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

Acute liver failure

Acute liver failure (ALF) is a life-threatening disorder characterised by rapid deterioration of liver function, coagulopathy, and hepatic encephalopathy in the absence of pre-existing liver disease. The cause of ALF varies across the world. Common causes of ALF in adults include drug toxicity, hepatotropic and non-hepatotropic viruses, herbal and dietary supplements, antituberculosis drugs, and autoimmune hepatitis. The cause of liver failure affects the management and prognosis, and therefore extensive investigation for cause is strongly suggested. Sepsis with multiorgan failure and cerebral oedema remain the leading causes of death in patients with ALF and early identification and appropriate management can alter the course of ALF. Liver transplantation is the best current therapy, although the role of artificial liver support systems, particularly therapeutic plasma exchange, can be useful for patients with ALF, especially in non-transplant centres. In this Seminar, we discuss the cause, prognostic models, and management of ALF.

Review article: Hepatic steatosis and its associations with acute and chronic liver diseases

BACKGROUND

Hepatic steatosis is a common finding in liver histopathology and the hallmark of metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), whose global prevalence is rising.

AIMS

To review the histopathology of hepatic steatosis and its mechanisms of development and to identify common and rare disease associations.

METHODS

We reviewed literature on the basic science of lipid droplet (LD) biology and clinical research on acute and chronic liver diseases associated with hepatic steatosis using the PubMed database.

RESULTS

A variety of genetic and environmental factors contribute to the development of chronic hepatic steatosis or steatotic liver disease, which typically appears macrovesicular. Microvesicular steatosis is associated with acute mitochondrial dysfunction and liver failure. Fat metabolic processes in hepatocytes whose dysregulation leads to the development of steatosis include secretion of lipoprotein particles, uptake of remnant lipoprotein particles or free fatty acids from blood, de novo lipogenesis, oxidation of fatty acids, lipolysis and lipophagy. Hepatic insulin resistance is a key feature of MASLD. Seipin is a polyfunctional protein that facilitates LD biogenesis. Assembly of hepatitis C virus takes place on LD surfaces. LDs make important, functional contact with the endoplasmic reticulum and other organelles.

CONCLUSIONS

Diverse liver pathologies are associated with hepatic steatosis, with MASLD being the most important contributor. The biogenesis and dynamics of LDs in hepatocytes are complex and warrant further investigation. Organellar interfaces permit co-regulation of lipid metabolism to match generation of potentially toxic lipid species with their LD depot storage.

Rare liver diseases in Egypt: Clinical and epidemiological characterization

Illnesses that afflict a tiny number of individuals are referred to as rare diseases (RDs), sometimes called orphan diseases. The local healthcare systems are constantly under financial, psychological, and medical strain due to low incidence rates, unusual presentations, flawed diagnostic standards, and a lack of treatment alternatives for these RDs. The effective management of the once widely spread viral hepatitis B and C has altered the spectrum of liver diseases in Egypt during the last several years. The detection of uncommon disorders such as autoimmune, cholestatic, and hereditary liver diseases has also been made easier by the increasing knowledge and greater accessibility of specific laboratory testing. Finally, despite Egypt's large population, there are more uncommon liver disorders than previously thought. This review article discusses the clinical and epidemiological characteristics of a few uncommon liver disorders and the information currently accessible concerning these illnesses in Egypt.

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.

[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 liver failure in low-income and middle-income countries

Acute liver failure is a rare condition involving the rapid development, progression, and worsening of liver dysfunction, characterised by coagulopathy and encephalopathy, and has a high mortality unless liver transplantation is performed. Population-based studies are scarce, and most published data are from high-income countries, where the main cause of acute liver failure is paracetamol overdose. This Review provides an overview of the scanty literature on acute liver failure in low-income and middle-income countries, where patients are often admitted to primary care hospitals and viral hepatitis (especially hepatitis E), tropical infections (eg, dengue), traditional medicines, and drugs (especially anti-tuberculosis drugs) have an important role. We discuss incidence, cause, occurrence in children and pregnant women, prognostic factors and scores, treatment, and mortality. To conclude, we advocate for international collaboration, the establishment of central registries for the condition, and better diagnostics.

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.

Acute Fatty Liver of Pregnancy Complicated With Mild Encephalitis/Encephalopathy With a Reversible Splenial Lesion: A Case Report

Acute fatty liver of pregnancy (AFLP) is a rare complication of pregnancy that may result in fulminant hepatic failure. A 28-year-old woman, at 36 weeks of gestation, presented to a maternal-fetal outpatient clinic with fever and headache. She was prescribed analgesics and was planned for follow-up. Two days later, she was taken back for evaluation by her husband to the previous physician again because of the subacute onset of impaired consciousness. Blood tests showed a marked elevation of liver enzymes and C-reactive protein (CRP), and the patient was transported to a tertiary hospital. A clinical diagnosis of AFLP or hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome was made, and an emergency cesarean section was performed. Unconsciousness was prolonged due to mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) for three days. A liver biopsy was performed on postoperative day 11. Liver biopsy results showed large and small droplet fatty deposits, and the diagnosis of AFLP was confirmed. Thereafter, the elevated liver enzymes resolved spontaneously solely by supportive care. The patient presented with symptoms of impaired consciousness due to mild encephalitis/encephalopathy with a reversible splenial lesion (MERS), which led to a visit to a tertiary hospital and early intervention for AFLP. This case suggested that there may be similarities between the two pathologies of AFLP and MERS.

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.

A case of preeclampsia with severe features following septic shock and drug-induced acute kidney injury

Objectives

This article outlines a process for differentiating preeclampsia from other potential causes of end-organ damage in a critically ill patient.

Case Presentation

A patient in her early 30s, G2P1001 with intrauterine pregnancy at 12 weeks’ gestation was admitted seven months after delivering her first child due to new-onset psychosis and starvation ketosis. She was started on lithium for postpartum psychosis at 20 weeks’ gestation. She subsequently developed respiratory failure at 26 weeks’ gestation due to aspiration pneumonia in the setting of lithium toxicity, requiring admission to the intensive care unit (ICU) and intubation. She received antibiotics and vasopressors for suspected septic shock in addition to dialysis for lithium-induced acute kidney injury. One week after ICU admission, her sepsis resolved, her serum creatinine levels returned to normal, and her respiratory status improved. However, after vasopressors were discontinued, she suddenly developed persistently elevated blood pressures with proteinuria and elevated liver function tests (LFT’s). Due to concern for preeclampsia with severe features and rapidly increasing LFT’s, the patient underwent cesarean delivery at 27 weeks’ gestation.

Conclusions

In a critically ill patient with multiple comorbidities, it can be difficult to diagnose preeclampsia using the standard criteria. It is important to exclude other potential etiologies, as a misdiagnosis can have potentially devastating consequences.

Urgent Liver Transplantation for Acute Liver Failure in Pregnant Women: The Optimum Timing for Delivery

BACKGROUND

The occurrence of acute liver failure (ALF) in pregnant women due to an etiology unrelated to pregnancy (pregALF) that leads to liver transplantation (LT) has rarely been reported. The objective was to report the outcome of pregnant women and fetus and propose a strategy for the timing of delivery and of LT in these patients.

METHODS

Five consecutive pregnant patients with ALF were admitted to our center between 1986 and 2018 and underwent an LT. A systematic review of case reports concerning patients with pregALF who underwent LT was extracted from the literature.

RESULTS

Three with gestational ages (GA) at admission of 15, 22, and 31 weeks of gestation (WG) were transplanted after delivery (n = 1) or intrauterine demise (n = 2) and 2 with GA of 16 and 23 WG before delivery. One infant survived in each group. Among the 32 cases published previously, 11 (34%) had been transplanted after delivery (median GA:31 [28-33]); 10 of these 11 infants were alive at birth. The other 21 mothers were transplanted before delivery (GA:21 WG [18-22]). The median GA at delivery was 30 WG [27.75-37]. Twelve of 21 infants were alive at birth. One-year survival among the ALF patients in our series and in the literature was 100%. Overall, the perinatal survival rate was low (64.8%).

CONCLUSIONS

In pregnant patients presenting with ALF not related to the pregnancy, the LT lifesaving procedure had an excellent outcome. Overall, 65% of the infants were alive at delivery with major mortality in those fetus <22 WG despite continued pregnancy.

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.

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.

Timely identification and successful treatment of acute fatty liver of pregnancy without obvious clinical symptoms: Case reports

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.

Placenta in the Critically Ill Mother

The placenta is a temporary, multifunctional organ composed of both maternal and fetal components. It maintains homeostasis to ensure the growth of the fetus and well-being of the mother. Abnormalities in placental development have been known to be responsible for several disorders of pregnancy. Conditions coincident with pregnancy can upset the homeostasis and result in critical illness, which can greatly impact placental function and in turn affect the fetus. Decreased blood flow, acidemia, hypercarbia, and hypoxia seen in critically ill pregnant mothers can result in fetal death. Understanding the physiological changes and functioning of the maternal-fetal-placental unit will aid in better management of critically ill mothers.

How to cite this article

Taggarsi DA, Krishna B. Placenta in the Critically Ill Mother. Indian J Crit Care Med 2021;25(Suppl 3):S200-S205.

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.

State of the Art in Hepatic Dysfunction in Pregnancy

Hepatic dysfunction in pregnant women is always challenging for the obstetrician, as the spectrum of hepatic abnormalities can be very large and have various implications, both for mother and fetus. There is a diagnostic and therapeutic polymorphism of hepatic dysfunction in pregnancy and insufficient knowledge related to the etiopathogenesis and epidemiology of this disease. The clinical forms of hepatic dysfunction encountered in pregnancy can vary from liver diseases related to pregnancy (e.g., HELLP syndrome, intrahepatic cholestasis, hyperemesis gravidarum, or acute fatty liver of pregnancy) to de novo ones occurring in pregnancy, and pre-existing liver disease (cholelithiasis, Budd-Chiari syndrome, and cirrhosis). We performed a systematic literature search over 10 years. The review protocol assumed a search of two databases (PubMed®/MEDLINE and Web of Science Core Collection). The strategy regarding the management of these diseases involves multidisciplinary teams composed of different specialists (obstetricians, gastroenterologists and anesthetists) from specialized tertiary centers. Despite the improving prognosis of pregnant women with liver diseases, the risk of maternal-fetal complications remains very high. Therefore, it is necessary to ensure careful monitoring by a multidisciplinary team and to inform the patients of the potential risks.

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.

A Rare Disease Presenting Postpartum: Acute Fatty Liver of Pregnancy

Acute fatty liver of pregnancy is a rare but highly fatal disease affecting women most frequently during the third trimester of pregnancy or in the postpartum period. It is considered a diagnosis of exclusion and requires a timely diagnosis to avoid maternal mortality. We present the case of a 33-year-old primigravida who required an emergency cesarean section due to fetal bradycardia. On postoperative day one, the patient was noted jaundiced, oliguric, and hypoglycemic. Laboratory tests revealed important hepatic dysfunction, coagulopathy, and renal failure. She was admitted to the Intensive Care Unit with the suspicion of acute fatty liver of pregnancy. Plasma exchange was started on postoperative day 5 with major clinical and laboratory improvement. A transjugular hepatic biopsy confirmed the diagnosis. The patient had satisfactory evolution and was discharged 15 days after delivery. Acute fatty liver of pregnancy is a highly morbid disease that needs a high index of suspicion to be diagnosed. Admission to an Intensive Care Unit to ensure maximum supportive care is mandatory in this disease.

Fever, cough and gastrointestinal symptoms in a pregnant woman

Despite distinct diagnostic criteria, several gastrointestinal pathologies can masquerade haemophagocytic lymphohistiocytosis (HLH) during the peripartum period. Acute fatty liver of pregnancy, HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome, miliary tuberculosis, visceral leishmaniasis, abdominal surgical emergencies, haemolytic anaemias and haematological malignancies may have clinical and laboratory presentation similar to that of HLH. In this report, we present the case of a 26-year-old woman with 38-weeks' gestation and abdominal pain, vomiting, intermittent fever and non-productive cough for 1-2 months. A thorough investigation suggested HLH and the patient was successfully treated with corticosteroids. This patient demonstrates the importance of a focused investigation strategy and timely management to prevent mortality and morbidity to both the mother and fetus in this rare and fatal disease.

Viscoelastic Hemostatic Assays for Postpartum Hemorrhage

This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.

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.

Hepatitis E and Pregnancy: An Unholy Alliance Unmasked from Kashmir, India

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.

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.

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.

Clinicobiochemical Parameters and Predictors of Liver Disease in Hospitalized Asian Indian Pregnant Women in a Tertiary Care Center in Northern India

Introduction  During pregnancy, liver dysfunction is more frequent than expected and may require specialized care. For the early diagnosis, it is important to determine if changes in liver physiology may develop into liver disease. Liver disease during pregnancy may require intervention from a hepatologist for adequate monitoring of mother-fetus health outcomes. This study was aimed to evaluate the clinical profile and predictors of maternal mortality in patients with liver diseases among Asian-Indian-females. Methods We conducted a prospective, open-label, consecutive all-comers study of 2,663 pregnant Asian Indian women admitted in the hospital, which included 92 with liver dysfunction. The medical aspects of the pregnancy were then followed prospectively with laboratory and clinical data during the hospital stay and analyzed. The current study was approved by the Institutional Ethical Committee. Results We found that 92 out of 2,663 patients had liver dysfunction with a prevalence of 3.45%. Fifty-four (58.7%) patients had icterus followed by fever in 23 (25.0%), hypertension in 22 (23.9%), central nervous system manifestations in 21 (22.8%), abdominal pain in 19 (20.6%), vomiting in 19 (20.6%), and pruritus in six (6.5%). Predictors of maternal mortality were icterus (p = 0.04), hepatomegaly (p = 0.04), presenting serum-bilirubin greater than 10 milligram% (mg%) (p = 0.008). The most common etiology was acute viral hepatitis (45.6%), followed by a hypertensive disorder of pregnancy (29.3%), acute fatty liver of pregnancy (1.1%), cholestatic jaundice (9.8%), hyperemesis gravidarum (2.2%), septicemic hepatitis (3.3%), dengue immunoglobulin M (IgM), and plasmodium vivax malaria antigen positive in (2.2%) each. Four patients (4.3%) were leptospira IgM reactive and had co-infection with hepatitis E virus. There was one patient (1.1%) with underlying chronic liver disease. Idiopathic liver disease was present in 5.4% of patients. Conclusion Liver disease is relatively common in Indian pregnant women. It is associated with high maternal and perinatal mortality, even in a tertiary referral center. When managing pregnancy in a tertiary care center, for adequate follow-up of the disease and to prevent adverse consequences for mother and child, it is important to discard liver alterations early. For this purpose, liver disease during pregnancy needs early diagnosis for proper management. Furthermore, it is difficult to manage patients with preexisting liver disease, and it may require specialized intervention from a hepatologist and a gastroenterologist.

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.

Missing or making the timely diagnosis of acute fatty liver of pregnancy (AFLP): lessons learned

OBJECTIVE

To review the presenting signs, symptoms, laboratory findings, clinical courses, complications, and maternal outcomes in women determined on medicolegal review to have had acute fatty liver of pregnancy (AFLP).

METHODS

We retrospectively studied case files from women with medical and/or hypertensive complications of pregnancy which had been reviewed by the first author, deidentified and divested of legal documents so that only medical-related information was retained for later research and teaching purposes. Main outcomes are 12 lessons learned from this review to be offered for the future benefit of clinicians encountering patients with AFLP.

RESULTS

Eleven women with AFLP were identified within the 161 file database. Signs and symptoms present in 91-100% of women with AFLP were altered sensorium, a fast resting maternal pulse >100/min, gastrointestinal complaints, muscle pain and evidence of fetal compromise/stillbirth. Laboratory findings in 91-100% revealed abnormal liver, renal and coagulation tests, hyperuricemia, and very low serum glucose and albumin. A correct initial diagnosis of AFLP was made for only three women; the most common incorrect presumptive diagnosis was HELLP syndrome. Four women survived. Twelve major findings are discussed.

CONCLUSION

Rapid, timely and thorough evaluation of third trimester women presenting with A (Altered mental status changes/extreme sleepiness), F (Fast resting pulse >100 in the absence of fever or heart causation), L (Liver-related gastrointestinal complaints) and P (Pain as myalgias and body aches), often in association with evidence of fetal compromise or stillbirth, should initiate efforts to investigate a possible diagnosis of AFLP. Adoption of the concepts summarized including core initial laboratory testing, immediate patient transfer to tertiary care, and aggressive correction of consumptive coagulopathy could form the basis of a patient safety bundle to guide future management for patients with AFLP.

Potential predictors for prognosis and postpartum recovery time of acute fatty liver of pregnancy

BACKGROUND

Acute fatty liver of pregnancy (AFLP) is a potentially lethal condition of pregnant women with a high mortality rate. Potential predictors related to postpartum recovery time and prognostic factors of AFLP are still unclear. This study aimed to evaluate potential predictors for prognosis and postpartum recovery time of AFLP.

METHODS

We retrospectively analyzed the clinical data of 76 AFLP patients in our hospital from 2002 to 2017 and investigated potential predictors using univariate analysis and multivariate logistic regression analysis.

RESULTS

Hepatic encephalopathy (HE) was found to be associated with prognosis in AFLP patients (P = 0.005, OR = 26.844). The postpartum recovery time analysis showed that AFLP patients with a age < 25 had the shortest recovery time, but no significant difference (P = 0.134, OR = 5.952). The postpartum recovery time of patients with liver failure (LF) was significantly prolonged compared to those without LF (P = 0.036, OR = 10.052). Cryoprecipitate, and plasma infusion showed no significant effect on prognosis or recovery time. Artificial liver support therapy (ALST) had no effect on prognosis, but it might affect postpartum recovery time with no statistical significance (P = 0.128, OR = 5.470).

CONCLUSION

HE is a potential predictor for prognosis of AFLP. LF is a potential predictor for postpartum recovery time.

Complicated COVID-19 in pregnancy: a case report with severe liver and coagulation dysfunction promptly improved by delivery

BACKGROUND

It has been proposed that pregnant women and their fetuses may be particularly at risk for poor outcomes due to the coronavirus (COVID-19) pandemic. From the few case series that are available in the literature, women with high risk pregnancies have been associated with higher morbidity. It has been suggested that pregnancy induced immune responses and cardio-vascular changes can exaggerate the course of the COVID-19 infection.

CASE PRESENTATION

A 26-year old Somalian woman (G2P1) presented with a nine-day history of shortness of breath, dry cough, myalgia, nausea, abdominal pain and fever. A nasopharyngeal swab returned positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Her condition rapidly worsened leading to severe liver and coagulation impairment. An emergency Caesarean section was performed at gestational week 32 + 6 after which the patient made a rapid recovery. Severe COVID-19 promptly improved by the termination of the pregnancy or atypical HELLP (Hemolysis, Elevated Liver Enzymes and Low Platelet Count) exacerbated by concomitant COVID-19 infection could not be ruled out. There was no evidence of vertical transmission.

CONCLUSIONS

This case adds to the growing body of evidence which raises concerns about the possible negative maternal outcomes of COVID-19 infection during pregnancy and advocates for pregnant women to be recognized as a vulnerable group during the current pandemic.

Scrub Typhus Leading to Acute Liver Failure in a Pregnant Patient

Scrub typhus is a mite-borne rickettsial infection that presents with fever and a diverse array of complications. Lately, many epidemics have been reported from the Indian subcontinent. Data from these outbreaks suggest that liver injury in scrub typhus is common and reversible. We are reporting the case of a 27-year-old pregnant female who presented with fever, encephalopathy, jaundice and seizure. She had acute liver failure and dead fetus on admission. Despite appropriate antibiotics and supportive treatment, she continued to deteriorate and developed multiorgan dysfunction, leading to her demise.

Acute Fatty Liver of Pregnancy

Acute fatty liver of pregnancy (AFLP) is a rare but life-threatening condition that develops in the third trimester of pregnancy. AFLP shares similar clinical features with other more common pregnancy-associated conditions. However, early correct diagnosis is important for maternal and fetal survival. Once the diagnosis has been established, immediate delivery and maternal intensive support should be undertaken. Both parents and the infant should be tested for deficiencies of the mitochondrial fatty acid oxidation, especially for long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency, as many cases of AFLP are related to disruption of this physiological enzymatic pathway.

Acute Fatty Liver Disease of Pregnancy in the Second Trimester

Acute fatty liver of pregnancy (AFLP) is a rare disorder that typically presents in the third trimester. We report a case of a 21-year-old woman with a history of intrauterine fetal demise at 19 weeks' gestation who developed fulminant liver failure 1 week after the fetal demise. She was diagnosed with AFLP as per the Swansea criteria. An orthotopic liver transplant was attempted but was unsuccessful. AFLP usually presents between the 30th to 38th weeks of gestation. However, it can occur in the postpartum period after only 19 weeks of gestation as highlighted in our case.