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Acute Fatty Liver of Pregnancy Workup

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

Laboratory Studies

The following laboratory studies can be evaluated to help make the diagnosis of acute fatty liver of pregnancy (AFLP).

  • Aspartate transaminase (AST) and alanine transaminase (ALT) are not elevated in normal pregnancies. These can become elevated in many different conditions during pregnancy. Some are unique to pregnancy, such as preeclampsia/eclampsia, HELLP, and AFLP. High levels of ALT can be seen in patients with viral hepatitis; however, the highest levels are seen in patients with acute toxic liver injury, as can be seen in acetaminophen overdose.[11] Both AST and ALT can be elevated due to the hepatic injury.
  • Hepatic injury results in 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.
  • In addition, laboratory findings may be consistent with disseminated intravascular coagulation (DIC), specifically, prolongation of prothrombin time, low fibrinogen, and low antithrombin levels. This results in a clinical picture similar to DIC; however, in AFLP, the values are abnormal, not due to consumption of the clotting factors but rather to decreased production by the damaged liver.[12]
  • Bilirubin levels are elevated. This elevation is primarily the conjugated form, with levels exceeding 5 mg/dL. This can result in jaundice, which is rarely seen in patients with other forms of pregnancy-related hepatic injury, including preeclampsia.
  • Some patients may develop pancreatitis, which can result in elevated amylase, lipase, and increased blood sugars.
  • As the maternal kidneys become affected, blood creatine and uric acid can become elevated, leading to metabolic acidosis.
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Imaging Studies

Imaging studies have a low sensitivity for diagnosing AFLP and should not be used to exclude the diagnosis. Liver ultrasonographic examination may reveal increased echogenicity in severe cases. A computed tomography (CT) scan may show decreased or diffuse attenuation in the liver.[13]

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Histologic Findings

Although the criterion standard for diagnosis of AFLP is liver biopsy, this is rarely performed in clinical practice due to the risk of hemorrhage. In addition, AFLP can easily be differentiated from viral or drug-induced hepatitis by obtaining viral serologies and measuring acetaminophen levels in serum.

If a biopsy is performed, the histological findings demonstrate pericentral microvesicular fat infiltration with minimal inflammation or necrosis.[11]

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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
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  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].

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  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].

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

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  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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