Acute Liver Failure (ALF) in Pregnancy: How Much Is Pregnancy Related?

Abstract

BaCKgRoUND aND aIMS: Acute liver failure (ALF), characterized by sudden onset of coagulopathy (international normalized ratio [INR] ≥ 1.5) and encephalopathy, may occur during pregnancy either as a pregnancy-associated etiology or an unrelated and coincidental liver injury. The U.S. Acute Liver Failure Study Group, comprised of 33 tertiary care liver centers, has enrolled consecutive patients with ALF or acute liver injury (ALI; INR ≥ 2.0 with no encephalopathy), over two decades. appRoaCH aND ReSUltS: Etiologies, clinical features, and outcomes of 70 of 3,155 patients (2.2%) who developed ALF or ALI during pregnancy were reviewed to determine how many were pregnancy associated (pregnancy-associated liver disease; PAALD) and how many were attributed to other etiologies. Thirty-five of the 70 were considered PAALD, of whom nearly half were attributed to hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and half to acute fatty liver of pregnancy (AFLP), although, in some instances, the distinction was unclear. Virtually all with PAALD had been delivered before hepatology referral, mostly by cesarean section. Acetaminophen toxicity accounted for 21 (60% of the remaining cases), with the remainder resulting from a variety of other causes, but not including viral hepatitis A through E. Although recovery with delivery or supportive measures was possible in most cases, 11 of 70 (16%) required liver transplantation and 8 (11%) died. Swansea criteria to diagnose AFLP were met by all patients with PAALD and also by virtually all women with other forms of ALF. CoNClUSIoNS: Only half of those with ALF during pregnancy appeared to have HELLP or AFLP. Morbidity and mortality for mother and fetus are strongly associated with etiology of liver failure. (Hepatology 2020;72:1366-1377). A cute liver failure (ALF) is a rare condition, affecting approximately 2,000-3,000 patients annually in the United States. (1) ALF occurring in pregnancy is associated with significant maternal and fetal morbidity and mortality. (2,3) Certain liver conditions that lead to ALF, such as hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and acute fatty liver of pregnancy (AFLP), are limited solely to pregnant women, occur during the third trimester, and can be classified as pregnancy-associated acute liver diseases (PAALDs). (4-6) In the obstetrical literature, diagnostic criteria for AFLP, known as the Swansea criteria, have been proposed as a means to distinguish AFLP from other causes of liver dysfunction, including HELLP, but these have not been extensively validated. (7,8) Not all ALF that occurs during pregnancy is directly related to the pregnancy itself. For example, certain viruses occur relatively frequently in the reproductive years; likewise, pregnant women may be more susceptible to

Self-Medication Among Pregnant Women: Prevalence and Associated Factors

“…( Yusuff and Omarusehe, 2011 ; Odalovic et al, 2012 ; Cabut et al, 2017 ; Jambo et al, 2018 ; Zewdie et al, 2018 ). Beyond the possible association between prenatal exposure to acetaminophen and behavior problems in childhood ( Liew et al, 2014 ; Liew et al, 2016 ; Stergiakouli et al, 2016 ; Bauer et al, 2018 ), acetaminophen can cause acute liver failure in mothers ( Casey et al, 2020 ), leading to serious health problems, such as organ transplantation ( Gill et al, 2002 ; Thornton and Minns, 2012 ), representing another risk to the fetus.…”

Letter to the Editor: Response to Casey et al., Acute Liver Failure in Pregnancy: How Much Is Pregnancy‐Related?

“…As illustrated by Casey et al and others, PAALD may progress despite delivery. This is highlighted by the >30% and >20% mortality seen by Casey et al ( 1 ) and others, ( 5 ) respectively. The unacceptably high mortality further underscores the need to have easily available objective prognostic indices such as MELD that can be accepted and compared worldwide.…”

“…I read with great interest the article by Casey et al ( 1 ) An important contribution of the study is their result showing failure of the Swansea criteria to differentiate between acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes, and low platelets (HELLP) and other causes of acute liver failure (ALF). AFLP is a histological diagnosis, and advanced imaging techniques such as proton density fat fraction (PDFF) estimation by magnetic resonance imaging (MRI) ( 2 ) may be used as surrogate markers in the diagnosis or progression/regression of disease.…”

Delayed Fulminant Hepatic Failure from Dydrogesterone-Related In Vitro Fertilization Therapy Requiring Liver Transplantation During Pregnancy

“…Acute liver failure occurring during the first and second trimesters of pregnancy are associated with poor fetal outcomes, including developmental delays, neurological abnormalities, spontaneous abortions, and neonatal death [ 6 – 16 ]. However, only ~16% of pregnant women with fulminant liver failure will require liver transplantation [ 2 ].…”