Second‐trimester acute fatty liver disease of pregnancy: A brief review of the literature and a case report

Abstract

Acute fatty liver disease of pregnancy (AFLP) is a rare life‐threatening medical emergency unique to pregnancy. It is characterized by progressive microvesicular fatty infiltration of maternal hepatocytes, but the exact etiology has yet to be elucidated. AFLP typically manifests in late third trimester or immediately postpartum and seldom during second trimester. Prompt delivery, irrespective of gestational age or severity, is crucial for arresting the insult and permitting recovery. We hereby report a 21‐year‐old Lebanese second‐gravid woman at 20 weeks' gestation diagnosed with AFLP depending on clinical features and compatible laboratory studies (score of 8 on Swansea criteria), in spite of early occurrence. A review and analysis of early AFLP (second trimester) compared to late (third trimester) was also presented. AFLP appearing during second trimester is as serious as the disease manifesting in late third trimester, with similar diagnostic difficulties, less association with hypertension, but with greater hesitation of obstetricians to affect prompt delivery and higher adverse perinatal outcome due to added effect of premature delivery in second trimester.

Soluble fms‐like tyrosine kinase 1 (sFlt‐1): A novel biochemical marker for acute fatty liver of pregnancy

“…To date, applying the Swansea criteria reflects the best diagnostic strategy to identify AFLP. However, applying these criteria may delay the diagnosis of AFLP because they seem to be most efficient when the disease is already in an advanced state and life‐threatening complications are occurring 25 . Our data demonstrate that an s‐Flt1 value >31 100 pg/mL may be an additional parameter, if not even a key criterion, besides the Swansea criteria, to focus our attention on the differential diagnosis of AFLP.…”

“…However, applying these criteria may delay the diagnosis of AFLP because they seem to be most efficient when the disease is already in an advanced state and life-threatening complications are occurring. 25 Our data demonstrate that an s-Flt1 value >31 100 pg/ mL may be an additional parameter, if not even a key criterion, besides the Swansea criteria, to focus our attention on the differential diagnosis of AFLP. We postulate that sFlt-1 levels may herald AFLP before the presence of the Swansea criteria and before the patient is already severely ill.…”

“…We used the Swansea criteria as a diagnostic tool for AFLP. Patients were considered positive if at least six criteria were present 5,25 . To correct for gestational‐age‐dependent angiogenic profile patterns, the time‐points of blood draw were matched (±1 week) and each AFLP case was matched with two patients with HELLP syndrome with and without preeclampsia.…”

Two Fatty Liver Conditions Masquerading as Autoimmune Hepatitis

“…A separate cohort analysis found that 19% of AFLP cases had mutations in the MTP α-subunit responsible for LCHAD deficiency [13]. Most cases of AFLP occur in the third trimester or early postpartum period, but there are case reports as early as the second trimester with the earliest reported case at 18 weeks of gestation [1][2][3][4][5][6]. Clinically, AFLP leads to liver failure but is also associated with renal failure, coagulopathy, hypoglycemia, encephalopathy, and multisystem organ failure [17][18][19]-all of which occurred in the presented case.…”

“…e pathophysiology remains unclear, but research has implicated defective mitochondrial fatty acid oxidation as a contributing factor. AFLP typically presents in the third trimester or early postpartum period, but rare cases have been described in the second trimester [1][2][3][4][5][6]. Diagnosis is usually based on the Swansea criteria [7] in conjunction with serologic and biochemical testing although liver biopsy can be performed under certain circumstances.…”