Acute Fatty Liver of Pregnancy

Question 1

What is acute fatty liver of pregnancy?

Answer 1

a severe, rare liver disease related to pregnancy, which can result in hepatic failure and necessitates immediate medical and obstetric intervention.

Question 2

What causes acute fatty liver of pregnancy?

Answer 2

The LCHAD mutation leads to the accumulation of fatty acid metabolites in the placenta, which are then shunted into the maternal circulation and subsequently accumulate in the maternal liver.

Question 3

How can AFLP present?

Answer 3

Nausea
Vomiting
Headache
Anorexia
Abdominal pain

HAVAN

In some cases, these symptoms rapidly progress to liver failure, manifesting as hepatic encephalopathy, jaundice, hypoglycaemia, and coagulopathy. Symptoms almost always develop in the third trimester.

Question 4

What are differentials for AFLP?

Answer 4

AFLP can be challenging to distinguish from HELLP syndrome, as they share many clinical and laboratory features. Women with AFLP are more likely to have:

1. synthetic liver dysfunction with coagulopathy
2. hypofibrinogenaemia
3. lower cholesterol levels
4. higher bilirubin levels
5. hypoglycaemia
6. hepatic encephalopathy
7. hyperammonaemia
8. DIC
9. more severe AKI.

Question 5

What levels are raised in AFLP?

Answer 5

AST
ALT
Bilirubin
Creatinine
Ammonia
Lactate
Serum uric acid

Question 6

What do haematological tests demonstrate in AFLP?

Answer 6

leukocytosis, low to normal platelets, and a normocytic normochromic anaemia. The coagulopathy is usually severe, with a prolonged PT, hypofibrinogenaemia, and elevated D-dimer.

Question 7

What criteria is used to establish a diagnosis of AFLP?

Answer 7

The Swansea criteria

Question 8

How is AFLP managed prior to and post delivery?

Answer 8

The only curative treatment for AFLP is delivery of the fetus.

Prior to delivery, maternal stabilisation should be achieved with correction of hypoglycaemia, coagulopathy, and hypertension.

After delivery, intensive supportive care in a multidisciplinary team is required. Six-hourly LFTs, renal function and haematological parameters should be performed within the first 24–48 hours after delivery.

Question 9

What should be done in cases of ongoing deterioration with AFLP?

Answer 9

In cases of ongoing deterioration in liver function post-delivery or hepatic rupture, patients should be transferred to a liver transplant centre for assessment. Transplantation should be considered in cases of ALF or hepatic rupture.

Question 10

What are the most reliable indicators of mortality with AFLP?

Answer 10

Elevated lactate levels with hepatic encephalopathy are the best predictors of maternal death or need for liver transplantation.