Acute fatty liver of pregnancy

Last revised by Jeremy Jones on 16 Apr 2023

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.

The Swansea criteria for the diagnosis of acute fatty liver of pregnancy states that six or more of the following findings are required in the absence of another cause 10:

  • vomiting

  • abdominal pain

  • polydipsia/polyuria

  • encephalopathy

  • elevated bilirubin >14 µmol/l

  • hypoglycemia <4 mmol/l

  • elevated urea >340 µmol/l

  • leukocytosis >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.

  • 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:

It was first described by Harold Leeming Sheehan (1900-1988) et al. in 1940 6.

Considerations include:

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