Acute Fatty Liver of Pregnancy

Jeevitha1*, Malathi C2, Dhariniya3, Ruby Ravichandran4

1Staff Nurse, Mother ICU, Maa Kauvery, Trichy, Tamil Nadu

2Incharge, Mother ICU, Maa Kauvery, Trichy, Tamil Nadu

3Nursing Educator, Maa Kauvery, Trichy, Tamil Nadu

4Senior Deputy Nursing Superintendent, Maa Kauvery, Trichy, Tamil Nadu

*Correspondence

Abstract

Acute Fatty Liver of Pregnancy is a rare but life-threatening obstetric emergency occurring in late pregnancy. It is associated with hepatic dysfunction, hypoglycemia, coagulopathy, and multi-organ involvement. We presented a 26-year-old prim gravida at 34+1 week’s gestation who presented with fatigue, abdominal pain, and biochemical evidence of liver dysfunction and metabolic acidosis. Early diagnosis, multidisciplinary management, and timely delivery resulted in a favorable maternal and fetal outcome despite complications including acute kidney injury and coagulopathy.

Key words: Acute Fatty Liver of Pregnancy (AFLP); Hepatic dysfunction; Coagulopathy

Introduction

Acute Fatty Liver of Pregnancy (AFLP) is an uncommon but severe condition typically occurring in the third trimester or early postpartum period. It is believed to result from abnormalities in fetal fatty acid metabolism, leading to accumulation of micro vesicular fat in maternal hepatocytes. Clinically, AFLP presents with nonspecific symptoms such as malaise, nausea, vomiting, and abdominal pain, progressing rapidly to liver failure, encephalopathy, and disseminated intravascular coagulation if untreated. Early recognition and prompt delivery are crucial to reducing maternal and fetal morbidity and mortality.

History

A 26-year-old female, prim gravida at 34 weeks + 1 day gestation, presented with complaints of fatigue and intermittent abdominal pain for four days. She initially received treatment at an outside hospital before being referred to due to worsening clinical condition. She also reported fever for one day, constipation for four days, and giddiness. There was no history of prior significant surgical illness, but she was a known case of hypothyroidism on treatment for seven months. Her menstrual cycles were regular, and she had conceived spontaneously.

Clinical Findings

On admission, the patient was found to be hypotensive with evidence of systemic involvement. Laboratory investigations revealed elevated liver enzymes, hyperbilirubinemia, renal dysfunction, metabolic acidosis, and hypoglycemia. She was managed initially with fluid resuscitation and supportive care.

On examination, the patient was conscious, oriented, and afebrile. There was no pallor or edema noted. Her vital signs included a pulse rate of 110 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 110/60 mmHg after resuscitation. Oxygen saturation was maintained at 98% on oxygen support.

Systemic examination revealed normal cardiovascular findings, and bilateral conducted breath sounds on respiratory examination. Per abdominal examination showed a soft abdomen. Obstetric examination revealed a uterus corresponding to 34–36 weeks gestation with good fetal heart rate. Per vaginal examination showed an uneffaced cervix with closed os.

Investigations and results

Laboratory investigations showed hemoglobin levels of 9.2 g/dL improving to 10.3 g/dL, and leukocytosis with total white blood cell count increasing from 14,130 to 15,060 cells/cu mm. Platelet count decreased from 178,000 to 125,000 cells/µL on next day, suggesting evolving coagulopathy.

On admission Coagulation profile showed prolonged prothrombin time (14.5 seconds) and activated partial thromboplastin time (37 seconds), with an INR of 1.25. Liver function tests revealed elevated total bilirubin (up to 5.2 mg/dL), with both direct and indirect fractions raised. Transaminases were elevated (SGOT 126 IU/L, SGPT 122 IU/L initially), and serum albumin was low (2.18–2.19 g/dL).

Renal function tests indicated acute kidney injury with elevated serum creatinine (1.6–1.65 mg/dL) and urea levels. Serum uric acid was elevated (9.37 mg/dL). Electrolytes showed mild hypernatremia and hyperchloremia. Fibrinogen levels were reduced (98 mg/dL), indicating consumptive coagulopathy.

Arterial blood gas analysis revealed metabolic acidosis with hypoglycemia (68 mg/dL). Ultrasound antenatal scan showed a single live intrauterine fetus with cephalic presentation, adequate liquor, and gestational age corresponding to 34–35 weeks. Abdominal ultrasound revealed mild right hydronephrosis. Echocardiograms were normal, and venous Doppler studies showed no evidence of thrombosis.

Diagnosis

Based on clinical presentation and laboratory findings, a diagnosis of Acute Fatty Liver of Pregnancy was made. Associated complications included hypovolemic shock, acute kidney injury, hypothyroidism, and disseminated intravascular coagulation.

Management

The patient was managed with a multidisciplinary approach involving obstetricians, gastroenterologists, cardiologists, and hematologists. After obtaining informed consent, a decision was made for emergency cesarean section in view of maternal deterioration. Preoperatively, the patient stabilized with intravenous fluids, correction of hypoglycemia, and supportive care. Broad-spectrum intravenous antibiotics (meropenem and metronidazole), proton pump inhibitors, N-acetyl cysteine, thiamine, and multivitamins were administered. During surgery, an emergency cesarean section was performed under general anesthesia, delivering a live female baby weighing 3.06 kg. Placenta and membranes were delivered completely. Postpartum hemorrhage was managed using a Foley’s tamponade technique. Blood products including packed red blood cells and fresh frozen plasma were transfused intraoperatively.

Outcome

Postoperatively, the patient was electively intubated and shifted to the intensive care unit for close monitoring. Imaging showed bilateral basal lung collapse with minimal pleural effusion. She received cryoprecipitate and further plasma transfusions to correct coagulopathy. With intensive supportive care, the patient’s condition gradually improved. Liver and renal parameters stabilized, and coagulation abnormalities were corrected over time.

Discharge

After stabilization and adequate recovery, the patient was weaned off ventilator support and transitioned to oral medications. She was discharged in stable condition with advice for regular follow-up, monitoring of liver and renal function, and continuation of hypothyroidism treatment.

Discussion. Acute Fatty Liver of Pregnancy is a rare but critical condition requiring high clinical suspicion. It often presents nonspecific symptoms, making early diagnosis challenging. The presence of hypoglycemia, elevated liver enzymes, hyperbilirubinemia, renal dysfunction, and coagulopathy should alert clinicians to the possibility of AFLP. Differential diagnoses include HELLP syndrome and viral hepatitis; however, hypoglycemia and severe metabolic derangements are more characteristic of AFLP. Early delivery remains the cornerstone of management, as continuation of pregnancy worsens maternal condition. Multidisciplinary care, aggressive supportive therapy, and timely correction of metabolic and hematological abnormalities significantly improve outcomes. Advances in intensive care have reduced maternal mortality rates considerably.

Conclusion

Acute Fatty Liver of Pregnancy is a life-threatening obstetric emergency that requires prompt recognition and intervention. This case highlights the importance of early diagnosis, multidisciplinary management, and timely delivery in improving maternal and fetal outcomes. Awareness among clinicians and rapid initiation of treatment can significantly reduce complications and ensure recovery.

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