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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==Differential Diagnosis==
==Differential Diagnosis==
*Often initially misdiagnosed as [[preeclampsia]]/[[HELLP]]
**Hypoglycemia, jaundice, ascites, hypofibrinogenemia all ''more'' common in AFLP
{{Postpartum emergencies DDX}}
{{Postpartum emergencies DDX}}
===Indirect Hyperbilirubinemia===
{{Jaundice DDX}}
*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]]
*[[Acute liver failure|Fulminant hepatic failure]]
*[[alcoholic hepatitis]]
*Ischemia
*Toxins
**[[Isoniazid]]
**[[Phenytoin]]
**[[Acetaminophen (Tylenol) Toxicity|acetaminophen]]
**Ritonavir
**Halothane
**Sulronamide
*[[Autoimmune hepatitis]]
**Primary biliary cirrhosis
*[[HELLP Syndrome]]
*Congestive Hepatopathy
**[[CHF]]
**[[Sepsis]] (Shock Liver)
 
===Pregnancy Related===
*[[HELLP Syndrome]]
*[[Acute fatty liver of pregnancy]]
*[[Hyperemesis gravidarum]]
*[[Cholestasis of pregnancy]]
 
===Transplant Related===
*[[Transplant complications|Transplant rejection]]
*[[Graft-vs-host disease]]
 
===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]]


==Evaluation==
==Evaluation==
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===Diagnosis===
===Diagnosis===
*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:
*[[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==
==Management==

Latest revision as of 22:59, 13 November 2024

Background

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

Differential Diagnosis

3rd Trimester/Postpartum Emergencies

Jaundice

Differential diagnosis of hyperbilirubinemia.

Indirect Hyperbilirubinemia

Direct (Conjugated) Hyperbilirubinemia

Hepatocellular damage

Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase

Pregnancy Related

Transplant Related

Pediatric Related

Additional Differential Diagnosis

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
  • CBC
  • 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

Disposition

  • Admit ICU or transfer to center with Ob

See Also

External Links

References

  1. ↑ Ko H, Yoshida EM (2006). Acute fatty liver of pregnancy. Canadian Journal of Gastroenterology. 20 (1): 25–30
  2. ↑ 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
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