A Case of Emergent Cesarean Delivery Under Spinal Anesthesia in a Patient with Undiagnosed Acute Fatty Liver of Pregnancy
Abstract Number: T1D-5
Abstract Type: Case Report/Case Series
Introduction: Acute fatty liver of pregnancy (AFLP) is a rare, potentially fatal complication that occurs in the third trimester or early postpartum period (1). Early diagnosis can be difficult as the disease shares characteristics with more common conditions such as preeclampsia, viral hepatitis, and cholestasis of pregnancy.
Case: 34 yo G2P1 at 37.5 weeks presented with category III fetal heart rate tracing; IV was placed, labs were drawn, and a stat cesarean section (CS) called. The patient had no known contraindications to spinal anesthesia. A lateral spinal was placed, followed by an uncomplicated CS with an EBL of 800mL. Initial labs later reported an INR 2 and fibrinogen of 81 mg/dL. The patient showed no signs of bleeding and repeat labs were drawn. ROTEM showed a FIBTEM A10 of 5mm consistent with fibrinogen <100mg/dL (fig 1), at which point she received 2g human fibrinogen concentrate. The repeat INR of 2.5 and fibrinogen of <60mg/dL were consistent with initial ROTEM results. She then received 2 units cryoprecipitate followed by a FIBTEM A10 of 12mm, indicating a fibrinogen level >200mg/dL (fig 2). The patient's INR continued to trend upward to 2.6. Hepatology was consulted and diagnosed AFLP secondary to her malaise, deranged liver synthetic function, and hypoglycemia.
Discussion: AFLP is diagnosed in the third trimester although it has been reported as early as 26 weeks and as late as the immediate postpartum period (2). Clinical findings vary and include malaise, headache, fever, jaundice, and right upper quadrant tenderness. Laboratory tests show leukocytosis, prolonged PT and PTT, hypofibrinogenemia, elevated liver enzymes, and hypoglycemia. Symptoms and laboratory findings overlap with other common diseases and it is therefore a diagnosis of exclusion. Acuity of onset along with signs of jaundice or hypoglycemia can set AFLP apart from preeclampsia. Ultrasound and MRI may demonstrate fatty infiltration of the liver but this is insufficient to make a definitive diagnosis. Treatment of AFLP is hinged on early diagnosis, expedient delivery, and intensive postpartum monitoring and support. Our patient was delivered upon presentation and coagulation abnormalities were immediately corrected. Liver transplant is warranted for those with fulminant hepatic failure despite aggressive supportive care (3).
1. Ko. Can J Gastroent 2006;20:25-30.
2. Knox. NEJM 1996;335:569-76.
3. Ockner. Hepato 1990;11:59-64.