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When It's Not Preeclampsia: A Case Report of Acute Fatty Liver of Pregnancy
Abstract Number: SAT-78
Abstract Type: Case Report/Case Series
Acute fatty liver of pregnancy (AFLP) is an uncommon disease, with an incidence of 1 in 7,000 to 1 in 20,000 deliveries and occurring primarily during the third trimester of pregnancy (1). Although rare, this disease can be potentially fatal for the parturient and her fetus. AFLP often presents with signs and symptoms similar to preeclampsia however can be distinguished by the presence of hepatic insufficiency.
We present a case of a 32 year old female at 34 weeks with a di-di pregnancy who was diagnosed with preeclampsia but was ultimately found to have AFLP. She was initially diagnosed with preeclampsia with severe features based on hypertension, transaminitis and proteinuria. Her lab work was also notable for uremia, hyperbilirubinemia, hypoglycemia, low fibrinogen and a metabolic acidosis. Given her severe features and fetal malpresentation, she was planned for urgent cesarean section. She underwent an uncomplicated cesarean delivery under spinal anesthesia. Post-operatively, she became hypotensive with altered mental status. Repeat lab work demonstrated worsening hypoglycemia and an INR 1.9. She continued to be hemodynamically unstable and an arterial line was place. She was transferred to the ICU for management of her hypoglycemia, coagulopathy and hepatic dysfunction. Her multidisciplinary team, including ICU, Maternal Fetal Medicine, Gastroenterology and Hematology, felt her presentation was most consistent with acute liver failure attributed to AFLP. Anesthesia was actively involved in her postpartum neurologic monitoring given the fact that her spinal was placed while she was coagulopathic. Her neurologic exam remained normal postpartum. Her hospital course was complicated by a worsening coagulopathy with development of a pelvic hematoma. By postoperative day 7 however, her acute liver failure improved and she was transferred to the floor.
Although rare, AFLP should be suspected in any parturient presenting with symptoms of preeclampsia and with signs of liver failure, including hypoglycemia and coagulopathy. AFLP has been reported to have maternal and fetal mortality rates of 12% and 66%, respectively (2). As a result, it is imperative to keep AFLP high on the differential diagnosis. This is especially true for the Anesthesiologist caring for the patient because the coagulopathy associated with the disease can significantly affect the anesthetic plan. Our patient’s coagulopathy put her at risk of developing a spinal-epidural hematoma. Had AFLP had been diagnosed earlier, her section would likely have been performed under general anesthesia.
1.Castro MA, Fassett MJ et al. Reversible peripartum liver failure:A new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. American Journal of Obstetrics and Gynecology 181(2):389-395, 1999.
2.Chestnut, David H.Chestnut's Obstetric Anesthesia: Principles and Practice. 5th edition. Philadelphia, PA: Elsevier/Saunders,2014