Acute fatty liver of pregnancy: Difference between revisions
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==Background==
==Background==
[[File:Sobo 1906 389.png|thumb|Inferior view of the liver with surface showing lobes and impressions.]]
[[File:Sobo 1906 389.png|thumb|Inferior view of the liver with surface showing lobes and impressions.]]
*Rare, potentially fatal complication that presents in second half of pregnancy or (less commonly) early postpartum
*Rare, potentially fatal complication that presents in second half of pregnancy or (less commonly) early postpartum
*Exact etiology unclear, but thought to involve abnormal fetal fatty acid metabolism  
*Exact etiology unclear, but thought to involve abnormal fetal fatty acid metabolism  
*Fat vesicles accumulate within hepatocytes, interfering with liver function
*Fat vesicles accumulate within hepatocytes, interfering with liver function


==Clinical Features==
==Clinical Features==
*Usually presents in 3rd trimester, but may occur any time in 2nd half of pregnancy to early postpartum
*Usually presents in 3rd trimester, but may occur any time in 2nd half of pregnancy to early postpartum
*[[Nausea/vomiting]] (commonly severe)
*[[Special:MyLanguage/Nausea/vomiting|Nausea/vomiting]] (commonly severe)
*[[Jaundice]]
*[[Special:MyLanguage/Jaundice|Jaundice]]
*Findings consistent with [[preeclampsia]] in some women:
*Findings consistent with [[Special:MyLanguage/preeclampsia|preeclampsia]] in some women:
**[[Hypertension]]
**[[Special:MyLanguage/Hypertension|Hypertension]]
**Edema
**Edema
**[[Proteinuria]]
**[[Special:MyLanguage/Proteinuria|Proteinuria]]
*[[Hypoglycemia]]
*[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*Often, signs/symptoms of [[DIC]]
*Often, signs/symptoms of [[Special:MyLanguage/DIC|DIC]]
*+/- [[encephalopathy]], [[ascites]]
*+/- [[Special:MyLanguage/encephalopathy|encephalopathy]], [[Special:MyLanguage/ascites|ascites]]
 


==Differential Diagnosis==
==Differential Diagnosis==
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{{Postpartum emergencies DDX}}
{{Postpartum emergencies DDX}}
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{{Jaundice DDX}}
{{Jaundice DDX}}
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==Evaluation==
==Evaluation==
===Workup===
===Workup===
*[[LFTs]]
 
*[[Special:MyLanguage/LFTs|LFTs]]
**ALT/AST usually in 300-500 range, alk phos usually elevated in pregnancy
**ALT/AST usually in 300-500 range, alk phos usually elevated in pregnancy
**[[Hyperbilirubinemia]]- more pronounced than in preeclampsia
**[[Special:MyLanguage/Hyperbilirubinemia|Hyperbilirubinemia]]- more pronounced than in preeclampsia
*BMP
*BMP
**[[Hypoglycemia]]
**[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*[[DIC]] labs  
*[[Special:MyLanguage/DIC|DIC]] labs  
**Low fibrinogen, [[coagulopathy]]
**Low fibrinogen, [[Special:MyLanguage/coagulopathy|coagulopathy]]
**DIC present in as many as 70% of patients<ref>Ko H, Yoshida EM (2006). Acute fatty liver of pregnancy. Canadian Journal of Gastroenterology. 20 (1): 25–30</ref>
**DIC present in as many as 70% of patients<ref>Ko H, Yoshida EM (2006). Acute fatty liver of pregnancy. Canadian Journal of Gastroenterology. 20 (1): 25–30</ref>
*CBC
*CBC
**Often shows [[leukocytosis]]
**Often shows [[Special:MyLanguage/leukocytosis|leukocytosis]]
*[[UA]]
*[[Special:MyLanguage/UA|UA]]
**[[Proteinuria]]
**[[Special:MyLanguage/Proteinuria|Proteinuria]]
*[[RUQ US]]
*[[Special:MyLanguage/RUQ US|RUQ US]]
**Non-specific; the liver can even be normal in echotexture  
**Non-specific; the liver can even be normal in echotexture  
**Useful to rule out other causes of obstructive biliary tract pathology.
**Useful to rule out other causes of obstructive biliary tract pathology.


===Diagnosis===
===Diagnosis===
*Often initially misdiagnosed as [[preeclampsia]]/[[HELLP]]
 
*Often initially misdiagnosed as [[Special:MyLanguage/preeclampsia|preeclampsia]]/[[Special:MyLanguage/HELLP|HELLP]]
**Hypoglycemia, jaundice, ascites, hypofibrinogenemia all ''more'' common in AFLP
**Hypoglycemia, jaundice, ascites, hypofibrinogenemia all ''more'' common in AFLP


====Swansea criteria<ref>Dey M, Reema K. Acute Fatty liver of pregnancy. N Am J Med Sci. 2012;4 (11): 611-2. doi:10.4103/1947-2714.103339</ref>====  
 
====Swansea criteria<ref>Dey M, Reema K. Acute Fatty liver of pregnancy. N Am J Med Sci. 2012;4 (11): 611-2. doi:10.4103/1947-2714.103339</ref>====
 
At least six of the following findings, in the absence of another cause:
At least six of the following findings, in the absence of another cause:
*[[Vomiting]]
*[[Special:MyLanguage/Vomiting|Vomiting]]
*[[Abdominal pain]]
*[[Special:MyLanguage/Abdominal pain|Abdominal pain]]
*Polydipsia/polyuria
*Polydipsia/polyuria
*Encephalopathy
*Encephalopathy
*[[Elevated bilirubin]]
*[[Special:MyLanguage/Elevated bilirubin|Elevated bilirubin]]
*[[Hypoglycemia]]
*[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*Elevated urea  
*Elevated urea  
*Leukocytosis  
*Leukocytosis  
*[[Ascites]] or bright liver on ultrasound scan
*[[Special:MyLanguage/Ascites|Ascites]] or bright liver on ultrasound scan
*Elevated transaminases (AAT or ALT)  
*Elevated transaminases (AAT or ALT)  
*Elevated ammonia  
*Elevated ammonia  
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*Coagulopathy: elevated prothrombin time or PT
*Coagulopathy: elevated prothrombin time or PT
*Microvesicular steatosis on liver biopsy
*Microvesicular steatosis on liver biopsy


==Management==
==Management==
*Emergent Ob/Gyn consult
*Emergent Ob/Gyn consult
**Delivery typically results in rapid hepatic recovery
**Delivery typically results in rapid hepatic recovery
*[[Dextrose]] for hypoglycemia
*[[Special:MyLanguage/Dextrose|Dextrose]] for hypoglycemia
*[[FFP]], [[cryoprecipitate]], and/or [[platelets]] for [[coagulopathy]] (see [[DIC]])
*[[Special:MyLanguage/FFP|FFP]], [[Special:MyLanguage/cryoprecipitate|cryoprecipitate]], and/or [[Special:MyLanguage/platelets|platelets]] for [[Special:MyLanguage/coagulopathy|coagulopathy]] (see [[Special:MyLanguage/DIC|DIC]])
 


==Disposition==
==Disposition==
*Admit ICU or transfer to center with Ob
*Admit ICU or transfer to center with Ob


==See Also==
==See Also==
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==References==
==References==
<references/>
<references/>
[[Category:OBGYN]] [[category:GI]]
[[Category:OBGYN]] [[category:GI]]
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Revision as of 21:35, 4 January 2026

Other languages:

Background

Inferior view of the liver with surface showing lobes and impressions.
  • Rare, potentially fatal complication that presents in second half of pregnancy or (less commonly) early postpartum
  • Exact etiology unclear, but thought to involve abnormal fetal fatty acid metabolism
  • Fat vesicles accumulate within hepatocytes, interfering with liver function


Clinical Features


Differential Diagnosis

3rd Trimester/Postpartum Emergencies

Jaundice

Differential diagnosis of hyperbilirubinemia.

Indirect Hyperbilirubinemia

Direct (Conjugated) Hyperbilirubinemia

Hepatocellular damage

Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase

Pregnancy Related

Transplant Related

Pediatric Related

Additional Differential Diagnosis

Masqueraders

Only bilirubin stains the sclera

  • Carotenemia
  • Quinacrine ingestion
  • Dinitrophenol, teryl (explosive chemicals)


Evaluation

Workup

  • LFTs
    • ALT/AST usually in 300-500 range, alk phos usually elevated in pregnancy
    • Hyperbilirubinemia- more pronounced than in preeclampsia
  • BMP
  • DIC labs
  • CBC
  • UA
  • RUQ US
    • Non-specific; the liver can even be normal in echotexture
    • Useful to rule out other causes of obstructive biliary tract pathology.


Diagnosis

  • Often initially misdiagnosed as preeclampsia/HELLP
    • Hypoglycemia, jaundice, ascites, hypofibrinogenemia all more common in AFLP


Swansea criteria[2]

At least six of the following findings, in the absence of another cause:

  • Vomiting
  • Abdominal pain
  • Polydipsia/polyuria
  • Encephalopathy
  • Elevated bilirubin
  • Hypoglycemia
  • Elevated urea
  • Leukocytosis
  • Ascites or bright liver on ultrasound scan
  • Elevated transaminases (AAT or ALT)
  • Elevated ammonia
  • Renal impairment: elevated creatinine
  • Coagulopathy: elevated prothrombin time or PT
  • Microvesicular steatosis on liver biopsy


Management


Disposition

  • Admit ICU or transfer to center with Ob


See Also

External Links

References

  1. ↑ Ko H, Yoshida EM (2006). Acute fatty liver of pregnancy. Canadian Journal of Gastroenterology. 20 (1): 25–30
  2. ↑ Dey M, Reema K. Acute Fatty liver of pregnancy. N Am J Med Sci. 2012;4 (11): 611-2. doi:10.4103/1947-2714.103339
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