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Non-fatal Acute Fatty Liver of Pregnancy: A case report of an uncommon disease
Abstract Number: T-34
Abstract Type: Case Report/Case Series
We present a 35 year old G3P1011 female at 35 weeks with appropriate antenatal care that was admitted for contractions. She was seen at another facility for UTI symptoms (nausea, anorexia, and chills) and declined antibiotic therapy. Antepartum history was significant for gestational diabetes and a previous C-Section.
Physical exam showed a tachycardic (133bpm) and hypertensive (132/86) parturient with an average body weight. She was slightly lethargic with 4+ patellar reflexes bilaterally and 3 beat clonus and her glucose = 63. She was transferred to the operating room for an urgent C-Section due to persisting fetal late decelerations. She received a spinal anesthetic and the surgery lasted 91 minutes with uneventful intraoperative course. An acidotic female was delivered, requiring intubation and admission to NICU.
The patient continued to be lethargic in the recovery room, her glucose = 48 and VBG demonstrated metabolic acidosis with base deficit = 14.4. She was given Dextrose 25 gm and Sodium bicarbonate 50 mEq. The results for the labs drawn on admission returned demonstrating 14 fold elevation of LFTs, high PT/INR = 29.0/2.63, PTT = 49.5, lactic acid = 10.4, and low Fibrinogen = 75. She was transferred to ICU for management with close neuro-checks.
LFT derangement, hypoglycemia and elevated INR persisted. On POD 2, sudden onset confusion and tonic/clonic seizures occurred. She was intubated and CT scan showed a small subarachnoid hemorrhage. Neurosurgery was consulted and conservative treatment was recommended without surgical intervention.
On POD 3, she was diagnosed with Acute Fatty Liver of Pregnancy (AFLP) and was transferred to a liver transplant center for further evaluation if her liver failure symptoms continued to worsen. The patient had a lengthy post-operative course but eventually recovered and did not require liver transplant. The baby is alive and thriving after an 11 day course in NICU.
AFLP is a rare, and usually reversible, peripartum liver failure that is believed to affect <1 in 6700 gestations. Although routine assessment of liver function in every laboring patient is not practical, certain elements of a patient's history and physical exam can clue the anesthesiologist into further assessment. This case demonstrates the need for determination of liver functions during pregnancy for early recognition and termination of the pregnancy in such cases. Obstetrical emergencies can lead to death of both mother and child if not diagnosed in time to prevent coagulopathic complications.
While regional anesthesia in the setting of elevated INR may pose an unacceptable risk due to adverse neurologic outcomes, it must be weighed carefully with the inherent risks of general anesthesia in the parturient (e.g. difficult intubation and full stomach). Although our patient did not suffer any neurological deficits, if time permits every effort should be made to correct the coagulopathy prior to any neuraxial technique.