Acute Fatty Liver of Pregnancy

Naoum, Emily E.; Leffert, Lisa; Chitilian, Hovig V.; Gray, Kathryn J.; Bateman, Brian T.

doi:10.1097/aln.0000000000002597

Cited by 52 publications

(15 citation statements)

References 111 publications

(312 reference statements)

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“…During normal pregnancy, the oxidation of both long and medium chain fatty acids decreases physiologically, leading to an increase in maternal fatty acid levels during pregnancy, which makes patients vulnerable to the hepatotoxic effects of fatty acids. [ 9 ] AFLP is characterized by microvesicular fatty infiltration of hepatocytes, caused by genetic defects in enzymes involved in fetal fatty acid mitochondrial metabolism. [ 10 ] Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) is one of the most common involved enzymes.…”

Section: Discussionmentioning

confidence: 99%

“…Early detection coupled with advancements in critical care management have changed acute fatty liver of pregnancy from being a highly fatal complication of pregnancy to a treatable entity. [ 9 ] Two reasonable recommendations are AFLP screening for pregnant women at week 34 [ 21 ] and longitudinal monitoring for children of mothers with LCHAD deficiency . [ 32 ] Joueidia et al studies have shown that in AFLP, prothrombin time must be carefully monitored to anticipate major maternal complications, [ 33 ] although more work is needed to determine which diagnostic parameters are most specific, reliable and prognostic.…”

Section: Discussionmentioning

confidence: 99%

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Acute fatty liver of pregnancy causes severe acute pancreatitis and stillborn fetus

Ye¹,

Mai²,

Pan³

et al. 2021

Medicine

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Rationale: Acute fatty liver of pregnancy (AFLP) is a potentially fatal obstetric emergency characterized by acute hepatic failure secondary to fatty infiltration. The resultant effects include coagulopathy, electrolyte abnormalities, and multisystem organ dysfunction. Pancreatitis typically develops after the onset of renal and hepatic dysfunction. Pancreatitis has been suggested as a poor prognostic indicator because it is associated with more adverse outcomes. Patient concerns: A 29-year-old Chinese woman at 34.7 weeks pregnancy was admitted to hospital due to paroxysmal hypogastric pain and massive colporrhagia for 1 day. Diagnosis: Laboratory tests revealed hepatic and renal impairment, coagulopathy. Thoracoabdominal computed tomography (CT) scanning showed pleural and peritoneal effusion, fatty liver, and pancreatitis. She was diagnosed with AFLP, severe acute pancreatitis (SAP), multiple organ dysfunction syndrome (MODS), and intrauterine fetal death. Interventions: The patient was treated with blood component transfusions, plasma exchange combined with renal replacement therapy, antibiotic de-escalation, gastric and pancreatic secretion inhibitor, and enteral nutrition. Outcomes: After successful management, the patient was discharged without any complications on day 35 of admission. At 10 months follow-up, thoracoabdominal enhanced CT revealed was normal and laboratory tests revealed normal liver and kidney function. Lessons: Once AFLP is highly suspected or confirmed, the pregnancy should be terminated in time and active symptomatic management should be given.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Acute fatty liver of pregnancy causes severe acute pancreatitis and stillborn fetus

Ye¹,

Mai²,

Pan³

et al. 2021

Medicine

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“…This may lead to inadequate triggers for the innate immune response which in turn could lead to enhanced viral replication and severe liver injury. HEV-gt1 (but not HEV-gt3) in pregnant women was shown to evade early antiviral response and cause adverse consequences due to poor IFN response in placental cells [137]. Pregnant women with HEV-ALF have significantly higher levels of pro-inflammatory cytokines (TNF-alpha, IL-6, IFN-gamma, and TGF-beta) and this had a significant positive correlation with viral load, serum bilirubin, and prothrombin time.…”

Section: Immune Response In Hev Infected Pregnant Womenmentioning

confidence: 99%

“…Therapeutic termination of pregnancy and its beneficial effects on the liver disease in the mother needs serious consideration [28,136], as events in the maternal-fetal interface and the fetus are involved are being incriminated in the severity of the maternal disease [124,130]. Therapeutic termination has proved effective in other two clinical syndromes namely HELP syndrome and acute fatty liver of pregnancy, wherein fetal events drive the maternal disease [137,138]. Several investigators do not recommend termination of pregnancy in pregnant women with HEV-ALF [139,140].…”

Section: Managementmentioning

confidence: 99%

Hepatitis E and Pregnancy: An Unholy Alliance

Khuroo¹

2021

Preprint

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The adverse relationship between viral hepatitis and pregnancy in developing countries was seen as a reflection of retrospective biased hospital-based data collection by the West. However, the discovery of HEV from an epidemic of non-A, non-B hepatitis in Kashmir and documenting increased incidence and severity of hepatitis E in pregnancy from a house-to-house survey unmasked the unholy alliance. Among the family of HEV’s, genotype (gt)-1, with a unique ORF4-encoded protein enhancing viral polymerase activity and viral replication, is the sole HEV that shows this adverse relationship. The epidemics caused by HEV-gt1 and not by HEV-gt2 show adverse relationship with pregnancy. The pathogenesis of the unholy alliance is complex and at present not well understood. Possibly multiple factors play a role in causing severe liver disease in the mother including: infection, replication and damage to the maternal-foetal interface by HEV-gt1; vertical transmission of HEV to foetus causing severe foetal/neonatal hepatitis; and combined viral and hormone related immune dysfunction of diverse nature in the mother promoting viral replication. Management is multidisciplinary and needs a close watch for the development and management of ALF. Preliminary data suggest beneficial maternal outcomes by early termination of pregnancy in patients with lower grades of encephalopathy.

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“…Therapeutic termination of pregnancy and its beneficial effects on liver disease in the mother needs serious consideration [ 34 , 195 ], as events in the maternal–fetal interface and the fetus are involved and are incriminated in the severity of the maternal disease [ 151 , 184 ]. Therapeutic termination has proved effective in two other clinical syndromes, namely HELP syndrome and acute fatty liver in pregnancy, wherein fetal events drive the maternal disease [ 196 , 197 ]. Several investigators do not recommend termination of pregnancy in pregnant women with HEV-ALF [ 198 , 199 ].…”

Section: Managementmentioning

confidence: 99%

Hepatitis E and Pregnancy: An Unholy Alliance Unmasked from Kashmir, India

Khuroo

2021

Viruses

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The adverse relationship between viral hepatitis and pregnancy in developing countries had been interpreted as a reflection of retrospectively biased hospital-based data collection by the West. However, the discovery of hepatitis E virus (HEV) as the etiological agent of an epidemic of non-A, non-B hepatitis in Kashmir, and the documenting of the increased incidence and severity of hepatitis E in pregnancy via a house-to-house survey, unmasked this unholy alliance. In the Hepeviridae family, HEV-genotype (gt)1 from genus Orthohepevirus A has a unique open reading frame (ORF)4-encoded protein which enhances viral polymerase activity and viral replication. The epidemics caused by HEV-gt1, but not any other Orthohepevirus A genotype, show an adverse relationship with pregnancy in humans. The pathogenesis of the association is complex and at present not well understood. Possibly multiple factors play a role in causing severe liver disease in the pregnant women including infection and damage to the maternal-fetal interface by HEV-gt1; vertical transmission of HEV to fetus causing severe fetal/neonatal hepatitis; and combined viral and hormone related immune dysfunction of diverse nature in the pregnant women, promoting viral replication. Management is multidisciplinary and needs a close watch for the development and management of acute liver failure. (ALF). Preliminary data suggest beneficial maternal outcomes by early termination of pregnancy in patients with lower grades of encephalopathy.

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Acute Fatty Liver of Pregnancy

Abstract: A narrative review of the pathophysiology, diagnosis, management, delivery implications, obstetric anesthesia care, and potential critical care needs in patients presenting with acute fatty liver of pregnancy.

Cited by 52 publications

References 111 publications

Acute fatty liver of pregnancy causes severe acute pancreatitis and stillborn fetus

Acute fatty liver of pregnancy causes severe acute pancreatitis and stillborn fetus

Hepatitis E and Pregnancy: An Unholy Alliance

Hepatitis E and Pregnancy: An Unholy Alliance Unmasked from Kashmir, India

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