Massive Postpartum Hemorrhage Following Vaginal Twin Delivery in a Patient with Acute Fatty Liver of Pregnancy
Abstract Number: 155
Abstract Type: Case Report/Case Series
Introduction: Acute fatty liver of pregnancy (AFLP) is a rare cause of acute liver failure in late pregnancy. The presentation of AFLP is often non-specific and is associated with major maternal morbidity including: obstetric hemorrhage, coagulopathy and multi-organ failure. We present a case of massive postpartum hemorrhage following vaginal delivery in a patient with severe AFLP.
Case: A healthy 30 yr-old G3P0 patient at 35 weeks with a twin gestation presented to the emergency room with nausea and vomiting, non-specific abdominal pain, pedal edema and vaginal spotting. She was hemodynamically stable and presence of fetal heart tones were initially confirmed by ultrasound (US). After transfer to the labor and delivery unit, the patient became increasingly encephalopathic. A repeat US revealed demise of both fetuses. Admitting labs were: AST=625, ALT=370, Cr=3.3, Ammonia=124, Glucose=44, Hct=54, Plts=99. The obstetric team planned an induction of labor, and large bore IV access and an arterial line were placed. Repeated boluses of 50% dextrose IV were given to treat profound refractory hypoglycemia (Glu<60). The initial INR was 11.8, and FFP transfusion was commenced. The patient was moved to the OR for vaginal delivery due to concern for hemorrhage. The fetuses were delivered with vacuum assistance causing massive hemorrhage from vaginal lacerations and atony; general anesthesia was induced and endotracheal intubation was performed. A Bakri balloon was placed for uterine tamponade, the vagina was packed and the patient was transferred to ICU. The most abnormal hematologic values were: HCT=28; INR=11.8; APTT=150, Fib<30, Plts=67. The total perioperative blood loss was 8 liters and the patient received 25 U PRBC, 21 U FFP, 5 U platelets, 4 U cryoprecipitate, 5.5 L crystalloids and 6 mg Factor VIIa. The patient was transferred to ICU seven hours after admission (HCT=50; INR=1.3 on arrival), where she required CVVH for acute renal failure. Other postoperative complications included: sepsis, necrotizing pancreatitis, retroperitoneal hematoma, and intraabdominal abscess, necessitating multiple subsequent operations. The patient was discharged from the hospital 12 weeks postpartum in stable condition.
Discussion: AFLP occurs in 1/10,000 - 1/15,000 pregnancies and carries a high maternal and fetal mortality (18% and 23%, respectively). Possible risk factors include nulliparity and multiple gestation.(1) The presentation is similar to HELLP syndrome, however severe hypoglycemia requiring aggressive treatment with dextrose IV is common in AFLP.(2) Recombinant FVIIa may be necessary in the treatment of severe peripartum hemorrhage due to AFLP after massive transfusion of RBC and blood products.
(1) World J Gastroenterol 2009;15:897-906. (2) Int J Obstet Anesth 2007;16:175-9.