acute fatty liver of pregnancy (aflp)

7/30/2019 Acute Fatty Liver of Pregnancy (AFLP)

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Dr KABERA Ren

Family Physician

Rwanda

ACUTE FATTY LIVER OF PREGNANCY (AFLP)


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INTRODUCTION

Acute fatty liver of pregnancy (AFLP) is a rare complication

of the third trimester. Sheehan described the pathology in 1940 as an "acute yellow

atrophy" of the liver, then thought to be related to delayed

chloroform poisoning.

Early recognition and termination of the pregnancy (delivery)

and extensive supportive therapy have reduced the mortality

rate to approximately 20%.

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PATHOPHYSIOLOGY

A familial deficiency of long-chain 3-hydroxyacyl-CoA

dehydrogenase (LCHAD) caused by a single codon mutation

Recessively inherited mitochondrial abnormalities of fatty acid

oxidation.

The mitochondrial dysfunction in the oxidation of fatty acidsleads to an accumulation in hepatocytes.

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PHYSIOPATHOLOGY

The microvesicular steatosis in the liver.

The infiltration of fatty acids causes acute liver insufficiency.

It is associated with a high maternal and neonatal morbidity and

mortality

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EPIDEMIOLOGY

Rare complication (1/13000)

Unique for pregnancy

For inexplicable reasons, the disease is more common in

nulliparas.

It likely is more common with a male fetus

15 percent of cases have a multifetal gestation

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CLINICAL PRESENTATION

Complaints

Malaise

Nausea and vomiting (70%); this may present for the first time in

the third trimester

Bleeding

Abdominal pain

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CLINICAL PRESENTATION

Physical

Hypertension(50%)

Bleeding

Confusion and altered mental status (encephalopathy)

Jaundice

Right upper-quadrant and epigastric pain (50-80%)

Edema

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DIFFERENTIALS

Drug-Induced Hepatotoxicity

Eclampsia

HELLP Syndrome

Hepatitis, Viral

Preeclampsia

Toxicity, Acetaminophen

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DIAGNOSIS

Aspartate transaminase (AST) and alanine transaminase (ALT) can be

elevated due to the hepatic injury. Decreased gluconeogenesis and, therefore, decreased blood glucose

levels.

Liver detoxification is also affected, resulting in elevated levels of

blood ammonia, especially late in the disease course leading to

encephalopathy.

Disseminated intravascular coagulation (DIC) with prolongation of

prothrombin time, low fibrinogen, and low antithrombin levels DIC is not due to consumption of the clotting factors but to decreased

production by the damaged liver.

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DIAGNOSIS

Bilirubin levels are elevated. This elevation is primarily the

conjugated form, with levels exceeding 5 mg/dL. Some patients may develop pancreatitis, which can result in

elevated amylase, lipase, and increased blood sugars.

In 50 % blood creatine and uric acid can become elevated,leading to metabolic acidosis.

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DIAGNOSIS

Imaging Studies

Imaging studies have a low sensitivity for diagnosing AFLP and should notbe used to exclude the diagnosis.

Liver ultrasonographic examination may reveal increased echogenicity in

severe cases.

A computed tomography (CT) scan may show decreased or diffuseattenuation in the liver.

Histologic Findings

Although the criterion standard for diagnosis of AFLP is liver biopsy The histological findings demonstrate pericentral microvesicular fat

infiltration with minimal inflammation or necrosis

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MANAGEMENT

Maternal deaths are reported to be caused by sepsis, hemorrhage,aspiration, renal failure, pancreatitis, and gastrointestinal bleeding. Therapy

is directed toward these complications.

Delivery of the fetus, regardless of gestational age ,if no delivery in 24 hrs.

prior to diagnosis a C-section may be done Mode of delivery is dependent on the following several factors:

Close monitoring of Fetal status

Due to Maternal coagulation status: replacement of their coagulation factors Normal diet and D5 for Management of the severe hypoglycemia .

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MANAGEMENT

Fluid balance should be closely monitored, as patients may

develop pulmonary edema due to low plasma oncotic pressures Maternal hemorrhage: Renal function impairment; acute tubular

necrosis, hepatorenal syndrome

Transfusions: fresh-frozen plasma, cryoprecipitate, whole blood,packed red cells, and platelets are usually necessary if surgery

is performed or if lacerations complicate vaginal delivery

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REFERENCES

Williams Obstetrics23rd Ed.

Current Diagnosis in Obstetrics and Gynecology - 10th Ed.

Current diagnosis and treatment in Gastroenterology 2nd Ed.

Acute Fatty liver of pregnancy. Dey M, Reema K. N Am J Med

Sci. 2012 Nov;4(11):611-2

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Thank you

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acute fatty liver of pregnancy (aflp)

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