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    Acute Fatty Liver of Pregnancy: Letter To Editor

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    saryindriany
    This letter describes a case of acute fatty liver of pregnancy (AFLP) in a 21-year old primigravida woman. She delivered twins via vaginal birth but later developed significant vaginal bleeding requiring multiple blood transfusions. Her liver enzymes and coagulation parameters worsened. She developed renal failure, respiratory failure, and grade 2-3 hepatic encephalopathy. Ultrasound showed hepatomegaly and fatty liver changes. She was treated with hemodialysis and supportive care. Her condition gradually improved and she was discharged on postpartum day 25 after her liver enzymes and renal function normalized. AFLP is a rare but life-threatening condition that typically presents late in pregnancy with liver dysfunction, hypogly

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    Acute Fatty Liver of Pregnancy: Letter To Editor

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    saryindriany
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    This letter describes a case of acute fatty liver of pregnancy (AFLP) in a 21-year old primigravida woman. She delivered twins via vaginal birth but later developed significant vaginal bleeding requiring multiple blood transfusions. Her liver enzymes and coagulation parameters worsened. She developed renal failure, respiratory failure, and grade 2-3 hepatic encephalopathy. Ultrasound showed hepatomegaly and fatty liver changes. She was treated with hemodialysis and supportive care. Her condition gradually improved and she was discharged on postpartum day 25 after her liver enzymes and renal function normalized. AFLP is a rare but life-threatening condition that typically presents late in pregnancy with liver dysfunction, hypogly

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    This letter describes a case of acute fatty liver of pregnancy (AFLP) in a 21-year old primigravida woman. She delivered twins via vaginal birth but later developed significant vaginal bleeding requiring multiple blood transfusions. Her liver enzymes and coagulation parameters worsened. She developed renal failure, respiratory failure, and grade 2-3 hepatic encephalopathy. Ultrasound showed hepatomegaly and fatty liver changes. She was treated with hemodialysis and supportive care. Her condition gradually improved and she was discharged on postpartum day 25 after her liver enzymes and renal function normalized. AFLP is a rare but life-threatening condition that typically presents late in pregnancy with liver dysfunction, hypogly

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    33 views2 pages

    Acute Fatty Liver of Pregnancy: Letter To Editor

    Uploaded by

    saryindriany
    This letter describes a case of acute fatty liver of pregnancy (AFLP) in a 21-year old primigravida woman. She delivered twins via vaginal birth but later developed significant vaginal bleeding requiring multiple blood transfusions. Her liver enzymes and coagulation parameters worsened. She developed renal failure, respiratory failure, and grade 2-3 hepatic encephalopathy. Ultrasound showed hepatomegaly and fatty liver changes. She was treated with hemodialysis and supportive care. Her condition gradually improved and she was discharged on postpartum day 25 after her liver enzymes and renal function normalized. AFLP is a rare but life-threatening condition that typically presents late in pregnancy with liver dysfunction, hypogly

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    [Downloaded free from http://www.najms.org on Friday, February 22, 2019, IP: 36.68.179.

    197]

    Letter to Editor

    Acute Fatty Liver of hours and oozing was still present. Repacking was done.
    Liver enzymes kept on increasing (maximum serum

    Pregnancy bilirubin 15.5 mg%, SGOT 3450 IU/L, SGPT 2600 IU/L
    on postpartum day 3) and clinically she was in grade 1
    to grade 2 encephalopathy. Viral markers for hepatitis
    A, B, C and E were negative. Following hemodialysis for
    Dear Editor, the fourth continuous day, her vitals were found to be
    Acute fatty liver of pregnancy (AFLP) is a rare, stabilized. Vaginal pack was removed after 48 hours of
    potentially life‑threatening, pregnancy‑related disease repacking and she was extubated on fourth postpartum
    that affects 1 in 7000 to 16,000 pregnancies. [1]. The day. LFT though decreasing continued to be deranged.
    condition occurs more commonly in primigravidas, Urine output was 450 ‑ 500ml/24 h. Hemodialysis was
    multiple pregnancy, and pregnancies carrying a male done every alternate day till 16th postpartum day. During
    fetus.[2] At presentation, one should keep in mind other this period she developed ascites and bilateral pleural
    pregnancy‑related liver disease that mimic AFLP such effusion owing to hypoproteinemia for which she was
    as HELLP syndrome (hemolysis, elevated liver enzymes, treated with albumin. Alternate day USG carried out and
    and low platelet count). Bleeding and disseminated showed improvement in fatty changes, disappearance of
    intravascular coagulation (DIC) are one of most common ascites and pleural effusion. Liver enzymes normalized
    complications. on 19th postpartum day. Urine output started increasing
    and 25th postpartum day she was discharged.
    We report that a 21‑year‑old primigravida
    ( B M I –   2 0 . 4   k g /  m 2 ) w i t h t w i n p r e g n a n c y Acute fatty liver almost always manifests late in pregnancy
    (diamniotic‑dichorionic), admitted with labor pains at with a mean gestational age of 37.5 weeks;[3] some do not
    35 weeks and 3 days period of gestation with blood become clinically evident until delivery.[4] Persistent
    pressure of 150/96 mm Hg and urine albumin of 1+. nausea and vomiting are major symptoms with half of
    Her biochemical and hematological parameters were affected women might have hypertension, proteinuria
    within normal limits. She delivered 2 live female babies and edema, alone or in combination. According to
    by vaginal delivery with episiotomy weighing 2.25 kg the Swansea criteria,[5] six or more of the following
    and 1.9 kg at 20:25 hrs and 20:28 hrs, respectively. features are used to diagnose AFLP in the absence
    Post‑delivery at 02:00 hrs, vulval hematoma was drained of other explanations: vomiting; abdominal pain;
    in OT. Postoperatively, she was found to have pallor polydipsia/polyuria; encephalopathy; elevated bilirubin
    and minimal vaginal oozing. She was given 2 PRBC >14 μmol/L (0.8 mg%); hypoglycemia <4 mmol/L
    and 10 mg vitamin K. Four hours later, blood clots were (72 mg%); elevated urate >340 μmol/L (5.7 mg%);
    found in vagina (approx 800 ml). Exploration under GA leukocytosis >11 × 10 9 /L; ascites or bright liver
    was done. Tear was excluded. There was active bleeding on ultrasound; elevated transaminases; elevated
    from the uterus, oozing from the episiotomy site. Vaginal ammonia >47 μmol/L (27.5 mg%); renal impairment
    packing, inj. PGF2 alpha 02 doses at 20 min apart, 4 creatinine >150 μmol/L (1.7mg%); coagulopathy
    units of PRBC and 8 FFP were given in the OT, and she (PT >14 sec or APTT >34 sec), or microvesicular steatosis
    was shifted to ICU. Hematological investigations were on liver biopsy. Using these criteria, we anticipated
    suggestive of consumptive coagulopathy with deranged the diagnosis of AFLP. The patient had elevated
    liver enzymes and coagulation parameters [SGOT: 756 bilirubin, elevated transaminases, elevated creatinine,
    IU/L, SGPT: 356 IU/L, LDH: 2754 IU/L, INR: 3.19, encephalopathy, leukocytosis, fatty liver grade 2‑3 and
    platelets 130,000/mm3, PT: 32 sec (13), PTTK: 39 sec (27), coagulopathy. A patient with severe preeclampsia/
    TLC 19,000/mm3]. She was given injectable antibiotics, HELLP will usually present with proteinuria.
    FFP 2 units 6 hourly and cryoprecipitates 8 units. She was
    put on ventilator at 15:00 hrs in P‑SIMV mode, PEEP 5, Systemic complications of AFLP are due to fulminant
    and respiratory rate 15/min. Investigations 6 hours later hepatic failure and include encephalopathy, acute renal
    showed increasing liver enzymes, INR 2.94, platelets failure, infection, pancreatitis, gastrointestinal hemorrhage,
    48,000/mm3, Hb 6.5 gm% with low urine output. In coagulopathy, and at least mild hypoglycemia. Symptoms
    view of ARF and risk of fluid overload, dialysis was may rapidly progress from restlessness, confusion,
    started along with frusemide infusion. She continued on and disorientation to asterixis, seizures, psychosis,
    blood products. USG abdomen revealed hepatomegaly and ultimately coma.[6] Other systemic effects include
    with fatty changes grade 2‑3, medical renal disease, respiratory failure, sometimes requiring assisted
    and minimal ascites. Vaginal packing removed after 24 ventilation, ascites,[4] and gastrointestinal bleeding

    North American Journal of Medical Sciences | November 2012 | Volume 4 | Issue 11 | 611
    [Downloaded free from http://www.najms.org on Friday, February 22, 2019, IP: 36.68.179.197]

    Letter to Editor

    from gastric ulceration and Mallory‑Weiss syndrome.[7] References


    Hepatorenal syndrome eventually develops and leads to
    oliguria and acute tubular necrosis.[6] Ultrasound and CT 1. Reyes H, Sandoval L, Wainstein A, Ribalta J, Donoso S,
    Smok G, et al. Acute fatty liver of pregnancy: A clinical study
    scans of the liver have been used for diagnosis, but the
    of 12 episodes in 11 patients. Gut 1994;35:101‑6.
    specificity and sensitivity of these studies are insufficient 2. Fesenmeier MF, Coppage KH, Lambers DS, Barton JR, Sibai
    to make a diagnosis and the likelihood of false negative BM. Acute fatty liver of pregnancy in 3 tertiary care centres.
    results is high.[4] Liver biopsy is the gold standard test, Am J Obstet Gynaecol 2005;192:1416‑9.
    but it is invasive and requires a patient with normal 3. Castro MA, Goodwin TM, Shaw KJ, Ouzounian JG,
    coagulation status.[3] McGehee WG. Disseminated intravascular coagulation and
    antithrombin III depression in acute fatty liver of pregnancy.
    Am J Obstet Gynecol 1996a;174:211‑6.
    Supportive care of patients with AFLP should include
    4. Bacq Y. Liver diseases unique to pregnancy: A 2010 update.
    careful monitoring for evidence of progressive hepatic
    Clin Res Hepatol Gastroenterol 2011;35:182‑93.
    failure, hypoglycemia, and coagulopathy. This should
    5. Joshi D, James A, Quaglia A, Westbrook RH, Heneghan MA.
    occur in an intensive care setting and in consultation with Liver disease in pregnancy, Lancet 2010;375:594‑605.
    physicians well‑versed in the care of critically ill patients. 6. Castro MA, Fassett MJ, Reynolds TB, Shaw KJ, Goodwin
    Spontaneous resolution usually follows delivery. Maternal TM. Reversible peripartum liver failure: A new perspective
    deaths are caused by sepsis, hemorrhage, aspiration, on the diagnosis, treatment, and cause of acute fatty liver
    renal failure, pancreatitis and gastrointestinal bleeding.[8] of pregnancy, based on 28 consecutive cases. Am J Obstet
    Although maternal mortality rates in the past approached Gynecol 1999;181:38995.
    75 percent but Sibai (2007) cites an average mortality rate 7. Ibdah JA. Acute fatty liver of pregnancy: An update on
    pathogenesis and clinical implications. World J Gastroenterol
    of 7 percent with 70 percent preterm delivery rate and 2006;12:7397 ‑404.
    perinatal mortality rate of approximately 15 percent, 8. Martin JN Jr, Briery CM, Rose CH, Owem MT, Bifill JA,
    which in the past was nearly 90 percent.[9] Early diagnosis, Files JC. Postpartum plasma exchange as adjunctive therapy
    prompt therapy, adequate supportive care and a for severe acute fatty liver of pregnancy. J Clin Apher
    multidisciplinary approach are the key to a good outcome. 2008;23:138‑43.
    9. Sibai BM. Imitators of severe preeclampsia. Obstet Gynecol
    2007;199:956‑66.
    Acknowledgement
    Col PJ Kumar (Nephrologist), Col GS Narula (Critical Care), Lt
    Col Shalin Trivedi, Maj Ashish Vadhera (Anesthesist).
    Access this article online

    Madhusudan Dey, Kumar Reema Quick Response Code:


    Website:
    www.najms.org

    Department of Obstetrics and Gynecology,


    Armed Forces Medical Services, Military Hospital, DOI:
    Jalandhar, Punjab, India. 10.4103/1947-2714.103339
    E-mail: [email protected]

    612 North American Journal of Medical Sciences | November 2012 | Volume 4 | Issue 11 |

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