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Acute Fatty Liver of Pregnancy Treatment & Management

  • Author: Michael J Barsoom, MD, FACOG; Chief Editor: Ronald M Ramus, MD  more...
 
Updated: Jan 15, 2015
 

Medical Care

Delivery of the fetus, regardless of gestational age, is the only treatment for acute fatty liver of pregnancy (AFLP) once the diagnosis has been made.

Mode of delivery is dependent on the following several factors:

  • Fetal status: Many fetuses demonstrate evidence of asphyxia and hypoxia; therefore, close monitoring of fetal status is necessary, along with the ability to expedite delivery should fetal compromise be evident. [14]
  • Maternal coagulation status: Due to coagulation abnormalities that can accompany AFLP, patients may need to have replacement of their coagulation factors should cesarean delivery be necessary.
  • Likelihood of success with induction of labor: If delivery cannot be safely accomplished within 24 hours from the time of diagnosis, then cesarean delivery may be optimal.

Management of the severe hypoglycemia that may occur is necessary to avoid coma and death. Patients require at least a 5% Dextrose solution to maintain blood glucose levels. Blood glucose should be monitored closely until hepatic function returns and the patient tolerates a regular diet.

Renal function can also be affected by several factors, including maternal hemorrhage, which can lead to acute tubular necrosis and hepatorenal syndrome. Fluid balance should be closely monitored, as patients may develop pulmonary edema due to low plasma oncotic pressures.

Martin et al reported on using postpartum plasma exchange to treat severe cases of AFLP in the postpartum period. Patients with severe encephalopathy, on ventilator support, or with severe liver or renal insufficiency who failed to respond to conventional management, underwent plasma exchange. All patients showed improved signs and laboratory values.[15] Jin et al reported success with plasma exchange in 39 patients.[16] Chu et al achieved success in combining plasma exchange with continuous hemodiafiltration for patients with multiple organ dysfunction.[17]

More recent case reports have reported similar success with plasmapheresis[18] or plasmapheresis with continuous renal replacement therapy[19] for women with AFLP during pregnancy.

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Surgical Care

No specific surgical treatment exists for AFLP. Because of coagulation problems, careful evaluation of the genital tract for lacerations after vaginal delivery or maintaining good hemostasis during cesarean delivery should be practiced.[20]

Not all types of anesthesia can be used in patients with AFLP as some are hepatotoxic with decreased hepatic blood flow. Regional anesthesia may be obtained if a coagulopathy is not evident. However, if a coagulopathy is present, it should be corrected prior to regional anesthesia as bleeding at the puncture site is a concern. With general anesthesia, the anesthesiologist should be careful not to use agents that have potential hepatotoxicity, such as halothane. Isoflurane has no hepatotoxicity and may improve hepatic blood flow.

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Contributor Information and Disclosures
Author

Michael J Barsoom, MD, FACOG Director, Division of Maternal-Fetal Medicine, Alegent Health at Bergan Mercy Medical Center

Michael J Barsoom, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Brent J Tierney, MD Resident Physician, Department of Obstetrics and Gynecology, Creighton University Medical Center

Brent J Tierney, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Nebraska Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine

Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Medical Society of Virginia, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, AAGL, North American Menopause Society, American Medical Association, Association of Reproductive Health Professionals

Disclosure: Nothing to disclose.

References
  1. Rajasri AG, Srestha R, Mitchell J. Acute fatty liver of pregnancy (AFLP)--an overview. J Obstet Gynaecol. 2007 Apr. 27(3):237-40. [Medline].

  2. Ahmed KT, Almashhrawi AA, Rahman RN, Hammoud GM, Ibdah JA. Liver diseases in pregnancy: diseases unique to pregnancy. World J Gastroenterol. 2013 Nov 21. 19(43):7639-46. [Medline]. [Full Text].

  3. Bellig LL. Maternal acute fatty liver of pregnancy and the associated risk for long-chain 3-hydroxyacyl-coenzyme a dehydrogenase (LCHAD) deficiency in infants. Adv Neonatal Care. 2004 Feb. 4(1):26-32. [Medline].

  4. Vigil-de Gracia P, Montufar-Rueda C. Acute fatty liver of pregnancy: diagnosis, treatment, and outcome based on 35 consecutive cases. J Matern Fetal Neonatal Med. 2011 Sep. 24(9):1143-6. [Medline].

  5. Kaplan MM. Acute fatty liver of pregnancy. N Engl J Med. 1985 Aug 8. 313(6):367-70. [Medline].

  6. Rajasri AG, Srestha R, Mitchell J. Acute fatty liver of pregnancy (AFLP)--an overview. J Obstet Gynaecol. 2007 Apr. 27(3):237-40. [Medline].

  7. Hepburn IS, Schade RR. Pregnancy-associated liver disorders. Dig Dis Sci. 2008 Sep. 53(9):2334-58. [Medline].

  8. Ockner SA, Brunt EM, Cohn SM, Krul ES, Hanto DW, Peters MG. Fulminant hepatic failure caused by acute fatty liver of pregnancy treated by orthotopic liver transplantation. Hepatology. 1990 Jan. 11(1):59-64. [Medline].

  9. Ibdah JA. Acute fatty liver of pregnancy: an update on pathogenesis and clinical implications. World J Gastroenterol. 2006 Dec 14. 12(46):7397-404. [Medline].

  10. Boregowda G, Shehata HA. Gastrointestinal and liver disease in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2013 Dec. 27(6):835-53. [Medline].

  11. Jamjute P, Ahmad A, Ghosh T, Banfield P. Liver function test and pregnancy. J Matern Fetal Neonatal Med. 2009 Mar. 22(3):274-83. [Medline].

  12. Sibai BM. Imitators of severe pre-eclampsia. Semin Perinatol. 2009 Jun. 33(3):196-205. [Medline].

  13. Sibai BM. Imitators of severe preeclampsia. Obstet Gynecol. 2007 Apr. 109(4):956-66. [Medline].

  14. Castro MA, Fassett MJ, Reynolds TB, Shaw KJ, Goodwin TM. Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. Am J Obstet Gynecol. 1999 Aug. 181(2):389-95. [Medline].

  15. Martin JN Jr, Briery CM, Rose CH, Owens MT, Bofill JA, Files JC. Postpartum plasma exchange as adjunctive therapy for severe acute fatty liver of pregnancy. J Clin Apher. 2008. 23(4):138-43. [Medline].

  16. Jin F, Cao M, Bai Y, Zhang Y, Yang Y, Zhang B. Therapeutic effects of plasma exchange for the treatment of 39 patients with acute fatty liver of pregnancy. Discov Med. 2012 May. 13(72):369-73. [Medline].

  17. Chu YF, Meng M, Zeng J, Zhou HY, Jiang JJ, Ren HS, et al. Effectiveness of combining plasma exchange with continuous hemodiafiltration on acute Fatty liver of pregnancy complicated by multiple organ dysfunction. Artif Organs. 2012 Jun. 36(6):530-4. [Medline].

  18. Seyyed Majidi MR, Vafaeimanesh J. Plasmapheresis in acute Fatty liver of pregnancy: an effective treatment. Case Rep Obstet Gynecol. 2013. 2013:615975. [Medline]. [Full Text].

  19. Yu CB, Chen JJ, Du WB, et al. Effects of plasma exchange combined with continuous renal replacement therapy on acute fatty liver of pregnancy. Hepatobiliary Pancreat Dis Int. 2014 Apr. 13(2):179-83. [Medline].

  20. Castro MA, Goodwin TM, Shaw KJ, Ouzounian JG, McGehee WG. Disseminated intravascular coagulation and antithrombin III depression in acute fatty liver of pregnancy. Am J Obstet Gynecol. 1996 Jan. 174(1 Pt 1):211-6. [Medline].

  21. Apiratpracha W, Yoshida EM, Scudamore CH, Weiss AA, Byrne MF. Chronic pancreatitis: a sequela of acute fatty liver of pregnancy. Hepatobiliary Pancreat Dis Int. 2008 Feb. 7(1):101-4. [Medline].

  22. Goto K, Saito A, Nagase S, Sinohara H. Acute phase response of plasma proteins in analbuminemic rats. J Biochem. 1988 Dec. 104(6):952-5. [Medline].

 
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