Clinical diagnosis and treatment of acute fatty liver of pregnancy: a literature review and 11 new cases

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.

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.

Liver Biopsy in Pregnancy: Two Case Reports and Review of the Literature

The etiology of most cases of liver diseases in pregnancy can be diagnosed with a thorough history, physical examination, laboratory values, serology, and noninvasive imaging. However, atypical clinical and laboratory presentations of liver diseases/chemistries require a liver biopsy to render an accurate diagnosis in cases where the biopsy results affect the timing of delivery or impact choice of medical therapy. According to the American College of Gastroenterology, liver biopsy can be effectively and safely conducted in pregnant women. Conventional routes of performing a liver biopsy include the percutaneous, transjugular route, and surgical methods. Endoscopic ultrasound-guided liver biopsy is a recent technique that has not yet gained widespread adoption but can potentially serve as an alternative route for obtaining the liver sample. Adverse events associated with liver biopsy include abdominal pain and hemorrhage. Maternal and fetal outcomes are limited to increased risk of preterm birth and small for gestational age neonate. However, very few studies have formally evaluated the safety of liver biopsy in pregnant women. In this review, we present two successful cases of liver biopsy performed during pregnancy and summarize the most recent evidence regarding the safety and outcomes of the procedure in pregnancy to assist clinicians in their decision to perform a liver biopsy during pregnancy or postpone it until after delivery.

Risk Factors for Maternal and Fetal Mortality in Acute Fatty Liver of Pregnancy and New Predictive Models

Acute fatty liver of pregnancy (AFLP) is a rare but potentially life-threatening hepatic disorder that leads to considerable maternal and fetal mortality. To explore the risk factors for maternal and fetal mortality in AFLP and develop new predictive models, through this retrospective study, we analyzed the demographic characteristics, clinical symptoms, and laboratory findings of 106 patients with AFLP who were admitted to Shandong Provincial Hospital. Risk factors for maternal and fetal mortality were analyzed by univariate and multivariate logistic regression analysis. The new models based on the multivariate logistic regression analysis and the model for end-stage liver disease (MELD) were tested in AFLP. The receiver operating characteristic curve (ROC) was applied to compare the predictive efficiency, sensitivity, and specificity of the two models. Prenatal nausea (p = 0.037), prolonged prothrombin time (p = 0.003), and elevated serum creatinine (p = 0.003) were independent risk factors for maternal mortality. The ROC curve showed that the area under the curve (AUC) of the MELD was 0.948, with a sensitivity of 100% and a specificity of 83.3%. The AUC of the new model for maternal mortality was 0.926, with a sensitivity of 90% and a specificity of 94.8%. Hepatic encephalopathy (p = 0.016) and thrombocytopenia (p = 0.001) were independent risk factors for fetal mortality. Using the ROC curve, the AUC of the MELD was 0.694, yielding a sensitivity of 68.8% and a specificity of 64.4%. The AUC of the new model for fetal mortality was 0.893, yielding a sensitivity of 100% and a specificity of 73.3%. Both the new predictive model for maternal mortality and the MELD showed good predictive efficacy for maternal mortality in patients with AFLP (AUC = 0.926 and 0.948, respectively), and the new predictive model for fetal mortality was superior to the MELD in predicting fetal mortality (AUC = 0.893 and 0.694, respectively). The two new predictive models were more readily available, less expensive, and easier to implement clinically, especially in low-income countries.

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.

Acute fatty liver of pregnancy cases in a maternal and child health hospital of China: Three case reports

RATIONALE

Acute fatty liver of pregnancy (AFLP) is extremely hazardous to pregnant woman in the 3rd trimester of pregnancy. AFLP has an insidious onset and nonspecific experimental indicators, which therefore is difficult to be diagnosed.

PATIENT CONCERNS

Case 1 was transferred to our hospital for hypertensive disorders complicating pregnancy at gestation of 38 weeks + 3 days. Case 2 was transferred to our hospital for suspicious fetal heart monitoring response at gestation of 36 weeks + 4 days. Case 3 was transferred to our hospital for prelabor rupture of membranes at gestation of 37 weeks + 1 days.

DIAGNOSIS

The diagnosis of AFLP was based on the Swansea criteria.

INTERVENTIONS

All 3 cases were delivered by cesarean section, and they were all transferred to intensive care unit for further treatment. Cases 2 and 3 were subjected to plasma exchange and continuous renal replacement therapy.

OUTCOMES

In this study, all 3 patients were initially diagnosed as gastritis. In addition, case 1 was diagnosed as preeclampsia and her AFLP was misdiagnosed with postpartum hemorrhage after cesarean delivery. Case 2 was admitted to the hospital for intrahepatic cholestasis of pregnancy and fetal distress, but we considered it as AFLP before delivery. Case 3 was treated according to severe intrahepatic cholestasis of pregnancy, but we rediagnosed it as postpartum hemorrhage and disseminated intravascular coagulation after cesarean delivery. Neonatal asphyxia and complications were not found. All of the 3 cases were fully recovered and discharged from our hospital.

LESSONS

If there are multiple risk factors including vomiting, abdominal pain, and fetal distress, AFLP should be highly suspected. Early diagnosis, especially before termination of pregnancy, is the key to successful treatment of AFLP.

Maternal and neonatal outcomes and prognostic factors in acute fatty liver of pregnancy

OBJECTIVE

To report complications of Acute Fatty Liver of pregnancy (AFLP), a rare liver disease of pregnancy, and identify prognostic factors for mothers and children.

STUDY DESIGN

We conducted a retrospective descriptive study over 18 years in three French maternities. Demographic, clinical, biological data, and outcomes of patients and their infants were reviewed.

RESULTS

142,450 pregnancies from centers were studied. Eighteen patients with AFLP were identified The prevalence of AFLP was estimated as 1/7,914 pregnancies. Prolonged prothrombin time was identified as a risk factor of maternal complications (OR = 0.86, p = 0.0493). Gestational age at delivery was the only risk factor associated with fetal or neonate complications (OR = 0.37, p = 0.0417). One boy died of previously undiagnosed β-oxidation deficiency at eight months.

CONCLUSION

In AFLP, prothrombin time must be carefully monitored to anticipate major maternal complications. Infants born to mothers with ALFP should be screened as early as possible for mitochondrial fatty acid oxidation deficiency.

Risk factors assessment in patients with acute fatty liver of pregnancy treated without plasma exchange or renal replacement therapy

Objective: Acute fatty liver of pregnancy(AFLP) is a rare but very urgent obstetric disease in clinical. It is a common cause of liver failure in pregnancy and often needs to be admitted to the department of critical care medicine because of the rapid development of acute hepatic dysfunction and severe acute renal dysfunction. The etiology and pathogenesis of this disorder is not very clear although there have been many studies on it before. Meanwhile, the relatively high mortality requires a better recognition in order to better guide clinical decision making. Our previous multicentre retrospective study on AFLP demonstrated that total bilirubin and serum creatinine were independent risk factors for perinatal maternal mortality. And we aim to further assess maternal outcomes and risk factors in AFLP patients treated without plasma exchange or renal replacement therapy based on previous data we collected.Methods: Retrospective cohort study of 133 hospitalized patients with AFLP was collected from four Chinese tertiary hospitals during the period between January 2009 and April 2014. One hundred thirty three patients were divided into two subgroups containing patients treated without plasma exchange (PE) or renal replacement therapy (CRT) and patients treated with PE or/and CRT. Logistic regression was used to analyze independent risk factors for maternal mortality of AFLP treated without PE or CRT.Results: The maternal mortality rate was 12.0% in subgroup of patients treated without PE or CRT. And in subgroup of patients treated with PE or/and CRT, the maternal mortality rate was 26.8%. Independent risk factors for maternal mortality of AFLP treated without PE or CRT were direct bilirubin (OR = 1.012; 95% CI, 1.002-1.022) and serum creatinine (OR = 1.022; 95% CI, 1.007-1.036).Conclusion: Although less liver and kidney damage in AFLP treated without PE or CRT, direct bilirubin and serum creatinine remained to be independent risk factors for maternal mortality. Thus, the level of bilirubin and serum creatinine might not be necessary for AFLP to decide whether to give plasma exchange or dialysis treatment.

Hypoproteinemia as a parameter of poor perinatal/neonatal outcomes in women with preeclampsia diagnosed as hypertension plus proteinuria

OBJECTIVES

To investigate the relationship between serum total protein (TP) levels and maternal/neonatal outcomes among pregnant women with preeclampsia.

STUDY DESIGN

TP was measured at preeclampsia diagnosis and delivery in 94 women with singleton pregnancies and preeclampsia as hypertension with proteinuria who delivered at ≥ 22 gestational weeks (GWs). As a control group, measurements were also made in 188 women with singleton pregnancies without hypertension and/or proteinuria.

MAIN OUTCOME MEASURES

The relationship between serum TP levels and maternal outcomes.

RESULTS

Serum TP levels showed a significantly negative relationship with urine protein-to-creatinine (P/C) ratio at preeclampsia diagnosis and delivery. Serum TP levels at delivery in the preeclampsia group (53 ± 7 g/L) were lower than in the control group (61 ± 4 g/L, P < 0.0001). In each group, there was no relationship between the daily decrease in TP and the daily increase maternal body weight. However, there was a positive relationship between the daily increase in P/C ratio and the daily increase in maternal body weight in the preeclampsia group (P = 0.0021). Severe hypoproteinemia at preeclampsia diagnosis was a predictor of abruptio placentae (TP < 49 g/L; odds ratio, 21.3) and peripartum cardiomyopathy (TP < 45 g/L; odds ratio, 43.5). Furthermore, women with severe hypoproteinemia at delivery had higher morbidity due to pulmonary edema (TP < 55 g/L; odds ratio, 26.4) and central serous chorioretinopathy (TP < 42 g/L; odds ratio, 264).

CONCLUSIONS

Serum TP levels and proteinuria severity at preeclampsia diagnosis and delivery showed a positive relationship and predicted poor maternal outcome.

Early diagnostic test for acute fatty liver of pregnancy: a retrospective case control study

Background

Early diagnosis is important to lower the mortality rate of acute fatty liver of pregnancy (AFLP). The Swansea criteria is commonly used to diagnose AFLP, but some terms could only be reached when symptoms and signs have progressed, or are not efficient in clinical practice. Therefore, it is necessary to select cost effective tests to simplify and facilitate early suspicion of acute fatty liver of pregnancy.

Methods

This is a retrospective study of 28,800 medical records at the Second Xiangya Hospital from 2009 to 2015, including 41 patients with AFLP and 172 other diseases that could show similar symptoms to AFLP. The evaluated variables included past history of liver diseases, blood pressure, gastrointestinal symptoms, blood count, liver function test, coagulation function test and blood sugar test. The sensitivity, specificity, positive predict value and negative predict value were calculated for models in diagnosing AFLP.

Results

The significant variables associated with AFLP included gastrointestinal symptoms, blood pressure > 140/90 mmHg, aminotransferase> 42 IU/l, total bilirubin> 0.8 mg/dl, total bilirubin acid> 10.0 μmol/L, activated partial prothrombin time(APTT) > 34 s, prothrombin time(PT) > 14 s, white blood cells> 11 *10⁶/l and blood sugar< 72 mg/dl. Gastrointestinal symptoms +aminotransferase +bilirubin +bile acid +APTT/PT showed 97.6% sensitivity and 97.1% specificity to diagnose AFLP. Adding blood pressure, blood sugar or white blood cells decreased the accuracy of the statistical model.

Conclusions

Application of a statistical model including maternal symptoms, biochemical and haematological parameters has high diagnostic accuracy for earlier identification of AFLP. However, this finding needs to be tested in another cohort to determine whether this statistical model has the same performance.

The interpretation of liver function tests in pregnancy

Abnormal liver tests occur in 3-5% of pregnancies and show many different causes. Although alterations of liver enzymes could be a physiological phenomenon, it may also reflect potential severe liver injury, necessitating further assessment and accurate management. The work-up has to consider liver diseases specific of pregnancy and non pregnancy-related liver damage (coincidental and pre-existing to pregnancy). Pre-existing liver diseases during pregnancy are relatively uncommon, as pregnant women are generally young and healthy. Liver diseases unique to pregnancy are intrahepatic cholestasis of pregnancy, the HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) and acute fatty liver of pregnancy. These disorders may result in foetal distress, severe liver damage and sometime hepatic failure; for these reasons the diagnostic work-up and treatment must be very fast. This review focuses on the management of pregnant women with altered liver function tests. Furthermore, the main liver diseases specific of pregnancy are described.

Fatty liver in pregnancy: a narrative review of two distinct conditions

Introduction: Fatty liver is rather common in pregnancy, occurring in two totally different conditions, i.e. nonalcoholic fatty liver disease (NAFLD) in pregnancy and acute fatty liver of pregnancy (AFLP). The former is a common condition, resulting by chance association because of the epidemics of obesity and the older age of many pregnant women in Western countries; the latter is a rare disease whose pathophysiology is still incompletely understood.Areas covered: We reviewed the evidence-based knowledge on fatty liver in/of pregnancy. For NAFLD, a few large retrospective and prospective studies identify immediate and late risks for both the mother and the fetus. For AFLP, only small retrospective studies are available, indicating that prompt delivery and eventual referral to Liver Units for liver support or transplantation are mandatory to avoid maternal and fetal death.Expert opinion: The number of pregnant women with fatty liver is expected to increase in the next years. Pharmacologic treatment of NAFLD might be postponed, even when new drugs are approved by health authorities for the general population. In the case of AFLP, we need to improve our ability to correctly identify and treat the most severe cases not resolving with delivery.

Acute Fatty Liver of Pregnancy: Rare, but Potentially Fatal

BACKGROUND Acute fatty liver of pregnancy is an obstetric emergency characterized by liver dysfunction, which can lead to severe maternal and fetal complications. CASE REPORT A 34-year-old woman, 37 weeks and 2 days pregnant, reported symptoms of nausea, vomiting, jaundice, and prostration. Laboratory findings revealed liver dysfunction and coagulopathy. A clinical diagnosis of acute fatty liver was made and an emergency cesarean section was performed. The postoperative period was complicated by disseminated intravascular coagulation, acute hepatic and renal insufficiency, and pancreatitis. CONCLUSIONS Early recognition of this pathology, the interruption of pregnancy, and intensive therapy led to a favorable outcome.

Acute fatty liver of pregnancy in a Chinese Tertiary Care Center: a retrospective study

PURPOSE

To describe some prenatal clinical features and laboratory findings of AFLP and provide the clinicians with potential predictors in postpartum recovery time.

METHODS

Forty-four cases of AFLP previously treated in the First Affiliated Hospital of Zhengzhou University were retrospectively reviewed.

RESULTS

The maternal and fetal mortalities after treatment were both 18.2%. The main symptoms of AFLP were nausea and vomiting (63.6%), jaundice (61.4%). Moreover, the most common maternal complication was acute renal dysfunction (79.5%), followed by DIC (47.7%) and MODS (38.6%). The level of platelets, total protein and total bilirubin were found to be correlated with postpartum recovery time (Pearson correlation coefficient 0.434, P = 0.008; 0.466, P = 0.005; 0.484, P = 0.003).

CONCLUSIONS

AFLP is a rare, but lethal complication in the third trimester. Termination of pregnancy should be applied once AFLP was highly suspected. Prenatal platelets, total protein and total bilirubin may be potential predictors of postpartum recovery.

Postpartum acute fatty liver of pregnancy: a case report

Background

Acute fatty liver of pregnancy can be a very dramatic clinical event with significant risk of mortality to healthy women. The pathogenesis is still unknown. It usually occurs in the third trimester or in the immediate postpartum period. The clinical presentation is very variable. Medical staff have to be very cautious even regarding a minor complaint of feeling unwell. Skin rash has not been reported as one of the initial presentations of acute fatty liver of pregnancy. It is best treated in a center with a multidisciplinary approach. Admission to the intensive care unit is recommended.

Case presentation

We report a case of a 20-year-old Middle Eastern Arabic woman who developed an acute fatty liver of pregnancy. She was not known to have any medical disease. She had had two previous uncomplicated deliveries. She developed acute fatty liver of pregnancy on the first day after an uncomplicated normal vaginal delivery of a healthy male newborn. She started to have nonitchy skin rash over her abdomen and upper limbs. Then she started to feel unwell. Twelve hours later, she developed epigastric and right upper quadrant abdominal pain, followed by jaundice, nausea, and vomiting. She developed recurrent hypoglycemic attacks, hemolytic anemia, coagulopathy, and hepatorenal syndrome.

Conclusions

The clinical presentation of acute fatty liver of pregnancy is very variable and nonspecific. Skin rash can be a new presenting symptom of acute fatty liver of pregnancy. Immediate suspicion of the diagnosis, appropriate investigations, and urgent initiation of therapy in an intensive care unit and by a multidisciplinary team resulted in a good outcome with no adverse health consequences for our patient.

Intrahepatic Cholangiocarcinoma Masquerading as Acute Fatty Liver of Pregnancy: A Case Report and Review of the Literature

Cholangiocarcinoma (CCA) is an uncommon cancer and accounts only for 3% of all gastrointestinal malignancies. In this report, we present a case of an intrahepatic cholangiocarcinoma masquerading as acute fatty liver of pregnancy (AFLP). A 38-year-old female who is 36-week pregnant presented with a 1-week history of headache, nausea, vomiting, and right upper abdominal pain, along with hepatomegaly. Laboratory investigations were remarkable for mild leukocytosis, hyperbilirubinemia, proteinuria, and elevated transaminases and prothrombin time. Ultrasound of the liver revealed hepatomegaly, fatty infiltration, and a right hepatic lobe mass. Based on the overall picture, AFLP was suspected, and the patient underwent delivery by Cesarean section. However, bilirubin and liver enzyme levels gradually increased after delivery. MRI revealed a large dominant hepatic mass along with multiple satellite lesions in both lobes. Biopsy revealed the presence of intrahepatic CCA. CCA presenting during pregnancy is extremely rare with only 9 other cases reported in the literature. Therefore, the signs and symptoms can be easily confused with other more common disorders that occur during pregnancy.

Outcomes and risk factors of patients with acute fatty liver of pregnancy: a multicentre retrospective study

INTRODUCTION

Acute fatty liver of pregnancy (AFLP) frequently causes liver failure in pregnant women. A better understanding of the clinical characteristics, management, outcomes and risk factors of AFLP is required, given its relatively high mortality rate. We aimed to describe the characteristics of AFLP, and further assess its outcomes and potential risk factors from the perspectives of the mother and fetus.

METHODS

This was a retrospective cohort study of 133 patients with AFLP hospitalised at four tertiary hospitals in China between January 2009 and April 2014.

RESULTS

Among 133 patients, AFLP was diagnosed in the postpartum period for 13 (9.8%) patients. Potential factors influencing adverse maternal outcome were male fetus (p = 0.04), postpartum diagnosis of AFLP (p < 0.01), intrauterine fetal death (p = 0.04), disseminated intravascular coagulation (p < 0.01), prothrombin time (p < 0.01) and activated partial thromboplastin time (p = 0.04). The frequency of fetal distress (p = 0.03) and activated partial thromboplastin time (p < 0.05) were significantly higher in pregnancies with dead fetuses than in those where the fetuses survived. Independent risk factors for perinatal maternal mortality were history of legal termination of pregnancy (odds ratio [OR] 1.958, 95% confidence interval [CI] 1.133-3.385), total bilirubin (OR 1.009, 95% CI 1.003-1.014) and serum creatinine (OR 1.010, 95% CI 1.003-1.017).

CONCLUSION

Compared with total bilirubin and serum creatinine, history of legal termination of pregnancy appeared to be a greater risk factor for maternal mortality among patients with AFLP.

[Acute fatty liver of pregnancy and mitochondrial fatty acid oxidation. Consequences for the offspring]

Acute fatty liver of pregnancy (AFLP) is a rare liver disease unique to pregnancy that can lead to acute liver failure. The prognosis, initially often fatal for both mother and child, has been improved by prompt delivery. The diagnosis should be highly suspected if the mother presents epigastric pain, nausea and/or vomiting, or polyuria-polydipsia in the third trimester of pregnancy. AFLP has been found associated with a genetic deficiency of fatty acid beta-oxidation, which may cause sudden death in infancy. Consequently, the mother and her newborn should undergo screening for this deficiency.

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

Acute fatty liver of pregnancy (AFLP) is an obstetric emergency characterized by maternal liver failure and may have complications for the mother and fetus, including death. This review examines recent literature on the epidemiology, pathogenesis, diagnosis, and treatment of acute fatty liver of pregnancy. Pathogenesis of this disease has been linked to defects in fatty acid metabolism during pregnancy, especially in the setting of fetal genetic defects in fatty acid oxidation. The value of screening all patients for these genetic defects remains to be determined. Distinguishing AFLP from other high-risk liver diseases of pregnancy that have overlap features, such as HELLP and preeclampsia, can be challenging. Although sensitive diagnostic tools such as the Swansea criteria have been developed, further work is needed to diagnose AFLP more quickly. Although survival rates have improved in the past 30 years, delay in diagnosis and treatment of AFLP has life-threatening consequences; an algorithmic approach to AFLP may be a valuable resource for clinicians. Future epidemiological and long-term studies will improve our prediction of women at risk for developing AFLP and determine the long-term consequences of this condition.

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.

Effect of caesarean section on maternal and foetal outcomes in acute fatty liver of pregnancy: a systematic review and meta-analysis

Several studies have reported a positive association between caesarean section for expeditious pregnancy termination and perinatal outcomes in acute fatty liver of pregnancy (AFLP); however, the risks remain unclear and independent studies have reported conflicting findings. In this meta-analysis, we aimed to confirm the relationship between caesarean section and perinatal outcomes in AFLP. The PubMed, Embase, and China National Knowledge Infrastructure databases were searched (until July 17, 2015) for observational clinical studies focusing on the association between caesarean section and perinatal outcomes in AFLP. Data were extracted and processed independently by 2 authors. We also compared caesarean section with vaginal delivery to further investigate this relationship. We observed that 2 of the 3 primary outcomes in caesarean section exhibited positive effects-the maternal mortality rate was 44% lower (relative risk [RR], 0.56 [0.41-0.76]) and perinatal mortality rate was also reduced (RR, 0.52 [0.38-0.71]), compared to those for vaginal delivery. We did not find any associations between caesarean section and perinatal outcomes in AFLP in terms of neonatal mortality type and maternal multiple organ complications. These findings emphasise the significant prognostic value and clinical implications of caesarean section in AFLP, and suggest that the adverse outcomes should be reduced.

AISF position paper on liver disease and pregnancy

The relationship between liver disease and pregnancy is of great clinical impact. Severe liver disease in pregnancy is rare; however, pregnancy-related liver disease is the most frequent cause of liver dysfunction during pregnancy and represents a severe threat to foetal and maternal survival. A rapid differential diagnosis between liver disease related or unrelated to pregnancy is required in women who present with liver dysfunction during pregnancy. This report summarizes the recommendation of an expert panel established by the Italian Association for the Study of the Liver (AISF) on the management of liver disease during pregnancy. The article provides an overview of liver disease occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and an assessment of the available treatment options. The report contains in three sections: (1) specific liver diseases of pregnancy; (2) liver disease occurring during pregnancy; and (3) pregnancy in patients with pre-existing chronic liver disease. Each topic is discussed considering the most relevant data available in literature; the final statements are formulated according to both scientific evidence and clinical expertise of the involved physicians, and the AISF expert panel recommendations are reported.

Acute kidney injury during pregnancy

Acute kidney injury complicates the care of a relatively small number of pregnant and postpartum women. Several pregnancy-related disorders such as preeclampsia and thrombotic microangiopathies may produce acute kidney injury. Prerenal azotemia is another common cause of acute kidney injury in pregnancy. This manuscript will review pregnancy-associated acute kidney injury from a renal functional perspective. Pathophysiology of acute kidney injury will be reviewed. Specific conditions causing acute kidney injury and treatments will be compared.

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

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

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

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

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

Differentiation of acute fatty liver of pregnancy from syndrome of hemolysis, elevated liver enzymes and low platelet counts

As proposed criteria (Swansea criteria) for the diagnosis of acute fatty liver of pregnancy (AFLP) do not include antithrombin (AT) activity, diagnosis of AFLP may be delayed. The aim of this review is to underscore problems in the differential diagnosis of AFLP and the syndrome of hemolysis, elevated liver enzymes and low platelet counts (HELLP syndrome) and to facilitate prompt diagnosis of AFLP. Published works dealing with liver dysfunction in pregnancy, HELLP syndrome and AFLP were reviewed. AFLP and HELLP syndrome shared common clinical, laboratory, histological and genetic features, and differential diagnosis between them was often difficult. However, HELLP syndrome was likely to occur in patients with hypertension, but AFLP occurred often in the absence of hypertension. In addition, AFLP was exclusively associated with pregnancy-induced antithrombin deficiency (PIATD). Approximately 50% of patients with AFLP did not have thrombocytopenia at presentation. As the Swansea criteria for AFLP did not include PIATD, diagnosis of AFLP was delayed until manifestation of life-threatening complications; 60% of women were admitted to intensive care and 15% to a specialist liver unit. In conclusion, incorporation of AT activity of less than 65% into the diagnostic criteria for AFLP may facilitate suspicion and prompt diagnosis of AFLP, decrease uncertainty regarding the diagnosis of AFLP, and contribute to better investigation and understanding of the process leading to the development of liver dysfunction.

Acute fatty liver of pregnancy: a retrospective study of 32 cases in South China

OBJECTIVE

To describe 32 cases of acute fatty liver of pregnancy (AFLP) and identify the potential clinical predictors of maternal and fetal outcomes in South China.

METHODS

Thirty-two cases of AFLP previously treated in the First Affiliated Hospital of Nanchang University in the past 10 years were enrolled in the current study.

RESULTS

Sex of fetus and delivery method was the potential clinical predictor of fetal outcome. The main manifestations of AFLP were jaundice (n = 32), nausea and vomiting (n = 28), malaise (n = 25), and ascites (n = 25), and its complications included acute renal failure (n = 26), hepatic encephalopathy (n = 17), infection (n = 10), and postpartum hemorrhage (n = 7). Evidence of fatty changes of liver was demonstrated by B ultrasound and computed tomography (CT). Eighteen patients were recovered due to rapid diagnosis, early termination of pregnancy and supportive treatments.

CONCLUSIONS

Male sex and vaginal delivery was the risk factor of fetal outcome. Detailed history taking and proper management of potential predictors are important in making the decision of prompt delivery and choosing the appropriate delivery method. Further studies are needed to expand our knowledge on this disease.