasis of pregnancy and fetal distress, but we considered it as AFLP before delivery. Case 3 was treated according to severe intrahepatic cholestasis of pregnancy, but we rediagnosed it as postpartum hemorrhage and disseminated intravascular coagulation after cesarean delivery. Neonatal asphyxia and complications were not found. All of the 3 cases were fully recovered and discharged from our hospital. LESSONS If there are multiple risk factors including vomiting, abdominal pain, and fetal distress, AFLP should be highly suspected. Early diagnosis, especially before termination of pregnancy, is the key to successful treatment of AFLP.
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Affiliation(s)
| | - Quan Gan
- Department of Intensive Care Unit, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology. Wuhan, China
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Rath W, Tsikouras P, Stelzl P. HELLP Syndrome or Acute Fatty Liver of Pregnancy: A Differential Diagnostic Challenge: Common Features and Differences. Geburtshilfe Frauenheilkd 2020; 80:499-507. [PMID: 32435066 PMCID: PMC7234826 DOI: 10.1055/a-1091-8630] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/15/2019] [Accepted: 01/08/2020] [Indexed: 12/17/2022] Open
Abstract
HELLP syndrome and the less common acute fatty liver of pregnancy (AFL) are unpredictable, life-threatening complications of pregnancy. The similarities in their clinical and laboratory presentations are often challenging for the obstetrician when making a differential diagnosis. Both diseases are characterised by microvesicular steatosis of varying degrees of severity. A specific risk profile does not exist for either of the entities. Genetic defects in mitochondrial fatty acid oxidation and multiple pregnancy are considered to be common predisposing factors. The diagnosis of AFL is based on a combination of clinical symptoms and laboratory findings. The Swansea criteria have been proposed as a diagnostic tool for orientation. HELLP syndrome is a laboratory diagnosis based on the triad of haemolysis, elevated aminotransferase levels and a platelet count < 100 G/l. Generalised malaise, nausea, vomiting and abdominal pain are common symptoms of both diseases, making early diagnosis difficult. Clinical differences include a lack of polydipsia/polyuria in HELLP syndrome, while jaundice is more common and more pronounced in AFL, there is a lower incidence of hypertension and proteinuria, and patients with AFL may develop encephalopathy with rapid progression to acute liver failure. In contrast, neurological symptoms such as severe headache and visual disturbances are more prominent in patients with HELLP syndrome. In terms of laboratory findings, AFL can be differentiated from HELLP syndrome by the presence of leucocytosis, hypoglycaemia, more pronounced hyperbilirubinemia, an initial lack of haemolysis and thrombocytopenia < 100 G/l, as well as lower antithrombin levels < 65% and prolonged prothrombin times. While HELLP syndrome has a fluctuating clinical course with rapid exacerbation within hours or transient remissions, AFL rapidly progresses to acute liver failure if the infant is not delivered immediately. The only causal treatment for both diseases is immediate delivery. Expectant management between 24 + 0 and 33 + 6 weeks of gestation is recommended for HELLP syndrome, but only in cases where the mother can be stabilised and there is no evidence of foetal compromise. The maternal mortality rate for HELLP syndrome in developed countries is approximately 1%, while the rate for AFL is 1.8 – 18%. Perinatal mortality rates are 7 – 20% and 15 – 20%, respectively. While data on the long-term impact of AFL on the health of mother and child is still insufficient, HELLP syndrome is associated with an increased risk of developing cardiovascular, metabolic and neurological diseases in later life.
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Affiliation(s)
- Werner Rath
- Medizinische Fakultät, Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Panagiotis Tsikouras
- Democritus University of Thrace, Department of Obstetrics and Gynecology, Alexandroupolis, Greece
| | - Patrick Stelzl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
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Szczepanski J, Griffin A, Novotny S, Wallace K. Acute Kidney Injury in Pregnancies Complicated With Preeclampsia or HELLP Syndrome. Front Med (Lausanne) 2020; 7:22. [PMID: 32118007 PMCID: PMC7020199 DOI: 10.3389/fmed.2020.00022] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/15/2020] [Indexed: 01/12/2023] Open
Abstract
Acute kidney injury that occurs during pregnancy or in the post-partum period (PR-AKI) is a serious obstetric complication with risk of significant associated maternal and fetal morbidity and mortality. Recent data indicates that the incidence of PR-AKI is increasing, although accurate calculation is limited by the lack of a uniform diagnostic criteria that is validated in pregnancy. Hypertensive and thrombotic microangiopathic disorders of pregnancy have been identified as major contributors to the burden of PR-AKI. As is now accepted regarding preeclampsia, HELLP syndrome and atypical hemolytic uremic syndrome, it is believed that PR-AKI may have long-term renal, cardiovascular and neurocognitive consequences that persist beyond the post-partum period. Further research regarding PR-AKI could be advanced by the development of a pregnancy-specific validated definition and classification system; and the establishment of refined animal models that would allow researchers to further elucidate the mechanisms and sequelae of the disorder.
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Affiliation(s)
- Jamie Szczepanski
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Ashley Griffin
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, MS, United States
| | - Sarah Novotny
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Kedra Wallace
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, United States.,Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, MS, United States
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