Acute Fatty Liver Disease of Pregnancy: Updates in Pathogenesis, Diagnosis, and Management

Risk factors in patients with acute fatty liver of pregnancy: the role of abortion, total bilirubin and serum creatinine

PURPOSE

Acute fatty liver of pregnancy (AFLP) is a relatively rare obstetric emergency usually accompanied by fatal complications. Numerous studies have evaluated the potential risk factors for outcomes in patients with AFLP. But rare studies evaluated the predictive ability, sensitivity and specificity of the risk factors for maternal mortality. Thus, in this multicenter research, we aimed to further prove the predictive ability of the MELD model, investigated the prognostic value of history of abortion (HOA), total bilirubin (TBiL) and serum creatinine (SCr) and explored new predictive models for predicting maternal mortality in patients with AFLP.

METHODS

We performed a retrospective cohort study of 133 hospitalised patients with AFLP in four Chinese tertiary hospitals between January 2009 and April 2014.

RESULTS

The maximal AUC amongst three independent risk factors for maternal death was TBiL with a cut-off point of > 131.9 μmol/L, showing a sensitivity of 100% and a specificity of 55.9%. The threshold of the RF model for maternal mortality was - 1.629 and the AUC was 0.876, with an 81.8% sensitivity and an 80.2% specificity. The AUC for MELD model to predict maternal death was 0.894, and the best cut-off point was 28 with a sensitivity of 81.8% and a specificity of 84.7%.

CONCLUSIONS

Both the MELD model and the RF model showed good efficacy in predicting the maternal mortality in patients with ALFP (AUC = 0.894 and 0.876, respectively).

Liver imaging and pregnancy: what to expect when your patient is expecting

Liver diseases in pregnancy can be specific to gestation or only coincidental. In the latter case, the diagnosis can be difficult. Rapid diagnosis of maternal-fetal emergencies and situations requiring specialized interventions are crucial to preserve the maternal liver and guarantee materno-fetal survival. While detailed questioning of the patient and a clinical examination are highly important, imaging is often essential to reach a diagnosis of these liver diseases and lesions. Three groups of liver diseases may be observed during pregnancy: (1) diseases related to pregnancy: intrahepatic cholestasis of pregnancy, pre-eclampsia, eclampsia, hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, and acute fatty liver of pregnancy; (2) liver diseases that are more frequent during or exacerbated by pregnancy: acute herpes simplex hepatitis, Budd-Chiari syndrome, hemorrhagic hereditary telangiectasia, hepatocellular adenoma, portal vein thrombosis, and cholelithiasis; (3) coincidental conditions, including acute hepatitis, incidental focal liver lesions, metabolic dysfunction-associated steatotic liver disease, cirrhosis, hepatocellular carcinoma, liver abscesses and parasitosis, and liver transplantation. Specific knowledge of the main imaging findings is required to reach an early diagnosis, for adequate follow-up, and to avoid adverse consequences in both the mother and the fetus.Critical relevance statement Pregnancy-related liver diseases are the most important cause of liver dysfunction in pregnant patients and, in pregnancy, even common liver conditions can have an unexpected turn. Fear of radiations should never delay necessary imaging studies in pregnancy.Key points• Pregnancy-related liver diseases are the most frequent cause of liver dysfunction during gestation.• Fear of radiation should never delay necessary imaging studies.• Liver imaging is important to assess liver emergencies and for the diagnosis and follow-up of any other liver diseases.• Common liver conditions and lesions may take an unexpected turn during pregnancy.• Pregnancy-specific diseases such as pre-eclampsia and HELLP syndrome must be rapidly identified. However, imaging should never delay delivery when it is considered to be urgent for maternal-fetal survival.

Key Components of Successful Management of Acute Fatty Liver of Pregnancy: A Case Report and Literature Review

Acute fatty liver of pregnancy (AFLP) is a rare, potentially fatal obstetric emergency. Due to its nonspecific signs and symptoms, there is often a delay in diagnosis and management which is associated with morbid complications and high mortality. We report a case of a 30-year-old female gravida 3 para 2 at 32 weeks gestation who presented with nausea and vomiting for two weeks, pruritis for three days, and upper abdomen pain for a day. A clinical diagnosis of HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome/obstetric cholestasis/AFLP was made. Despite prompt management, her postpartum period was complicated by acute hepatic encephalopathy, hepatorenal shutdown, pancreatitis, coagulopathy, postpartum hemorrhage, and large abdominal wall hematoma. A high index of suspicion, prompt delivery, advanced critical support, and multidisciplinary team involvement led to successful fetomaternal outcomes in the patient.

Association between platelet counts and clinical outcomes in acute fatty liver of pregnancy: A retrospective cohort study

OBJECTIVES

To investigate whether platelet counts are associated with clinical outcomes in patients with acute fatty liver of pregnancy (AFLP).

METHODS

We retrospectively analyzed 140 patients with AFLP admitted to the Third Affiliated Hospital of Guangzhou Medical University between January 2010 and August 2022. In this cohort study, we used smooth curve fitting, Kaplan-Meier analysis, and multivariable logistic regression analysis to examine the independent relationship between platelet counts and 42-day postpartum mortality in AFLP.

RESULTS

There were 140 patients with AFLP, of which 15 died and 53 (37.86%) had thrombocytopenia. The overall 42-day postpartum maternal mortality was 10.7%. We observed a U-shaped relationship between the platelet counts and 42-day postpartum mortality. Two different slopes were observed below and above the inflection point at approximately 220 × 109 /L. After adjusting for some confounders, patients with thrombocytopenia (<100 × 109 /L) were found to have increased 42-day postpartum mortality compared with middle-tertile and highest-tertile patients. Patients with thrombocytopenia had a higher 42-day postpartum mortality, and higher proportions of intensive care unit admissions, postpartum hemorrhage, and multiple organ failure (P < 0.05).

CONCLUSIONS

A U-shaped association between platelet counts and 42-day postpartum mortality was observed in patients with AFLP. Thrombocytopenia is associated with poorer adverse clinical outcomes in women with AFLP.

Swansea criteria evaluation in acute fatty liver of pregnancy, hemolysis elevated liver enzyme and low platelet syndrome, pre-eclampsia, and viral acute liver failure in pregnancy

Not only AFLP but also HELLP and acute liver failure due to viruses in pregnancy meet the Swansea criteria, meriting a reappraisal and a reevaluation of the criteria.

[Acute Fatty Liver of Pregnancy - Case Series]

With a prevalence of 0,01-0,03%, acute fatty liver in pregnancy (AFLP) is a rare and dangerous complication of pregnancy and is difficult to distinguish from other, sometimes more common, pregnancy diseases such as HELLP syndrome, aHUS and TTP because of its mostly non-specific symptoms. Due to its rarity, AFLP is often not obvious to the obstetrician as a possible differential diagnosis. Yet early diagnosis and the fastest possible delivery is the only causal therapy and is important for the mortality rate. In the present manuscript, the pathophysiology, diagnosis and therapy of acute fatty liver in pregnancy are highlighted for the clinical routine based on case descriptions from three university hospitals, and reference is made to possible findings that are helpful in establishing the diagnosis. The angiogenic preeclampsia marker sFlt-1 plays a role and provides new opportunities to consider pathophysiological approaches.

Acute fatty liver of pregnancy causing multiple organ dysfunction syndrome in a Chinese intensive care unit

Acute fatty liver of pregnancy (AFLP) is a rare but severe condition associated with high rates of maternal and foetal morbidity and mortality. Timely discontinuation of pregnancy, professional supervision and appropriate management are helpful for a successful discharge. This article reports the presentation and nursing care of a pregnant woman who was diagnosed with AFLP and discharged from the intensive care unit (ICU) after a prolonged hospitalization. The patient was admitted to the ICU on the first day after a caesarean section, with deterioration of liver, kidney and coagulation function. On day 1 of ICU admission, she underwent transnasal high-flow oxygen therapy. Owing to worsening respiratory status and oxygen saturation <85%, the patient was intubated on day 3 in the ICU. Her urine output decreased significantly, her bilirubin level progressively increased, and she was treated with bilirubin adsorption and haemodialysis. Multiple organ dysfunction syndrome occurred, along with many other complications, including subarachnoid haemorrhage and lower extremity venous thrombosis. The patient was finally extubated on day 7, and haemodialysis was discontinued on day 42, with a daily urine output of approximately 2000 mL. The patient was discharged from the ICU 43 days after admission. Treatment and care activities under qualified nursing care, including managing haemorrhage and anticoagulation in haemodialysis, pain care based on psychological support, early rehabilitation and nutrition and providing appropriate care for respiratory support, contributed to the successful discharge of the patient from the ICU. During the patient's 43-day stay in the ICU, strict monitoring and personalized nursing care were implemented.

Diagnostic Approach to Elevated Liver Function Tests during Pregnancy: A Pragmatic Narrative Review

Liver disease is not uncommon during pregnancy and is associated with increased maternal and fetal/neonatal morbidity and mortality. Physiological changes during pregnancy, including a hyperestrogenic state, increase in circulating plasma volume and/or reduction in splanchnic vascular resistance, and hemostatic imbalance, may mimic or worsen liver disease. For the clinician, it is important to distinguish among the first presentation or exacerbation of chronic liver disease, acute liver disease non-specific to pregnancy, and pregnancy-specific liver disease. This last group classically includes conditions such as hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, liver disorders associated with the pre-eclampsia spectrum, and an acute fatty liver of pregnancy. All of these disorders often share pathophysiological mechanisms, symptoms, and laboratory findings (such as elevated liver enzymes), but a prompt and correct diagnosis is fundamental to guide obstetric conduct, reduce morbidity and mortality, and inform upon the risk of recurrence or development of other chronic diseases later on in life. Finally, the cause of elevated liver enzymes during pregnancy is unclear in up to 30-40% of the cases, and yet, little is known on the causes and mechanisms underlying these alterations, or whether these findings are associated with worse maternal/fetal outcomes. In this narrative review, we aimed to summarize pragmatically the diagnostic work-up and the management of subjects with elevated liver enzymes during pregnancy.

A Case Report on Acute Fatty Liver of Pregnancy: A Difficult Differential Diagnosis of Liver Disorder

Acute fatty liver of pregnancy is a rare but potentially dangerous pregnancy condition with significant maternal and fetal fatality rates. The disorder is driven by a complex pathophysiology and clinically manifests as a rapid worsening in health conditions, increasing the rate of mortality and necessitating expert diagnosis and management. The condition progresses from spontaneous resolution to post-operative complications, resulting in negative consequences. We offer a case report of a young primigravida patient diagnosed with acute fatty liver of pregnancy at term. The report describes the clinical course and its effect. The perinatal result, however, could not be improved due to the late diagnosis. Over the last 40 years, death rates have been dramatically lowered because of competence and a multidisciplinary approach, increasing maternal-fetal outcomes. In this scenario, time management is crucial to success.

The Role of Endothelial Dysfunction in the Pathogenesis of Pregnancy-Related Pathological Conditions: A Review

In the recent decades, endothelial dysfunction (ED) has been recognized as a significant contributing factor in the pathogenesis of many pathological conditions. In interaction with atherosclerosis, hypercholesterolemia, and hypertension, ED plays a crucial role in the pathogenesis of coronary artery disease, chronic renal disease, and microvascular complications in diabetes mellitus. Although ED plays a significant role in the pathogenesis of several pregnancy-related disorders such as preeclampsia, HELLP syndrome, fetal growth restriction, and gestational diabetes mellitus, the exact pathogenetic mechanisms are still a matter of debate. The increased prevalence of these entities in patients with preexisting vascular diseases highlights the essential pathological role of the preexisting ED in these patients. The abnormal uteroplacental circulation and the release of soluble factors from the ischemic placenta into the maternal bloodstream are the main causes of the maternal ED underlying the characteristic preeclamptic phenotype. Besides the increased risk for maternal and fetal poor outcomes, the preexisting ED also increases the risk of development of future cardiovascular diseases in these patients. This study aimed to look deeper into the role of ED in the pathogenesis of several pregnancy-related hypertensive and liver diseases. Hopefully, it could contribute to improvement of the awareness, knowledge, and management of these conditions and also to the reduction of the adverse outcomes and additional long-term cardiovascular complications.

Acute fatty liver of pregnancy complicated by coagulopathy: A case report

Key Clinical Message

We present the case of a rare obstetric emergency, which is usually fatal. Our case highlights suspicion of AFLP in patients presenting with jaundice in the third trimester with good maternal and fetal outcomes after a timely intervention.

Abstract

Acute fatty liver of pregnancy (AFLP) is a rare, obstetric emergency characterized by maternal liver dysfunction that can lead to maternal and fetal complications. We report a case of 28-year-old primigravida 39 weeks gestation diagnosed with AFLP complicated by coagulopathy with good maternal and fetal outcomes after a timely intervention.

The assessment in patients with acute fatty liver of pregnancy (AFLP) treated with plasma exchange: a cohort study of 298 patients

BACKGROUND

To assess the prevalence, risk factors, clinical characteristics of Acute fatty liver of pregnancy (AFLP) patients, and outcomes of AFLP patients treated with plasma exchange (PE).

METHODS

We retrospectively reviewed the AFLP patients admitted to the First Affiliated Hospital of Xi'an Jiaotong University and Xijing Hospital of Air Force Medical University from January 2012 to May 2022. Final prediction model for death among AFLP by means of stepwise backward elimination with p value < 0.05. Patients treated with and without PE were compared by propensity-matched cohort study.

RESULTS

Two hundred ninety eight patients with the diagnosis of AFLP, and finally 290 patients were enrolled in the cohort study, 50 of whom (17.2%) were dead. Compared with AFLP patients alive, the dead of patients were more likely to be combined encephalopathy (p < 0.01), postpartum hemorrhage (p < 0.01), and found significantly higher frequency of fetal distress (p = 0.04), fetal death (p < 0.01). we developed a predicted probability value and with an area under the receiver operating characteristics (ROC) curve of 0.94 (95%CI 0.87 to 1.00), indicating AFLP patients' death. The patients treated with PE had a significantly lower 60-day mortality rate (OR 0.42, 95% CI 0.29 to 2.64, p = 0.04), and significantly shorter duration of hospital-free days at day 28 (p = 0.01).

CONCLUSIONS

In conclusion, our study indicated that liver function were risk factors for maternal mortality, and PE was a protective factor for maternal 60-day mortality and hospital-free days at day 28 in AFLP patients.

Progress of potential drugs targeted in lipid metabolism research

Lipids are a class of complex hydrophobic molecules derived from fatty acids that not only form the structural basis of biological membranes but also regulate metabolism and maintain energy balance. The role of lipids in obesity and other metabolic diseases has recently received much attention, making lipid metabolism one of the attractive research areas. Several metabolic diseases are linked to lipid metabolism, including diabetes, obesity, and atherosclerosis. Additionally, lipid metabolism contributes to the rapid growth of cancer cells as abnormal lipid synthesis or uptake enhances the growth of cancer cells. This review introduces the potential drug targets in lipid metabolism and summarizes the important potential drug targets with recent research progress on the corresponding small molecule inhibitor drugs. The significance of this review is to provide a reference for the clinical treatment of metabolic diseases related to lipid metabolism and the treatment of tumors, hoping to deepen the understanding of lipid metabolism and health.

Acute fatty liver of pregnancy accompanied with disseminated intravascular coagulopathy and encephalopathy: A case report

Acute fatty liver disease of pregnancy (AFLP) is a rare condition associated with other common liver manifestations such as hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP). We present a 27-year-old pregnant woman who developed hepatic encephalopathy and DIC after being diagnosed with Acute fatty liver disease of pregnancy.

[Recurrent acute fatty liver of pregnancy: About a case and a review of the literature]

Acute fatty liver of pregnancy (AFLP) is a specific but rare hepatopathy that can usually complicate the third trimester of pregnancy. It is potentially fatal for the mother and the fetus. To our knowledge, only eight cases of recurrence have been published, we report a new case. The first episode presented by our 23-year-old patient was suspected in front of a cutaneous-mucosal jaundice with vomiting occurring on pregnancy of 35weeks of gestation (WG). Hyperleucytosis, abnormalities of the hepatic balance, as well as a hypoglycemia were biological elements supporting the diagnostic beam. On the other hand, medical imaging could not bring a clear confirmation. The evolution was favorable after deferred delivery by caesarean section for pulmonary maturation. Three years later, she presented to the obstetrical emergency room at 36weeks and six days of gestation, with a clinical and biological picture almost similar to that of the first episode. A caesarean section was then indicated for suspicion of recurrence. The evolution is favorable for the mother and her children. The interest of the communication on the risk of recurrence, the clinical and biological monitoring in particular in the third trimester of the subsequent pregnancy are imperative, in order to improve the prognosis of this pathology.

Obstetric Disorders and Critical Illness

In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.

An Altered Sphingolipid Profile as a Risk Factor for Progressive Neurodegeneration in Long-Chain 3-Hydroxyacyl-CoA Deficiency (LCHADD)

Long-chain 3-hydroxyacyl-CoA deficiency (LCHADD) and mitochondrial trifunctional protein (MTPD) belong to a group of inherited metabolic diseases affecting the degradation of long-chain chain fatty acids. During metabolic decompensation the incomplete degradation of fatty acids results in life-threatening episodes, coma and death. Despite fast identification at neonatal screening, LCHADD/MTPD present with progressive neurodegenerative symptoms originally attributed to the accumulation of toxic hydroxyl acylcarnitines and energy deficiency. Recently, it has been shown that LCHADD human fibroblasts display a disease-specific alteration of complex lipids. Accumulating fatty acids, due to defective β-oxidation, contribute to a remodeling of several lipid classes including mitochondrial cardiolipins and sphingolipids. In the last years the face of LCHADD/MTPD has changed. The reported dysregulation of complex lipids other than the simple acylcarnitines represents a novel aspect of disease development. Indeed, aberrant lipid profiles have already been associated with other neurodegenerative diseases such as Parkinson’s Disease, Alzheimer’s Disease, amyotrophic lateral sclerosis and retinopathy. Today, the physiopathology that underlies the development of the progressive neuropathic symptoms in LCHADD/MTPD is not fully understood. Here, we hypothesize an alternative disease-causing mechanism that contemplates the interaction of several factors that acting in concert contribute to the heterogeneous clinical phenotype.

Pr-AKI: Acute Kidney Injury in Pregnancy – Etiology, Diagnostic Workup, Management

Despite significant improvements in inpatient and outpatient management, pregnancy-related acute kidney injury (Pr-AKI) remains an important risk factor for early and late maternal and fetal morbidity and mortality. There is a discrepancy between the incidence of Pr-AKI in developing and in developed countries, with the former experiencing a decrease and the latter an increase in Pr-AKI in recent decades. Whereas septic and hemorrhagic complications predominated in the past, nowadays hypertensive disorders and thrombotic microangiopathy are the leading causes of Pr-AKI. Modern lifestyles and the availability and widespread use of in-vitro fertilization techniques in industrialized countries have allowed more women of advanced age to become pregnant. This has led to a rise in the percentage of high-risk pregnancies due to the disorders and comorbidities inherent to or accompanying aging, such as diabetes, arterial hypertension and preexisting chronic kidney disease. Last but not least, the heterogeneity of symptoms, the often overlapping clinical and laboratory characteristics and the pathophysiological changes related to pregnancy make the diagnosis and management of Pr-AKI a difficult and challenging task for the treating physician. In addition to general supportive management strategies such as volume substitution, blood pressure control, prevention of seizures or immediate delivery, each disease entity requires a specific therapy to reduce maternal and fetal complications. In this review, we used the current literature to provide a summary of the physiologic and pathophysiologic changes in renal physiology which occur during pregnancy. In the second part, we present common and rare disorders which lead to Pr-AKI and provide an overview of the available treatment options.

Managing hepatic complications of pregnancy: practical strategies for clinicians

Liver disorders specific to pregnancy are rare but can have potentially serious consequences for mother and fetus. Pregnancy-related liver disorders are the most common cause of liver disease in otherwise healthy pregnant women and pose a challenge to physicians because of the need to take into account both maternal and fetal health. A good knowledge of these disorders is necessary as prompt diagnosis and appropriate management results in improved maternal and fetal outcomes. This review will focus on pregnancy-specific disorders and will aim to serve as a guide for physicians in their diagnosis, management and subsequent monitoring.

Intestinal Barrier and Permeability in Health, Obesity and NAFLD

The largest surface of the human body exposed to the external environment is the gut. At this level, the intestinal barrier includes luminal microbes, the mucin layer, gastrointestinal motility and secretion, enterocytes, immune cells, gut vascular barrier, and liver barrier. A healthy intestinal barrier is characterized by the selective permeability of nutrients, metabolites, water, and bacterial products, and processes are governed by cellular, neural, immune, and hormonal factors. Disrupted gut permeability (leaky gut syndrome) can represent a predisposing or aggravating condition in obesity and the metabolically associated liver steatosis (nonalcoholic fatty liver disease, NAFLD). In what follows, we describe the morphological-functional features of the intestinal barrier, the role of major modifiers of the intestinal barrier, and discuss the recent evidence pointing to the key role of intestinal permeability in obesity/NAFLD.

The association between acute fatty liver disease and nitric oxide during malaria in pregnancy

BACKGROUND

Liver disease is a common feature of malaria in pregnancy, but its pathogenesis remains unclear.

METHODS

To understand the pathogenesis of liver disease during malaria in pregnancy, comparative proteomic analysis of the liver in a mouse model of malaria in pregnancy was performed.

RESULTS

Decreased levels of mitochondrial and peroxisomal proteins were observed in the livers of pregnant mice infected with the lethal rodent malaria parasite Plasmodium berghei strain NK65. By contrast, increased levels of perilipin-2, amyloid A-1, and interferon (IFN)-γ signalling pathway-related proteins were observed in the livers of infected pregnant mice, suggesting that IFN-γ signalling may contribute to the development of liver disease during malaria in pregnancy. IFN-γ signalling is a potential trigger of inducible nitric oxide synthase (iNOS) expression. Liver disease associated with microvesicular fatty infiltration and elevated liver enzymes in pregnant wild-type mice infected with malaria parasites was improved by iNOS deficiency.

CONCLUSIONS

In this study, a causative role of iNOS in liver disease associated with microvesicular fatty infiltration during malaria in pregnancy was demonstrated. These findings provide important insight for understanding the role of iNOS-mediated metabolic responses and the pathogenesis of high-risk liver diseases in pregnancy, such as acute fatty liver.

Acute Fatty Liver of Pregnancy

BACKGROUND Acute fatty liver of pregnancy (AFLP) is a rare obstetric emergency resulting from microvesicular infiltration of the liver by fat, leading to liver failure. It usually presents at 36 weeks of gestation, and risk factors include twin pregnancy and low BMI. The presentation of AFLP is nonspecific, requiring a high index of suspicion. The Swansea Criteria is used to aid diagnosis. CASE REPORT Case 1: A 23-year-old woman, G1P0 at 39 weeks of gestation, presented to the hospital with a 1-week history of fever, nausea, vomiting, and diarrhea. Examination revealed a gravid uterus with generalized abdominal tenderness. Laboratory investigations revealed elevated liver enzymes, with elevated total bilirubin and an INR of 1.26. CBC showed leukocytosis. Abdominal ultrasound was normal. Workup for other etiologies, including acetaminophen and salicylate overdose and infections, was negative. The Swansea score for AFLP was 8, confirming the AFLP diagnosis. An emergency Cesarean-section was performed, causing liver enzymes to improve over 3 days. Case 2: A 41-year-old woman, G1P1 with a twin gestation at 36 weeks, presented with a 3-day history of abdominal pain. She was jaundiced, with right upper quadrant tenderness. Laboratory investigations showed elevated liver enzymes and total bilirubin, with an INR of 1.26. Workup for viral hepatitis and autoimmune etiology was negative. Salicylate levels were within normal limits. She met criteria for AFLP and underwent emergency Cesarean-section. Liver enzymes improved over 4 days. CONCLUSIONS AFLP is a potentially life-threatening medical condition. From our experience, prompt diagnosis and early delivery leads to improved maternal and fetal outcomes.

Liver pathology in pregnancy

Liver dysfunction occurs in up to 3% of pregnancies and can be due to pregnancy-associated liver injury, exacerbation of pre-existing liver disease, or co-incident with pregnancy. The most common form of pregnancy-associated liver injury is intrahepatic cholestasis of pregnancy (ICP). This condition is typically benign and self-limited, but is associated with fetal morbidity and mortality with high levels of serum bile acids. Acute fatty liver of pregnancy (AFLP) and the hypertensive disorders of pregnancy (including pre-eclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets [HELLP] syndrome) are more commonly associated with maternal and fetal complications and may necessitate expedient delivery. Histologically, ICP shows nonspecific features of cholestasis, while AFLP and the hypertensive disorders have more characteristic histologic findings. While not a true liver disease, hyperemesis gravidarum can cause elevated liver enzymes. Pregnant patients are at increased risk of developing severe hepatitis E and herpesvirus infections, Budd-Chiari syndrome, and gallstones, and they may also experience worsening of known chronic liver disease. Mass lesions in pregnancy including hemangiomas, focal nodular hyperplasia, and hepatocellular adenomas and carcinomas can present unique challenges for diagnosis and management. This review will explore the pathophysiology, presentation, histologic features, and management of these conditions.

Acute fatty liver of pregnancy at 19 weeks and 0 days of gestation after prolonged hyperemesis gravidarum

Acute fatty liver of pregnancy (AFLP) is a rare disorder that typically develops in the third trimester. We successfully diagnosed and treated a case of AFLP that developed at 18 weeks' gestation. A 34-year-old woman-gravida 4, para 3-presented with continuous vomiting and abdominal pain and developed convulsive seizures and lost consciousness after transfusion therapy. Cerebral apoplexy was excluded by computed tomography of the brain. Blood tests revealed severe metabolic acidosis, coagulopathy, and leukocytosis, followed by severe hypoglycemia and elevated levels of transaminases and ammonia. The fetus was delivered dead. Whole-body computed tomography showed fatty liver. The patient was diagnosed with AFLP based on the Swansea criteria. AFLP may be a differential diagnosis in the second trimester, and rapid termination should be considered as radical treatment. Starvation may be a risk factor for this disorder.

Analysis of clinical characteristics and genetic testing in patients with acute fatty liver of pregnancy: a retrospective study

Background

Acute fatty liver of pregnancy (AFLP) is an acute, rare and potentially lethal disease typically occurring in the third trimester of pregnancy. So far, there is no effective means of prevention. Therefore, in this study, we retrospectively analyzed the clinical features of AFLP patients for a better understanding. Meanwhile, for the first time, the genetic background associated with the onset of AFLP was discussed by high-throughput sequencing, hoping to provide evidence for genetic counseling and prenatal diagnosis of AFLP.

Methods

Thirteen AFLP patients admitted to our hospital and other hospital from March 2012 to February 2020 were selected. Clinical data about general condition, laboratory test, liver biopsy and the prognosis of mother and fetus were collected for retrospective analysis. In addition, the peripheral blood of five patients with AFLP and one newborn infant of his mother with AFLP was sequenced with whole-exome sequencing and gene mutation was analyzed by bioinformatics methods.

Results

The initial symptoms of AFLP varied differently, with jaundice (9/13, 69%), fatigue (8/13, 62%) and nausea and vomiting (6/13, 46%) being the most common. Moreover, the main maternal complications were coagulopathy (13/13, 100%), followed by acute renal dysfunction (10/13, 77%). Raised serum bilirubin, transaminases and uric acid were found in all patients (100%), hypoglycemia was found in six patients (46%) and fatty liver on ultrasound was seen in five patients (5/12, 42%). One (7%) maternal death occurred and all neonates survived delivery. In addition, to our surprise, whole-exome sequencing showed that no gene mutation in related enzymes involved in fatty acid metabolism was noted in the pregnant women and children receiving genetic testing.

Conclusions

Early visit, early detection, early termination of pregnancy and multidisciplinary comprehensive treatment are the key factors to improve the prognosis of AFLP patients and their newborn infants. Furthermore, although limited size of study, to our knowledge, this report is the first to present the lack of common mutation involved in fatty acid oxidation in Chinese patients with AFLP via whole-exome sequencing. Thus, further studies are needed with larger and more varied samples to validate the conclusion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04095-8.

Pathological findings of liver steatosis that is difficult to evaluate with ultrasound

Although new ultrasound (US) methods able to quantitatively assess liver fat content have been recently developed, B-mode US is still the major method for detecting liver steatosis during medical checkups. However, some pathological cases yield false-positive or false-negative liver steatosis results using B-mode US. In addition, histologically, the degree of fat deposits and the size of fat droplets in the liver can affect the sensitivity and specificity of the diagnosis of liver steatosis using B-mode US. As B-mode US evaluation of fatty liver relies on operator expertise, the operator should be aware that there are some cases of liver steatosis that are difficult to evaluate with B-mode US. Here, we describe the pathological findings of liver steatosis that is difficult to evaluate with US.

Liver and Biliary Disease of Pregnancy and Anesthetic Implications: A Review

Liver and biliary disease complicates pregnancy in varying degrees of severity to the mother and fetus, and anesthesiologists may be asked to assist in caring for these patients before, during, and after birth of the fetus. Therefore, it is important to be familiar with how different liver diseases impact the pregnancy state. In addition, knowing symptoms, signs, and laboratory markers in the context of a pregnant patient will lead to faster diagnosis and treatment of such patients. This review article discusses changes in physiology of parturients, patients with liver disease, and parturients with liver disease. Next, general treatment of parturients with acute and chronic liver dysfunction is presented. The article progresses to specific liver diseases with treatments as they relate to pregnancy. And finally, important aspects to consider when anesthetizing parturients with liver disease are discussed.

Acute Fatty Liver of Pregnancy

Acute fatty liver of pregnancy is a rare, but potentially fatal obstetric disorder characterized principally by varying degrees of hepatic failure with an onset typically in late pregnancy. This review outlines the etiopathogenesis and describes the multiorgan involvement that often results in a number of clinical and laboratory aberrations. These laboratory derangements provide distinct features to differentiate from other obstetric complications, such as hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Once recognized, central to the management of acute fatty liver of pregnancy is delivery planning and meticulous supportive care. One particularly dangerous complication is profound coagulopathy. After delivery, the coagulation defect resolves over 1-2 days, and hepatic and renal function are restored soon thereafter. This report offers anticipated recovery and management strategies for commonly associated complications. Application of these factors has served to decrease mortality from as high as 80% down to 10%; however, given the seriousness of this condition, severe maternal morbidities are frequently associated with this obstetric emergency.

Differentiating Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome and Atypical Hemolytic Uremic Syndrome in the Postpartum Period

[Figure: see text].

Thrombotic microangiopathy during pregnancy

Pregnancy is a high-risk time for the development of different kinds of thrombotic microangiopathy (TMA). Three major syndromes including TTP (thrombotic thrombocytopenic purpura), PE/HELLP (preeclampsia/hemolysis, elevated liver function tests, low platelets), and aHUS (atypical hemolytic- uremic syndrome) should be sought in pregnancy-TMA. These severe disorders share multiple clinical features and overlaps and even the coexistence of more than one pathologic mechanism. Each of these disorders finally ends in endothelial damage and fibrin thrombi formation within the microcirculation that fragments RBCs (schystocytes), aggregates platelets, and creates ischemic injury in the targeted organs i.e.; kidney and brain. Although the mechanisms of these severe disorders have been revealed, pregnancy-related TMA still interfaces with diagnostic and therapeutic challenges. Here, we highlight the current knowledge of diagnosis and management of these complications during pregnancy.

Accurate Prediction of Total PlGF (Placental Growth Factor) From Free PlGF and sFlt-1 (Soluble Fms-Like Tyrosine Kinase-1): Evidence for Markedly Elevated PlGF Levels in Women With Acute Fatty Liver of Pregnancy

Acute fatty liver of pregnancy (AFLP) is characterized by elevated circulating sFlt-1 (soluble Fms-like tyrosine kinase-1), although the free circulating levels of its ligand, PlGF (placental growth factor) are not decreased. Here, we hypothesized that women with AFLP exhibit elevated PlGF production in comparison to women with preeclampsia or hemolysis elevated liver enzymes and low platelet count syndrome. Making use of the well-known mathematical formulas describing drug-receptor interactions, we established that serum total PlGF could be accurately predicted from sFlt-1 and free PlGF levels (n=42; mean calculated K_D of 50 pmol/L), yielding similar values as the previously published method of thermal dissociation of the sFlt-1-PlGF complexes (r=0.94, P<0.0001). We found that median levels of free PlGF were significantly lower in women with preeclampsia (n=13; 117pg/mL) or hemolysis elevated liver enzymes and low platelet count syndrome (n=12; 59 pg/mL) compared with women without preeclampsia (n=11; 349pg/mL, P<0.0001). In contrast, median total PlGF did not differ between women with no preeclampsia, preeclampsia, and hemolysis elevated liver enzymes and low platelet count syndrome (354 versus 435 versus 344pg/mL), whereas it was markedly elevated in AFLP compared with all groups (2054 pg/mL, P<0.0001). Furthermore, in AFLP, both sFlt-1 and total PlGF declined rapidly postdelivery, with significantly higher predelivery total PlGF (n=12; median, 2054 pg/mL) than postpartum levels (n=14; median, 163pg/mL, P<0.0001), suggesting that in AFLP, PlGF is largely placenta-derived. Collectively, our findings indicate that like sFlt-1, PlGF production is significantly upregulated in AFLP, mainly originating from the placenta. Importantly, total PlGF can now be easily calculated from already available free PlGF and sFlt-1 levels, allowing subsequent evaluation of other groups in whom PlGF is altered.

Soluble fms-like tyrosine kinase 1 (sFlt-1): A novel biochemical marker for acute fatty liver of pregnancy

INTRODUCTION

Acute fatty liver of pregnancy (AFLP) substantially contributes to maternal and neonatal morbidity and mortality. Other liver-associated pregnancy complications such as preeclampsia-associated HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome may be difficult to differentiate from AFLP as these diseases overlap with regard to multiple clinical and laboratory features. The aim of this study was to investigate angiogenic profiles by measuring soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) in pregnancies compromised by AFLP and to compare them with those complicated by HELLP syndrome.

MATERIAL AND METHODS

Pregnant women affected by AFLP or HELLP syndrome were enrolled. The study population of women with HELLP syndrome was part of a larger data collection obtained in our clinic that has been used for previous work. Patients' angiogenic profiles were assessed by measuring sFlt-1 and PlGF serum levels. To assess the diagnostic potential of these angiogenic markers in AFLP, as well as discriminating it from HELLP syndrome, non-parametric tests were used and receiver operating curves were calculated.

RESULTS

Six women with AFLP and 48 women with HELLP syndrome were included in the study. Patients with AFLP showed significantly higher sFlt-1 levels (median: 57 570 pg/mL; range 31 609-147 170 pg/mL) than patients with HELLP syndrome (9713 pg/mL; 1348-30 781 pg/mL; p < 0.001). PlGF serum levels were higher in patients with AFLP compared with those with HELLP syndrome (197 pg/mL; 127-487 pg/mL vs. 40 pg/mL; 9-644 pg/mL, respectively; p < 0.01). sFlt-1/PlGF ratios were not significantly different between AFLP and HELLP syndrome patients (192; 157-1159 vs. 232; 3-948, respectively; NS). In our study population, an sFlt-1 cut-off value of 31 100 pg/mL allowed differentiation between these two diseases with a sensitivity and specificity of 100%. A linear correlation was found between the cumulative numbers of Swansea criteria and sFlt-1 serum levels (r = 0.97; p < 0.01).

CONCLUSIONS

AFLP is associated with very high sFlt-1 serum levels in particular in women fulfilling eight or more Swansea criteria. Besides the suggested Swansea criteria to diagnose AFLP, an sFlt-1 value above 31 100 pg/mL may be an additional biochemical feature improving discrimination between AFLP and HELLP syndrome. However, because of the small number of pregnancies affected by AFLP included in this work further studies are needed to corroborate our findings.

Acute fatty liver of pregnancy causes severe acute pancreatitis and stillborn fetus: A case report

RATIONALE

Acutefatty liver of pregnancy (AFLP) is a potentially fatal obstetric emergency characterized by acute hepatic failure secondary to fatty infiltration. The resultant effects include coagulopathy, electrolyte abnormalities, and multisystem organ dysfunction. Pancreatitis typically develops after the onset of renal and hepatic dysfunction. Pancreatitis has been suggested as a poor prognostic indicator because it is associated with more adverse outcomes.

PATIENT CONCERNS

A 29-year-old Chinese woman at 34.7 weeks pregnancy was admitted to hospital due to paroxysmal hypogastric pain and massive colporrhagia for 1 day.

DIAGNOSIS

Laboratory tests revealed hepatic and renal impairment, coagulopathy. Thoracoabdominal computed tomography (CT) scanning showed pleural and peritoneal effusion, fatty liver, and pancreatitis. She was diagnosed with AFLP, severe acute pancreatitis (SAP), multiple organ dysfunction syndrome (MODS), and intrauterine fetal death.

INTERVENTIONS

The patient was treated with blood component transfusions, plasma exchange combined with renal replacement therapy, antibiotic de-escalation, gastric and pancreatic secretion inhibitor, and enteral nutrition.

OUTCOMES

After successful management, the patient was discharged without any complications on day 35 of admission. At 10 months follow-up, thoracoabdominal enhanced CT revealed was normal and laboratory tests revealed normal liver and kidney function.

LESSONS

Once AFLP is highly suspected or confirmed, the pregnancy should be terminated in time and active symptomatic management should be given.

Perinatal Outcomes and Risk Factors for Preterm Birth in Twin Pregnancies in a Chinese Population: A Multi-center Retrospective Study

Background: Twin pregnancies are associated with an increased risk of adverse maternal and neonatal outcomes, mainly owing to prematurity. Few studies have evaluated the risk factors for preterm birth (PTB) in Chinese population. The objective of this study is to present the short-term maternal-neonatal outcomes, investigating the potential risk factors associated with preterm birth in Chinese twin pregnancies.

Methods: A multi-center retrospective study of women pregnant with twins ≥28 weeks of gestation was conducted. Maternal and neonatal outcomes were analyzed. Logistic regression was used to identify potential risk factors for PTB before 37, 34, and 32 weeks, respectively.

Results: A total of 3,288 twin pregnancies and 6,576 neonates were included in 99,585 pregnancies. The rate of twin pregnancy was 3.3%, while the PTB rate before 37, 34, and 32 weeks among this population were 62.1, 18.8, and 10.4%, respectively. Logistic regression revealed that monochorionicity [Odds ratio (OR) 3.028, 95% confident interval (CI) 2.489–3.683, P < 0.001], gestational weight gain (GWG) <10 kg (OR 2.285, 95% CI 1.563–3.339, P < 0.001) and GWG between 10 and 15 kg (OR 1.478, 95% CI 1.188–1.839, P < 0.001), preeclampsia (PE) (OR 3.067, 95% CI 2.142–4.390, P < 0.001), and intrahepatic cholestasis of pregnancy (ICP) (OR 3.122, 95% CI 2.121–4.596, P < 0.001) were the risk factors for PTB before 37 weeks. Monochorionicity (OR 2.865, 95% CI 2.344–3.501, P < 0.001), age < 25 years (OR 1.888, 95% CI 1.307–2.728, P = 0.001), and GWG <10 kg (OR 3.100, 95% CI 2.198–4.372, P < 0.001) were risk factors for PTB before 34 weeks. Monochorionicity (OR 2.566, 95% CI 1.991–3.307, P < 0.001), age younger than 25 years (OR 1.964, 95% CI 1.265–3.048, P = 0.003), and GWG <10 kg (OR 4.319, 95% CI 2.931–6.364, P < 0.001) were the risk factors for PTB before 32 weeks.

Conclusions: Monochorionicity and GWG <10 kg were two major risk factors for PTB before 32, 34, and 37 weeks, whereas maternal age, PE, and ICP were also risk factors for PTB in specific gestational age.

Comparison of maternal and neonatal outcomes between acute fatty liver of pregnancy and hemolysis, elevated liver enzymes and low platelets syndrome: a retrospective cohort study

BACKGROUND

Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome are two uncommon disorders that mimic each other clinically, but are distinct pathophysiologically. This study aimed to compare maternal and neonatal outcomes between AFLP and HELLP syndrome.

METHODS

This retrospective cohort study was performed at a tertiary referral center in Taiwan between June 2004 and April 2020. We used the Swansea Criteria to diagnose AFLP, and the Tennessee Classification System to diagnose HELLP syndrome. Maternal characteristics, laboratory data, complications, and neonatal outcomes were compared. We analyzed the categorical variables with Chi-square test or Fisher's exact test and continuous variables with Student's t test or Mann-Whitney U test. Subsequent logistic regression analyses adjusting by potential confounding factors with significant difference were analyzed.

RESULTS

During the study period, 21 women had AFLP and 80 women had HELLP syndrome. There was a higher rate of preeclampsia (95.0 % versus 23.8 %) in the HELLP syndrome group compared to the AFLP group. However, the AFLP group had more other maternal complications including jaundice (85.7 % versus 13.8 %), acute kidney injury (61.9 % versus 15.0 %), disseminated intravascular coagulopathy (66.7 % versus 8.8 %), and sepsis (47.6 % versus 10.0 %) compared to the HELLP syndrome group. Nevertheless, higher rates of small for gestational age neonates (57.1 % versus 33.3 %), neonatal respiratory distress syndrome (39.2 % versus 8.3 %) and neonatal sepsis (34.2 % versus 12.5 %) were noted in the HELLP syndrome group.

CONCLUSIONS

AFLP is associated with a higher rate of multiple organ dysfunction in mothers, whereas HELLP syndrome is associated with a higher rate of neonatal morbidity.

Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group

Pregnancy and postpartum are high-risk periods for different forms of thrombotic microangiopathy (TMA). However, the management of pregnancy-associated TMA remains ill defined. This report, by an international multidisciplinary working group of obstetricians, nephrologists, hematologists, intensivists, neonatologists, and complement biologists, summarizes the current knowledge of these potentially severe disorders and proposes a practical clinical approach to diagnose and manage an episode of pregnancy-associated TMA. This approach takes into account the timing of TMA in pregnancy or postpartum, coexisting symptoms, first-line laboratory workup, and probability-based assessment of possible causes of pregnancy-associated TMA. Its aims are: to rule thrombotic thrombocytopenic purpura (TTP) in or out, with urgency, using ADAMTS13 activity testing; to consider alternative disorders with features of TMA (preeclampsia/eclampsia; hemolysis elevated liver enzymes low platelets syndrome; antiphospholipid syndrome); or, ultimately, to diagnose complement-mediated atypical hemolytic uremic syndrome (aHUS; a diagnosis of exclusion). Although they are rare, diagnosing TTP and aHUS associated with pregnancy, and postpartum, is paramount as both require urgent specific treatment.

A case of hypertensive disorders of pregnancy that developed at 9 weeks of gestation

Preeclampsia and superimposed preeclampsia usually develop after 20 weeks of gestation. We report a case of a 35-year-old Japanese woman who developed hypertensive disorders of pregnancy (HDP) before 20 weeks of gestation. She presented with hypertension and proteinuria at 9 and 11 weeks of gestation, respectively, and developed nephrotic syndrome at 17 weeks of gestation. She did not have definite hypertension or urinary abnormalities before pregnancy. The patient was serologically positive for the antinuclear antibody. However, the complement levels were normal and anti-phospholipid antibody was not detected. A renal biopsy performed at 18 weeks of gestation showed diffuse endotheliosis and tip lesions of secondary focal segmental glomerulosclerosis but no hypertensive changes of the arterioles. Although electron microscopic examination showed electron-dense deposits in the subendothelial lesions, they were considered nonspecific plasma exudation by mass spectrometry. An abortion was performed at 20 weeks gestation because the patient's congestive symptoms due to nephrotic syndrome had worsened and marked fetal growth restriction was observed. After delivery, the patient's symptoms resolved immediately without any additional treatment; however, continuous antihypertensive medication was required. Finally, the patient was diagnosed with HDP based on the renal biopsy findings and her clinical course after delivery. Compared to previous reports, this case describes the earliest onset of HDP. Thus, HDP should be considered as a differential diagnosis in pregnant women with hypertension or proteinuria presenting with symptoms before 20 weeks of gestation.

Two Fatty Liver Conditions Masquerading as Autoimmune Hepatitis

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.

Plasma exchange as treatment for acute fatty liver disease of pregnancy

Acute fatty liver disease of pregnancy AFLP is an obstetrical emergency, with severe complications that may include death. Management of AFLP is challenging and include plasma exchange which helps to improve the prognosis for both mother and fetus and delay liver transplantation.

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.