View source for Acute fatty liver of pregnancy

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==Background== <!--T:1-->

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[[File:Sobo 1906 389.png|thumb|Inferior view of the liver with surface showing lobes and impressions.]]
*Rare, potentially fatal complication that presents in second half of pregnancy or (less commonly) early postpartum
*Exact etiology unclear, but thought to involve abnormal fetal fatty acid metabolism 
*Fat vesicles accumulate within hepatocytes, interfering with liver function


==Clinical Features== <!--T:3-->

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*Usually presents in 3rd trimester, but may occur any time in 2nd half of pregnancy to early postpartum
*[[Special:MyLanguage/Nausea/vomiting|Nausea/vomiting]] (commonly severe)
*[[Special:MyLanguage/Jaundice|Jaundice]]
*Findings consistent with [[Special:MyLanguage/preeclampsia|preeclampsia]] in some women:
**[[Special:MyLanguage/Hypertension|Hypertension]]
**Edema
**[[Special:MyLanguage/Proteinuria|Proteinuria]]
*[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*Often, signs/symptoms of [[Special:MyLanguage/DIC|DIC]]
*+/- [[Special:MyLanguage/encephalopathy|encephalopathy]], [[Special:MyLanguage/ascites|ascites]]


==Differential Diagnosis== <!--T:5-->

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{{Postpartum emergencies DDX}}
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{{Jaundice DDX}}
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==Evaluation== <!--T:6-->


===Workup=== <!--T:7-->

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*[[Special:MyLanguage/LFTs|LFTs]]
**ALT/AST usually in 300-500 range, alk phos usually elevated in pregnancy
**[[Special:MyLanguage/Hyperbilirubinemia|Hyperbilirubinemia]]- more pronounced than in preeclampsia
*BMP
**[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*[[Special:MyLanguage/DIC|DIC]] labs 
**Low fibrinogen, [[Special:MyLanguage/coagulopathy|coagulopathy]]
**DIC present in as many as 70% of patients<ref>Ko H, Yoshida EM (2006). Acute fatty liver of pregnancy. Canadian Journal of Gastroenterology. 20 (1): 25–30</ref>
*CBC
**Often shows [[Special:MyLanguage/leukocytosis|leukocytosis]]
*[[Special:MyLanguage/UA|UA]]
**[[Special:MyLanguage/Proteinuria|Proteinuria]]
*[[Special:MyLanguage/RUQ US|RUQ US]]
**Non-specific; the liver can even be normal in echotexture 
**Useful to rule out other causes of obstructive biliary tract pathology.


===Diagnosis=== <!--T:9-->

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*Often initially misdiagnosed as [[Special:MyLanguage/preeclampsia|preeclampsia]]/[[Special:MyLanguage/HELLP|HELLP]]
**Hypoglycemia, jaundice, ascites, hypofibrinogenemia all ''more'' common in AFLP


====Swansea criteria<==== <!--T:11-->

 
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At least six of the following findings, in the absence of another cause:<ref>Dey M, Reema K. Acute Fatty liver of pregnancy. N Am J Med Sci. 2012;4 (11): 611-2. doi:10.4103/1947-2714.103339</ref>
*[[Special:MyLanguage/Vomiting|Vomiting]]
*[[Special:MyLanguage/Abdominal pain|Abdominal pain]]
*Polydipsia/polyuria
*Encephalopathy
*[[Special:MyLanguage/Elevated bilirubin|Elevated bilirubin]]
*[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*Elevated urea 
*Leukocytosis 
*[[Special:MyLanguage/Ascites|Ascites]] or bright liver on ultrasound scan
*Elevated transaminases (AAT or ALT) 
*Elevated ammonia 
*Renal impairment: elevated creatinine 
*Coagulopathy: elevated prothrombin time or PT
*Microvesicular steatosis on liver biopsy

==Management== <!--T:13-->

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*Emergent Ob/Gyn consult
**Delivery typically results in rapid hepatic recovery
*[[Special:MyLanguage/Dextrose|Dextrose]] for hypoglycemia
*[[Special:MyLanguage/FFP|FFP]], [[Special:MyLanguage/cryoprecipitate|cryoprecipitate]], and/or [[Special:MyLanguage/platelets|platelets]] for [[Special:MyLanguage/coagulopathy|coagulopathy]] (see [[Special:MyLanguage/DIC|DIC]])


==Disposition== <!--T:15-->

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*Admit ICU or transfer to center with Ob


==See Also== <!--T:17-->


==External Links== <!--T:18-->


==References== <!--T:19-->

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<references/>
[[Category:OBGYN]] [[category:GI]]
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