Acute fatty liver of pregnancy: Difference between revisions
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**Hypoglycemia, jaundice, ascites, hypofibrinogenemia all ''more'' common in AFLP | **Hypoglycemia, jaundice, ascites, hypofibrinogenemia all ''more'' common in AFLP | ||
{{Postpartum emergencies DDX}} | {{Postpartum emergencies DDX}} | ||
{{Jaundice}} | |||
==Evaluation== | ==Evaluation== | ||
Revision as of 13:34, 25 November 2021
Background
- 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
- Usually presents in 3rd trimester, but may occur any time in 2nd half of pregnancy to early postpartum
- Nausea/vomiting (commonly severe)
- Jaundice
- Findings consistent with preeclampsia in some women:
- Hypertension
- Edema
- Proteinuria
- Hypoglycemia
- Often, signs/symptoms of DIC
- +/- encephalopathy, ascites
Differential Diagnosis
- Often initially misdiagnosed as preeclampsia/HELLP
- Hypoglycemia, jaundice, ascites, hypofibrinogenemia all more common in AFLP
3rd Trimester/Postpartum Emergencies
- Acute fatty liver of pregnancy
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- HELLP syndrome
- Mastitis
- Peripartum cardiomyopathy
- Postpartum endometritis (postpartum PID)
- Postpartum headache
- Postpartum hemorrhage
- Preeclampsia
- Resuscitative hysterotomy
- Retained products of conception
- Septic abortion
- Uterine rupture
Evaluation
Workup
- LFTs
- ALT/AST usually in 300-500 range, alk phos usually elevated in pregnancy
- Hyperbilirubinemia- more pronounced than in preeclampsia
- BMP
- DIC labs
- Low fibrinogen, coagulopathy
- DIC present in as many as 70% of patients[1]
- CBC
- Often shows leukocytosis
- UA
- RUQ US
- Non-specific; the liver can even be normal in echotexture
- Useful to rule out other causes of obstructive biliary tract pathology.
Diagnosis
Swansea criteria[2]
At least six of the following findings, in the absence of another cause:
- Vomiting
- Abdominal pain
- Polydipsia/polyuria
- Encephalopathy
- Elevated bilirubin
- Hypoglycemia
- Elevated urea
- Leukocytosis
- 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
- Emergent Ob/Gyn consult
- Delivery typically results in rapid hepatic recovery
- Dextrose for hypoglycemia
- FFP, cryoprecipitate, and/or platelets for coagulopathy (see DIC)
Disposition
- Admit ICU or transfer to center with Ob