Acute fatty liver of pregnancy
Acute fatty liver of pregnancy (AFLP) is a rare pregnancy-associated condition that tends to manifest in the 3rd trimester of pregnancy or early postpartum period.
The estimated incidence is at around 1:7000-20,000 births.
Patients may present with nausea, vomiting, right upper quadrant pain, and/or jaundice.
The pathogenesis may be related to an abnormality in fetal fatty acid metabolism.
According to Swansea criteria for the diagnosis of acute fatty liver of pregnancy six or more of the following findings are required in the absence of another cause 10:
- abdominal pain
- elevated bilirubin > 14 µmol/l
- hypoglycaemia < 4 mmol/l
- elevated urea > 340 µmol/l
- leucocytosis > 11 x 10⁹ /l
- ascites or bright liver on ultrasound scan
- elevated transaminases (AAT or ALT) > 42 IU/l
- elevated ammonia > 47 µmol/l
- renal impairment: creatinine > 150 µmol/l
- coagulopathy: prothrombin time > 14 seconds or APPT > 34 seconds
- microvesicular steatosis on liver biopsy
Imaging features are often that of fatty infiltration of the liver.
Non-specific findings are usual and the liver can even be normal in echotexture 2. However, in the context of biliary type symptoms, ultrasound may be useful to rule out other causes of obstructive biliary tract pathology.
May show evidence of low attenuation 3-4 which is again non-specific.
Treatment and prognosis
- mortality is ~20%, with the cause of death usually due to sepsis, renal failure, circulatory collapse, pancreatitis or gastrointestinal bleeding
- liver function tests may show a continued deterioration for up to one week postpartum in the surviving patients and then the values slowly recover
Fat accumulation, along with ammonia production by hepatocytes can lead to:
- coagulopathy (e.g. disseminated intravascular coagulation)
- hypoglycemia secondary to evolving hepatic failure
History and etymology
It was first described by H L Sheehan et al in 1940 6.
- 1. Ong EM, Drukteinis JS, Peters HE et-al. Multimodality imaging of hepato-biliary disorders in pregnancy: a pictorial essay. Emerg Radiol. 2009;16 (5): 357-63. doi:10.1007/s10140-009-0800-3 - Pubmed citation
- 2. Van le L, Podrasky A. Computed tomographic and ultrasonographic findings in women with acute fatty liver of pregnancy. J Reprod Med. 1990;35 (8): 815-7. - Pubmed citation
- 3. Coche G, Moran V, Boillot A et-al. Acute fatty liver of pregnancy: CT evaluation. Case report. Eur J Radiol. 1988;8 (2): 115-7. - Pubmed citation
- 4. Mabie WC, Dacus JV, Sibai BM et-al. Computed tomography in acute fatty liver of pregnancy. Am. J. Obstet. Gynecol. 1988;158 (1): 142-5. - Pubmed citation
- 5. Monga M, Katz AR. Acute fatty liver in the second trimester. Obstet Gynecol. 1999;93 (5 Pt 2): 811-3. - Pubmed citation
- 6. Sheehan HL (1940). "The pathology of acute yellow atrophy and delayed chloroform poisoning". J Obstet Gynaecol Br. Emp. 47: 49–62.
- 7. Usta IM, Barton JR, Amon EA et-al. Acute fatty liver of pregnancy: an experience in the diagnosis and management of fourteen cases. Am. J. Obstet. Gynecol. 1994;171 (5): 1342-7. - Pubmed citation
- 8. Ko H, Yoshida EM. Acute fatty liver of pregnancy. Can. J. Gastroenterol. 2006;20 (1): 25-30. Free text at pubmed - Pubmed citation
- 10. 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 - Free text at pubmed - Pubmed citation