Acute fatty liver of pregnancy: Difference between revisions

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==Background==
<languages/>
<translate>
 
==Background== <!--T:1-->
 
<!--T:2-->
[[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== <!--T:3-->
 
<!--T:4-->
*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==
 
*Often initially misdiagnosed as [[preeclampsia]]
==Differential Diagnosis== <!--T:5-->
**Hypoglycemia, jaundice, ascites, hypofibrinogenemia all [[more]] common in AFLP
 
</translate>
{{Postpartum emergencies DDX}}
{{Postpartum emergencies DDX}}
===Indirect Hyperbilirubinemia===
<translate>
*Hemolytic
</translate>
**[[G6PD]]
{{Jaundice DDX}}
**Drug related
<translate>
**[[Autoimmune hemolytic anemia]]
 
*Hematoma resorption
*Ineffective erythropoiesis
*Gilbert's
===Direct (Conjugated) Hyperbilirubinemia===
*[[Choledocholithiasis]]
*[[Cholecystitis]]
*Ascending [[cholangitis]]
*[[AIDS]] cholangiopathy
*Stricture
*Neoplasm
**Pancreatic head
**Gallbladder
**Primary liver (e.g. [[hepatocellular carcinoma]]
**Metastatic
*Obstructing [[AAA]]
===Hepatocellular damage===
''Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase''
*[[Viral hepatitis]]
*[[Acute liver failure|Fulminant hepatic failure]]
*[[alcoholic hepatitis]]
*Ischemia
*Toxins
**[[Isoniazid]]
**[[Phenytoin]]
**[[Acetaminophen (Tylenol) Toxicity|acetaminophen]]
**Ritonavir
**Halothane
**Sulronamide
*[[Autoimmune hepatitis]]
**Primary biliary cirrhosis
*[[HELLP Syndrome]]
*Congestive Hepatopathy
**[[CHF]]
**[[Sepsis]] (Shock Liver)


===Pregnancy Related===
==Evaluation== <!--T:6-->
*[[HELLP Syndrome]]
*[[Acute fatty liver of pregnancy]]
*[[Hyperemesis gravidarum]]
*[[Cholestasis of pregnancy]]


===Transplant Related===
*[[Transplant complications|Transplant rejection]]
*[[Graft-vs-host disease]]


===Pediatric Related===
===Workup=== <!--T:7-->
*[[Inborn error of metabolism]]
*[[Neonatal jaundice]] (physiologic)


===Additional Differential Diagnosis===
<!--T:8-->
*[[Reye syndrome]]
*[[Special:MyLanguage/LFTs|LFTs]]
*TPN
*[[Heatstroke]]
*[[Budd-Chiari]] (with acute ascites)
*[[Wilson's disease]]
*[[Sarcoidosis]]
*[[Amyloidosis]]
==Evaluation==
*[[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]]
*[[Special:MyLanguage/RUQ US|RUQ US]]
**Non-specific; the liver can even be normal in echotexture
**Useful to rule out other causes of obstructive biliary tract pathology.
 
 
===Diagnosis=== <!--T:9-->
 
<!--T:10-->
*Often initially misdiagnosed as [[Special:MyLanguage/preeclampsia|preeclampsia]]/[[Special:MyLanguage/HELLP|HELLP]]
**Hypoglycemia, jaundice, ascites, hypofibrinogenemia all ''more'' common in AFLP


==Management==
 
====Swansea criteria<==== <!--T:11-->
 
<!--T:12-->
At least six of the following findings, in the absence of another cause:<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>
*[[Special:MyLanguage/Vomiting|Vomiting]]
*[[Special:MyLanguage/Abdominal pain|Abdominal pain]]
*Polydipsia/polyuria
*Encephalopathy
*[[Special:MyLanguage/Elevated bilirubin|Elevated bilirubin]]
*[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*Elevated urea
*Leukocytosis
*[[Special:MyLanguage/Ascites|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== <!--T:13-->
 
<!--T:14-->
*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== <!--T:15-->
 
<!--T:16-->
*Admit ICU or transfer to center with Ob
*Admit ICU or transfer to center with Ob


==See Also==


==See Also== <!--T:17-->
==External Links== <!--T:18-->


==External Links==


==References== <!--T:19-->


==References==
<!--T:20-->
<references/>
<references/>
[[Category:OBGYN]] [[category:GI]]
[[Category:OBGYN]] [[category:GI]]
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Latest revision as of 23:25, 12 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<

At least six of the following findings, in the absence of another cause:[2]

  • 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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