Acute Fatty Liver of Pregnancy

OVERVIEW

  • essentials of diagnosis: hepatic dysfunction + microvesicular infiltration of hepatocytes
  • thought to be a variant of PET
  • fetal and maternal mortality = 20%
  • aetiology unknown ?may be related to mother carrying fetus’ with disordered fat metabolism
  • often develop DI

CLINICAL FEATURES

History

  • last trimester of pregnancy or immediately postpartum
  • primiparous
  • multiple gestation
  • N+V
  • anorexia
  • malaise
  • epigastric pain/RUQ pain

Examination

  • often have hypertension
  • jaundice
  • abdominal tenderness
  • oedema
  • polyuria

Complications

  • hepatic encephalopathy
  • ascites
  • hypoglycaemia
  • consumptive coagulopathy
  • pancreatitis

INVESTIGATIONS

  • may have proteinuria
  • marked leukocytosis
  • normochromic, normocytic anaemia
  • fragmented RBCs
  • microangiopathic haemolytic anaemia
  • consumptive coagulopathy (DIC)
  • AST and ALT seldom > 1000I/L
  • ALP and bilirubin are elevated
  • severe hypoglycaemia
  • elevated lipase/amylase (pancreatitis)
  • hypernatraemia if has DI
  • liver biopsy

MANAGEMENT

  • urgent delivery of fetus once mother stablised

Resuscitation

  • mum and baby
  • full monitoring
  • CTG/Ultrasound
  • haematological resuscitation (products, vitamin K)
  • hydralazine for hypertension

Acid-base and Electrolytes

  • frequent monitoring
  • intravascular volume correction
  • hypoglycaemia treatment

Antidotes/Specific Treatments

  • MgSO4 IV (adjust in renal failure)
  • decrease protein intake (nutrition should be glucose based -> decrease hepatic metabolism burden)
  • lactulose to decrease ammonia production and absorption in the intestine -> diarrhoea
  • if develops DI -> desmopressin
  • liver transplantation

Underlying cause

  • deliver baby (usually be emergency LSCS)

References and Links

  • Lee NM, Brady CW. Liver disease in pregnancy. World J Gastroenterol. 2009 Feb 28;15(8):897-906. PMC2653411.
  • Ko H, Yoshida EM. Acute fatty liver of pregnancy. Can J Gastroenterol. 2006 Jan;20(1):25-30. PMC2538964.
  • Neligan PJ, Laffey JG. Clinical review: Special populations–critical illness and pregnancy. Crit Care. 2011 Aug 12;15(4):227. PMC3387584.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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