Acute fatty liver of pregnancy: Difference between revisions
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==Background== | ==Background== | ||
[[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 | *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 | *Exact etiology unclear, but thought to involve abnormal fetal fatty acid metabolism | ||
*Fat vesicles accumulate within hepatocytes, interfering with liver function | *Fat vesicles accumulate within hepatocytes, interfering with liver function | ||
==Clinical Features== | ==Clinical Features== | ||
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===Diagnosis=== | ===Diagnosis=== | ||
====Swansea criteria<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 | *Often initially misdiagnosed as [[preeclampsia]]/[[HELLP]] | ||
**Hypoglycemia, jaundice, ascites, hypofibrinogenemia all ''more'' common in AFLP | |||
====Swansea criteria<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>==== | |||
At least six of the following findings, in the absence of another cause: | At least six of the following findings, in the absence of another cause: | ||
*[[Vomiting]] | *[[Vomiting]] | ||
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*Polydipsia/polyuria | *Polydipsia/polyuria | ||
*Encephalopathy | *Encephalopathy | ||
*Elevated bilirubin | *[[Elevated bilirubin]] | ||
*[[Hypoglycemia]] | *[[Hypoglycemia]] | ||
*Elevated urea | *Elevated urea | ||
Latest revision as of 22:59, 13 November 2024
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
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
Jaundice
Indirect Hyperbilirubinemia
- Hemolytic
- G6PD
- Drug related
- Autoimmune hemolytic anemia
- Hematoma resorption
- Ineffective erythropoiesis
- Gilbert's
Direct (Conjugated) Hyperbilirubinemia
- Choledocholithiasis
- Cholecystitis
- Ascending cholangitis
- AIDS cholangiopathy
- Stricture
- Neoplasm
- Pancreatic head
- Gallbladder
- Primary liver (e.g. hepatocellular carcinoma)
- Metastatic
- Obstructing AAA
Hepatocellular damage
Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase
- Viral hepatitis
- Fulminant hepatic failure
- alcoholic hepatitis
- Ischemic hepatitis
- Toxins
- Isoniazid
- Phenytoin
- acetaminophen
- Ritonavir
- Halothane
- Sulfonamide
- Autoimmune hepatitis
- Primary biliary cirrhosis
- HELLP Syndrome
- Congestive Hepatopathy
Pregnancy Related
Transplant Related
Pediatric Related
- Inborn error of metabolism
- Neonatal jaundice (physiologic)
Additional Differential Diagnosis
- Reye syndrome
- TPN
- Heatstroke
- Budd-Chiari (with acute ascites)
- Wilson's disease
- Sarcoidosis
- Amyloidosis
Masqueraders
Only bilirubin stains the sclera
- Carotenemia
- Quinacrine ingestion
- Dinitrophenol, teryl (explosive chemicals)
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
- Often initially misdiagnosed as preeclampsia/HELLP
- Hypoglycemia, jaundice, ascites, hypofibrinogenemia all more common in AFLP
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