Acute fatty liver of pregnancy is a rare obstetric emergency that is characterised by maternal liver dysfunction and fetal complications, leading to death.
Patients with prior episode of acute fatty liver of pregnancy, low body mass index, malnutrition, pre-eclampsia, fetal male sex and multiple gestations are found to have an increased risk of developing this condition.
The development of acute fatty liver of pregnancy is considered to be due to the defects in the metabolism of fatty acids. There is normally an increased production of free fatty acids during pregnancy to compensate the needs of fetal growth. But if there is a defect in the metabolism of the free fatty acids, it leads to an accumulation of the intermediate products in the maternal hepatocytes leading to liver dysfunction.
Acute fatty liver of pregnancy is usually noticed between 30 to 38 weeks of gestational age. Patients initially develop non-specific symptoms such as nausea, vomiting, fatigue, loss of appetite and abdominal pain. As the liver dysfunction worsens, patient develops features of liver failure such as jaundice, altered mental status, ascites and bleeding tendency; it can also lead to multiorgan failure.
Blood tests reveal elevated bilirubin, serum ammonia levels, liver enzymes, renal parameters and low platelets. Ultrasound imaging of the abdomen shows non-specific fatty liver changes.
It is recommended to manage patients with acute fatty liver of pregnancy in a tertiary care center with facilities for liver transplant. Such patients will require a multidisciplinary team approach involving obstetrician, neonatologist, hepatologist and critical care physicians.
The goal of management includes treatment of hypoglycemia, coagulopathy and encephalopathy. Along with fetal monitoring, prompt delivery should be planned as soon as the diagnosis of acute fatty liver is done.
The major reasons for maternal mortality in such patients include hemorrhage, liver failure and acute kidney injury. Most of the acute fatty liver of pregnancy patients resolve completely post-delivery within a span of 7 to 10 days. However, a few patients worsen to develop fulminant hepatic failure requiring liver transplantation.
Patients with a history of acute fatty liver of pregnancy need close monitoring in their subsequent pregnancy. In addition to the routine antenatal care, additional investigations to regularly monitor liver and renal function is essential. Such patients will need close observation and frequent antenatal checkups to keep all parameters under surveillance.
Dr. Karishma Puthanpura Department of Critical Care Kauvery Hospital Chennai
