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A case of acute fatty liver of pregnancy: obstetric and anesthetic implications.
Abstract Number: S-57
Abstract Type: Case Report/Case Series
A 23 year old parturient, gravida 3, para 1, abortus 1, presented at 36 weeks' gestation with nausea, vomiting, pruritus and green discoloration of urine. Her past medical history included asthma, a recently treated urinary tract infection and newly diagnosed gestational diabetes. Her partner was known to be Hepatitis C positive. Her initial lab work revealed elevated transaminases beyond 1000 U/l, impaired coagulation (fibrinogen 124 mg/dl, INR 1.6) and liver function (albumin 2.7 gm/dl, total bilirubin 3.4 mg/dl) but a she had a normal platelet and white blood cell count. Renal function was impaired (creatinine 1.0 mg/dl) and her blood glucose level was trending between 60 and 100 despite the diagnosis of gestational diabetes. Ultrasound of the right upper quadrant showed evidence of hepatic steatosis but no signs of cholecystitis or cholelithiasis. Hepatitis serology was sent but came back negative. Urine samples showed no proteinuria and her blood pressure was not elevated. At this point the diagnosis of acute fatty liver of pregnancy (AFLP) was made and the plan was to deliver within the next 24 hours.
After stripping of membranes the patient was induced with misoprostol. Despite transfusing nine units of FFP and one unit of cryoprecipitate, her coagulopathy could not be corrected and therefore the patient did not receive neuraxial anesthesia. Pain control was accomplished using intravenous narcotics. The next morning the patient had a vaginal delivery of a healthy baby girl.
The patient subsequently complained of shortness of breath, possibly due to transfusion related volume overload. However a chest radiograph did not show clear evidence of volume overload. For further observation the patient was transferred to the intensive care unit and treated with intravenous diuresis. Later on the patient developed a fever as well as uterine tenderness and was started on empiric antibiotic therapy for endometritis. Despite acute liver failure, the patient did not show any signs of cerebral edema.
The next day her symptoms improved, transaminases fell below 200 U/l and she was transferred to the postpartum unit. Fever resolved and urine output improved over the next 24 hours. Antibiotics were discontinued the following day and after one more night of observation she was discharged home.
On a follow up appointment four days later, blood work revealed transaminases below 100 U/l, improved coagulation (fibrinogen 164 mg/dl), recovered liver (INR 1.1) and kidney function (creatinine 0.6 mg/dl).
This patient had AFLP but made a rapid recovery with no complications. We ruled out preeclampsia, which can sometimes co-exist with AFLP. Most patients present late in the disease process and in those circumstances there is a significant increase in maternal and neonatal morbidity and mortality. The differential diagnosis, prognosis, treatment, intensive care management and anesthetic implications of AFLP will be presented at the poster session.