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. Ending the pregnancy by delivery of the infant invariably results in resolution of the hepatic dysfunction and accompanying complications that occur in AFLP.
Mode of delivery is dependent on the following several factors:
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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. [19]
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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.
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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. [20] Jin et al reported success with plasma exchange in 39 patients. [21] Chu et al achieved success in combining plasma exchange with continuous hemodiafiltration for patients with multiple organ dysfunction. [22]
More recent case reports have reported similar success with plasmapheresis [23] or plasmapheresis with continuous renal replacement therapy [24] for women with AFLP during pregnancy.
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. [25]
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.
