Acute Fatty Liver Failure of Pregnancy
Katrin Book, MD and R.Zheng, MD
Department of Anesthesiology, University of Florida, Gainesville, Florida
Acute fatty liver failure of pregnancy is a rare but sometimes fatal
complication of pregnancy. The incidence seems to be between 1 in 13000 to 1
in 17000 with an associated mortality that has been reported up to 80%
previously. Prompt recognition and multidisciplinary supportive therapy is
key in preventing poor maternal and fetal outcomes.
We present the case of a 37year old female Para 1112 at 36 weeks with twin
gestation who was admitted with complaints of general malaise and weakness
of about 2 weeks duration. The prenatal care was only complicated by diet
controlled gestational diabetes. The initial evaluation revealed hepatic
dysfunction, acute renal failure and coagulopathy as evidenced by increased
liver enzymes, low normal platelet count, increased creatinine and an
international normalized ratio of 2.7. Blood pressures were only mildly
elevated. Urgent cesarean section under general anesthesia was performed due
to the evidence of liver failure. Fresh frozen plasma was started on
induction to correct the coagulopathy. Despite this, the patient developed
microvascular bleeding as evidenced by oozing at the surgical site as well
as bleeding through her nasogastric tube. At the conclusion of the procedure
the patient had spontaneous breathing with sufficient tidal volumes,
followed simple commands and showed sufficient strength confirmed by
sustained head lift and was therefore extubated successfully. At that time
the patient had received 3 units of fresh frozen plasma as well as 2000ml of
crystalloids with an estimated blood loss of 1400 ml. Repeated laboratory
values showed thrombocytopenia, a hematocrit of 29.5% and an international
normalized ratio of 2.2. Although the patient was hemodynamically stable,
she was transferred to the intensive care unit secondary to bleeding and
confusion. She remained there for 3 more days, requirering 6 more units of
fresh frozen plasma as well as two units of packed red blood cells. The only
other complication was a wound infection. With supportive care, hepatic and
renal function normalized and the coagulopathy resolved. The patient was
discharged home on the 10th day postpartum without lasting sequelae.
Our case presentation is fairly typical for acute fatty liver of pregnancy,
starting with relatively nonspecific symptoms and progressing to liver and
renal failure, with bleeding, infection and encephalopathy. With delivery
and supportive medical treatment, hepatic and renal function normalize.
