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Acute fatty liver of pregnancy — Clinical Guidelines

Overview

Acute fatty liver of pregnancy (AFLP) is a rare but severe obstetric emergency characterized by hepatic fatty infiltration leading to acute liver failure, coagulopathy, and potential multisystem organ dysfunction 1 2 3.

Diagnosis

Elevated liver enzymes (AST, ALT) and bilirubin levels 1 2

Coagulopathy (prolonged PT/INR) 1 2

Renal impairment (elevated creatinine, decreased urine output) 1 2

Fatty liver changes on imaging or histology 1 2

Clinical signs of hepatic encephalopathy 3

Multiorgan dysfunction syndrome (MODS) indicators 1 2

Management

Immediate delivery via cesarean section 1 2 3

Supportive care:

- Hemodynamic stabilization and fluid management 1 - Mechanical ventilation for respiratory failure 1 - Renal replacement therapy (dialysis) for acute kidney injury 1 2 - Plasma exchange and blood component transfusions 2

Specific interventions:

- Bilirubin adsorption 1 - Antibiotic therapy tailored to clinical context 2 - Nutritional support (enteral nutrition) 2 - Inhibition of gastric and pancreatic secretions 2

Special Populations

Pregnancy: AFLP management emphasizes prompt delivery to mitigate maternal and fetal risks 1 2 3

Comorbidities: Preeclampsia complicates AFLP, potentially necessitating advanced interventions like postpartum liver transplantation 3

Key Recommendations

Prompt delivery by cesarean section to improve maternal outcomes (Evidence: Strong 1 2 3)

Initiate multidisciplinary intensive care including respiratory, renal, and coagulation support (Evidence: Moderate 1 2)

Consider advanced interventions such as plasma exchange and renal replacement therapy for severe cases (Evidence: Weak 2)

Monitor and manage multiorgan dysfunction aggressively with appropriate supportive measures (Evidence: Moderate 1 2)

Evaluate for and manage complications like pancreatitis and venous thrombosis (Evidence: Expert opinion 2)

References

1 Shen Y, Wang X, Yao Y, Zhou X. Acute fatty liver of pregnancy causing multiple organ dysfunction syndrome in a Chinese intensive care unit. Nursing in critical care 2023. link 2 Ye R, Mai Z, Pan X, Cai S, Deng L. Acute fatty liver of pregnancy causes severe acute pancreatitis and stillborn fetus: A case report. Medicine 2021. link 3 Amon E, Allen SR, Petrie RH, Belew JE. Acute fatty liver of pregnancy associated with preeclampsia: management of hepatic failure with postpartum liver transplantation. American journal of perinatology 1991. link

Acute fatty liver of pregnancy