Acute Fatty Liver of Pregnancy

1. See Also
   1. Steatohepatitis (Nonalcoholic Fatty Liver)
2. Epidemiology
   1. Incidence: 1 in up to 7,000 pregnancies
3. Pathophysiology
   1. Idiopathic condition
   2. Abnormal hepatic mitochondrial function
   3. Results in buildup of fat droplets in hepatocytes
4. Symptoms: Onset in third trimester
   1. Vomiting (76%)
   2. Upper Abdominal Pain (43%)
   3. Anorexia (21%)
   4. Jaundice (16%)
5. Signs
   1. See Acute Hepatic Failure
6. Labs
   1. Liver Function Tests
      1. Serum Bilirubin increased, but <5 mg/dl
      2. Prothrombin Time (aPT and INR) increased
      3. Serum Transaminases (AST, ALT) <500 IU/L
         1. Contrast with much higher in Viral Hepatitis
   2. Platelet Count decreased mildly: 100,000 to 150,000
      1. Contrast with lower in HELLP Syndrome
   3. Chemistry panel
      1. Serum Creatinine increased
      2. Hypoglycemia
7. Radiology
   1. All imaging tests have high false positive rate
8. Differential Diagnosis
   1. Pregnancy related conditions
      1. Severe Preeclampsia
      2. HELLP Syndrome
   2. Hepatitis Causes
      1. See Acute Liver Failure
      2. Hepatotoxin
      3. Viral Hepatitis
      4. Steatosis
9. Management
   1. Delivery is critical and should be performed ASAP
      1. Delay may result in disease progression
   2. Avoid Hepatotoxins (e.g. certain general anesthetics)
   3. Treat concurrent Disseminated Intravascular Coagulation
      1. Correct coagulopathy with Blood Products
   4. Correct Hypoglycemia
      1. D10W infusion and
      2. Dextrose 50% boluses as needed
10. Course
    1. Fulminant hepatic failure if untreated
    2. Disease usually remits after delivery
11. Prognosis
    1. Maternal mortality: <10% (previously as high as 92%)
    2. Infant mortality: Previously as high as 50%
12. References
    1. Castro (1999) Am J Obstet Gynecol 181:389-95