Perioperative care of a patient with acute fatty liver of pregnancy

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: 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.

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 Fatty Liver of Pregnancy: A Retrospective Analysis of 56 Cases

Background:

Acute fatty liver of pregnancy (AFLP) is a rare but life-threatening complication occurring in the third trimester. It is often fatal to both mother and fetus. The complicated clinical manifestations as well as an insufficient understanding of the disease make the precise diagnosis and effective treatment of AFLP challenging. A full understanding of the risk factors, clinical features, and test findings of AFLP is critical for its timely diagnosis and treatment.

Methods:

We performed a retrospective study of 56 patients with AFLP between June 2008 and July 2013. We analyzed the clinical features, laboratory results, perioperative management, and patient outcomes.

Results:

The initial symptoms varied considerably, with nausea and vomiting (13/56, 23%) being the most common. Liver-function indexes were remarkable, including elevated levels of serum alanine aminotransferase (262.16 ± 281.71 U/L), aspartate aminotransferase (260.98 ± 237.91 U/L), lactic dehydrogenase (1011.76 ± 530.34 U/L), and direct bilirubin (85.59 ± 90.02 μmol/L). Coagulation disorders were indicated by abnormal levels of fibrinogen (245.95 ± 186.11 mg/dL), D-dimer (2.46 ± 4.01 mg/L), and fibrin degradation products (43.62 ± 48.71 mg/L). The main maternal complications were hypoproteinemia (75%), coagulopathy (54%), and acute renal failure (39%). Multivariate logistic regression analysis identified prothrombin time (PT; odds ratio [OR] = 1.558, 95% confidence interval [CI] =1.248–1.946, P = 0.016) and international normalized ratio (INR; OR = 40.034, 95% CI = 2.517–636.693, P = 0.009) as risk factors. The perinatal infant death rate was related to gestational age at delivery (OR = 1.298, 95% CI = 1.040–1.618, P = 0.021), direct bilirubin (OR = 1.05, 95% CI = 1.008–1.094, P = 0.020), and fibrin degradation products (OR = 0.973, 95% CI = 0.950–0.996, P = 0.021).

Conclusions:

Nausea and vomiting may be the most common symptoms of AFLP. Indexes of liver dysfunction and coagulation disorders should also be considered. PT and INR are risk factors for fatal complications in patients with AFLP, and perinatal mortality is linked to the level of fibrin degradation products. Timely delivery is crucial to controlling the development of AFLP.

[Acute fatty liver of pregnancy with right acute pyelonephritis on a twin pregnancy: a rare combination]

La Stéatose hépatique aiguë gravidique est une complication rare de la grossesse, et l'association avec la pyélonéphrite aiguë est encore plus rarissime survenant le plus souvent dans le troisième trimestre. Le diagnostic est affirmé par un faisceau d'argument clinique et biologique si non par l'histologie hépatique en dehors de trouble de la crase sanguine. Autrefois régulièrement mortelle, cette pathologie bénéficie actuellement d'un meilleur pronostic maternel et fœtal, du fait du diagnostic plus précoce, d'une délivrance rapide et du traitement symptomatique. Les auteurs ont jugé utile de rapporter une observation à travers d'un cas clinique d'une grossesse gémellaire associée à la pyélonéphrite aigue droite avec stéatose hépatique aiguë en milieu de réanimation.

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.

Acute fatty liver of pregnancy in a Taiwanese tertiary care center: a retrospective review

OBJECTIVE

To evaluate the demographics, clinical presentations, laboratory findings, and maternal and fetal outcomes in patients with acute fatty liver of pregnancy.

MATERIALS AND METHODS

A retrospective review was conducted of the records of pregnant patients with a diagnosis of acute fatty liver in a tertiary medical center over a 22-year period.

RESULTS

Eighteen patients with acute fatty liver of pregnancy were recruited, all of whom developed the disease in the third trimester. Eleven women (61%) were primigravid and four (22%) had twin pregnancies; six (33%) were diagnosed antepartum, and the other 12 (67%) were diagnosed postpartum. There were two maternal deaths (11%) and four fetal deaths (18%). The most common complications apart from severe liver dysfunction were acute renal failure (83%), hypoglycemia (61%), and disseminated intravascular coagulation (61%).

CONCLUSION

Women who become acutely ill during the third trimester of pregnancy should undergo tests for acute fatty liver of pregnancy, including laboratory tests for assessing liver function and coagulation profile.

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

Acute fatty liver of pregnancy is a rare, potentially fatal, complication of late pregnancy. The incidence is estimated at 1:7000-1:15000 pregnancies. Presentation is classically with malaise, nausea and vomiting, abdominal pain and rarely encephalopathy. Prolongation of laboratory clotting tests is an early feature. Ultrasound examination of the liver is performed to exclude biliary stasis. Rapid clinical deterioration may occur and urgent delivery should be organised. Anaesthetists form part of a multidisciplinary approach before, during and after delivery but there are few reports of anaesthetic involvement. One dilemma facing an anaesthetist called to assist in these cases is the potentially negative effect of general anaesthesia on hepatic encephalopathy versus the risks associated with regional anaesthesia in the presence of coagulopathy. Postoperative analgesia may also be complicated by impaired renal and hepatic function. We present three cases that occurred in our unit in a 6-month period illustrating the spectrum of disease severity and the successful use of different anaesthetic techniques to facilitate management including delivery.

Acute fatty liver of pregnancy

OBJECTIVE

Acute fatty liver of pregnancy (AFLP) is a rare and serious entity associated with significant maternal and neonatal mortality and morbidity. We describe our experience with the clinical diagnosis, management and course patients with AFLP.

STUDY DESIGN

Medical records of patients with AFLP were reviewed over a 10-year period. Records were reviewed for symptoms, laboratory findings, clinical course, and maternal and perinatal outcomes.

RESULTS

The incidence of AFLP was 1 in 7,270 births. The mean gestational age at onset was 34.6 +/- 4.9 weeks. Eight percent of the patients were multiparous with more than three pregnancies. The prodromic phase was variable; patients complained of nausea, abdominal pain, malaise, polyuria-polydipsia syndrome and headaches followed by jaundice. The laboratory results indicated coagulopathy, liver function abnormalities and hypoglycemia. Emergency cesarean section was performed in two cases. The diagnosis has been assessed by transcutaneous hepatic biopsies processed in all patients between the 4th and 15th day (8.4 +/- 4.3 days). Maternal morbidity included hypoglycaemia (40%), coagulopathy (50%) encephalopathy (30%) and renal failure (40%). There were no maternal deaths but fetal mortality is high 66%.

CONCLUSION

The early recognition of AFLP cases and prompt progressive management, including early termination of pregnancy and large dose infusion of fresh frozen plasma, the prognosis of AFLP is obviously improved.

Stéatose hépatique aiguë gravidique : une pathologie rare du troisième trimestre de grossesse

Acute fatty liver of pregnancy is a rare clinical syndrome of pregnancy that occurs during the third trimester. Clinicians must have a high index of suspicion for this condition when a woman has nausea or vomiting during the last trimester. Early diagnosis and prompt delivery improve foetal and maternal prognosis. We report a case of a previously healthy 23-year-old woman who presented an acute fatty liver of pregnancy with intrauterine fetal death. Based on this experience as well as on medical literature, characteristics of this uncommon pathology are discussed.