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Acute Fatty Liver In Pregnancy (AFLP): Causes, Symptoms, And Treatment

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Acute fatty liver of pregnancy (AFLP) is a relatively rare obstetric emergency that develops in the third trimester or after delivery. It is also referred to as acute yellow atrophy of the liver. AFLP is characterized by microvesicular steatosis (blocked liver capillaries).

The untreated condition could lead to liver failure, resulting in maternal or fetal complications. Timely diagnosis and treatment can help in the mother’s recovery (1). This post discusses the causes, risk factors, symptoms, effects, diagnosis, and treatment for AFLP.

Read this post to learn about the symptoms, risk factors, and complications of acute fatty liver of pregnancy and what you can do to improve clinical outcomes.

What Are The Causes Of Acute Fatty Liver Of Pregnancy?

The exact cause of AFLP is unclear. However, studies link the metabolic disorder to the following causes (1):

  • Pregnant women who carry a fetus with a metabolic liver disorder
  • Genetic defects, which may contribute to metabolic disorders, and fetal–maternal interaction
  • Fatty acid oxidation enzyme (liver enzyme) defects in the fetus that impair the normal function of the fetal liver
  • Mitochondrial dysfunction (an impaired cell powerhouse)

What Are The Risk Factors Of Acute Fatty Liver Of Pregnancy?

According to the Canadian Journal of Gastroenterology and Hepatology, some of the risk factors of AFLP are (2)

  • Genetic mutation of the long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) liver enzyme
  • Primipara or first pregnancy
  • Male fetus
  • Multiple gestation

What Are The Complications Of Acute Fatty Liver Of Pregnancy?

An unrecognized and untreated fatty liver disease may cause poor pregnancy outcomes. Some complications associated with AFLP are (3) (4)

  • Hepatic failure (liver failure)
  • Renal impairment (loss of kidney function)
  • Hepatic encephalopathy (brain damage)
  • Disseminated intravascular coagulation (overactive blood coagulation system)
  • Gastrointestinal and uterine bleeding
  • Poor fetal outcomes

What Are The Symptoms Of Acute Fatty Liver Of Pregnancy?

The clinical features of AFLP may vary, but some common symptoms are (5)

  • Jaundice
  • Abdominal pain
  • Nausea
  • Vomiting
  • General discomfort
  • Fatigue
  • Headache

How Is Your Body’s Metabolism Altered In Acute Fatty Liver Of Pregnancy?

The following are some changes in liver function that occur during AFLP (6):

  • Elevated levels of liver enzymes such as serum alanine aminotransferase, aspartate aminotransferase, and lactic dehydrogenase
  • Altered levels of fibrinogen (machinery for blood coagulation), causing coagulation abnormality
  • Increase in prothrombin time

How Is Acute Fatty Liver Of Pregnancy Diagnosed?

Some factors that make the diagnosis of AFLP difficult are (7) (8):

  • Differential diagnosis: AFLP is tricky to diagnose since its symptoms are similar to those of other pregnancy-related disorders (such as pre-eclampsia, viral hepatitis, and cholestasis).
  • Insufficient understanding of precise mechanism: An unclear biochemical and physiological understanding makes the diagnosis and treatment less efficient.
  • Unreliable examination/diagnosis: As the symptoms are similar to other pregnancy complications, no reliable examination specific to AFLP exists. Liver biopsy is the most accurate but may lead to further complications.

Since AFLP has no specific symptoms, the diagnosis comprises laboratory tests with symptom identification. The diagnosis of AFLP is as follows (6) (8):

  • Review of medical history: The doctor may review the health history and monitor clinical symptoms.
  • Blood tests: Some laboratory abnormalities that may indicate AFLP are
  • Elevated serum aminotransferase levels in liver function tests, which help evaluate the extent of liver damage.
  • High white blood cell (WBC) count and low platelet count (thrombocytopenia)
  • Elevated bilirubin in the blood
  • Time taken by the plasma to clot (prothrombin time) and the blood clot to heal (partial thromboplastin time)
  • Fibrinogen level in the blood
  • Elevated levels of blood urea, uric acid, ammonia, and creatinine
  • Hypoglycemia
  • Medical imaging: Computerized tomography (CT) and magnetic resonance imaging (MRI) scans help determine how much the liver has shrunken.
  • Liver biopsy: It is the most reliable method of AFLP diagnosis, where a sample of liver tissue is collected. It is an invasive method and associated with complications. Hence blood tests and scans are carried out to support the evidence of AFLP. Histologically, AFLP is characterized by microvesicular hepatic steatosis (small collections of fat in liver cells).

How Is Acute Fatty Liver Of Pregnancy Treated?

Early diagnosis of AFLP is the key to successful treatment, reducing the risk of complications in future pregnancies.

Some of the treatments available for AFLP are (6) (8) (9)

  • Nutrition: An early diagnosis of AFLP can be managed by adhering to a low protein and fat diet. Food with a higher glycemic index may be beneficial in managing the hypoglycemia symptoms.
  • Pregnancy interruption: If diagnosed with AFLP, the baby needs to be delivered early to reduce the fetal and maternal fatality risk. The doctor may suggest a prompt delivery by cesarean section
  • Intensive care: Intensive care may be required for the mother and baby until their health conditions improve.
  • Organ transplantation: In some cases, your doctor may suggest liver transplantation as the best recovery option.

Some extensive life-saving maternal treatments include

  • Anti-infective prophylactic therapy
  • Hemodialysis
  • Plasma exchange
  • Blood transfusion
  • Platelet transfusion
  • Liver protection therapy

AFLP is a rare complication of pregnancy that usually occurs toward the end of the pregnancy or postpartum and mainly affects liver function. However, there are no clear symptoms to identify the disorder. Thus, note any alarming symptoms and act proactively. Early diagnosis, treatment, and supportive care for AFLP patients may help to reduce maternal mortality and fetal complications.

References:

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  1. Jamel A Ibdah; (2006); Acute fatty liver of pregnancy: An update on pathogenesis and clinical implications.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4087582/
  2. Hin Ko and Eric Yoshida; (2006); Acute fatty liver of pregnancy.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2538964/
  3. Suchi Dwivedi and Ma Runmei; (2013); Retrospective Study of Seven Cases with Acute Fatty Liver of Pregnancy.
    https://www.hindawi.com/journals/isrn/2013/730569/
  4. Kiko Yamamoto; (2019); Severe fatty liver of pregnancy requiring an extremely large amount of blood transfusion, surgery and transarterial embolization: A case report.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599870/
  5. Acute Fatty Liver of Pregnancy.
    https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P02465
  6. Yan-Ping Zhang; (2016); Acute Fatty Liver of Pregnancy: A Retrospective Analysis of 56 Cases.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4878167/
  7. Madhusudan and Kumar Reema; (2012); Acute Fatty Liver of Pregnancy.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3503387/
  8. Qiang Wei; (2010); Clinical diagnosis and treatment of acute fatty liver of pregnancy: A literature review and 11 new cases.
    https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1447-0756.2010.01242.x
  9. Tatyana Kushner; (2019); Outcomes of liver transplantation for acute fatty liver disease of pregnancy.
    https://onlinelibrary.wiley.com/doi/10.1111/ajt.15401
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Anshuman Mohapatra

Anshuman Mohapatra is a biotechnology scientist with more than six years of research experience in analytical chemistry and biotechnology. He has submitted his Ph.D thesis at the Indian Institute of Technology Guwahati (IIT Guwahati) and served as a research fellow (JRF/SRF) during his Ph.D tenure. His research interest includes analytical chemistry, neurobiology and lipid disorder diseases. Three of his research... more