Pregnant woman with non‐comatose autoimmune acute liver failure in the second trimester rescued using medical therapy: A case report

Abstract

We present the case of a 25-year-old woman at 16 weeks of gestation who presented with non-comatose autoimmune acute liver failure and was at high risk of developing fulminant hepatitis. Predictive formulas indicated a high probability of developing fulminant hepatitis. Unenhanced computed tomography showed marked hepatic atrophy and broadly heterogeneous hypoattenuating areas. The course of her illness was subacute, and the etiology of liver injury was unclear. Considering all of the above, we predicted a poor prognosis. Plasma exchange (PE) and continuous hemodiafiltration (CHDF) therapy were initiated just after admission. A few days after admission, a high titer (×80) of antinuclear antibody was noted. Because autoimmune hepatitis (AIH) was considered a cause of liver failure, treatment with moderate prednisolone (30 mg/day) doses was administrated, with careful consideration of her pregnancy. Thereafter, her laboratory findings and clinical course gradually improved without the need for liver transplantation. A liver biopsy at 18 days after admission indicated a diagnosis of AIH. She continued the pregnancy and delivered a healthy baby without any complications. Eventually, prednisolone doses were decreased to 10 mg, after which her liver function worsened. The second liver biopsy also indicated a diagnosis of AIH. Accordingly, low-dose prednisolone and azathioprine doses (50 mg/day) were administrated to recover her liver function, after which her liver function regained normalcy. This case illustrates that a pregnant woman with non-comatose autoimmune acute liver failure in the first or second trimester of pregnancy and her fetus can be rescued by PE/CHDF therapy and safe moderate doses of prednisolone.

Pregnancy in Liver Transplantation

“…The development of acute liver failure during pregnancy from conditions such as acute fatty liver of pregnancy, hemolysis, elevated liver enzymes and low platelets syndrome, drug overdose, AIH, or acute hepatitis B/E is very rare . In pregnancy‐induced liver failure, delivery is nearly universally recommended to treat the underlying liver condition; however, emergency LT may need to be considered in selected patients …”

“…(94,95) In pregnancy-induced liver failure, delivery is nearly universally recommended to treat the underlying liver condition; however, emergency LT may need to be considered in selected patients. (96) Although most of the literature on this subject is based on case reports, fetal outcomes appear to be poor. Depending on the age of gestation and the viability of the fetus, continuation or termination of the pregnancy must be tactfully discussed with the patient.…”

Problematiche internistiche in corso di gravidanza

“…64 La cardioversione elettrica è considerate sicura per il feto e potrebbe essere necessaria in caso di fibrillazione atriale con instabilità emodinamica. 68 L'anestesia e in particolare quella epidurale, che comportano vasodilatazione, possono peggiorare il gradiente di efflusso ventricolare sinistro e produrre instabilità emodinamica.…”

“…Una AH che insorga durante il periodo di gravidanza di solito ha un decorso fulminante e il feto ha una bassa probabilità di sopravvivenza. 68 La presenza di cirrosi materna impatta negativamente sull'outcome del feto, e il tasso di nati vivi è inferiore rispetto alla popolazione normale. Invece le donne, la cui malattia è in remissione e non hanno cirrosi con ipertensione portale, hanno un'alta probabilità di un esito favorevole della gravidanza.…”

AISF position paper on liver disease and pregnancy

“…The maternal course is highly variable. In case of pregnancy occurring at presentation of AIH with "acute" onset, liver disease may have a fulminant course and the foetus has a low chance of survival [114]. In general, women who reach disease remission and do not have cirrhosis with portal hypertension, have a high chance of a favourable pregnancy outcome [115].…”