142 Successful pregnancy following acute fatty liver of pregnancy

Abstract

Introduction Acute fatty liver of pregnancy is defined by the infiltration of microvesicles of fat in hepatocytes and mitochondrial dysfunction, that occurs usually in the third trimester of pregnancy. It is very rare, occurring in 1: 700-1: 20,000 pregnant women, more often in multiple pregnancies. It is described mortality rates greater than 85% if there is no early recognition and prompt interruption of pregnancy. The main differential diagnosis is HELLP syndrome, since there is a large overlap of clinical signs and symptoms of these diseases. Treatment consists in maternal-fetal support until the resolution of pregnancy. Most patients reverse the symptoms and laboratory abnormalities less than one month after delivery. However, there is a risk of recurrence in subsequent pregnancies. Case report A 26 years old patient, Gravida 2 Para 1, with a 33w pregnancy, was hospital admitted due to fever, myalgia, vomiting and severe prostration for the last week. Physical examination revealed jaundice, dehydration, lower limbs edema, fever and tachycardia. Initial lab tests revealed mild leukocytosis, slightly elevated inflammatory markers, impaired renal function, increased bilirubin levels – due to direct bilirubin, substantially elevated aminotransferases, low albumin and enlarged IRN – context that supported the hypothesis of hepatic failure in pregnancy – acute fatty liver of pregnancy. Patient presented clinical worsening of liver and renal function + coagulopathy, and after maternal compensation opted for delivery – C/S. Intensive care and transfusional therapy were necessary to reverse the maternal morbidity context. Progressive improvement in the postpartum period was noted, and the patient was home discharged on day 17th, referred to family planning program – which she did not attend. Six months later, patient appears “de novo” to prenatal care, Gravida 3 Para 2, with a 18w pregnancy, raising the discussion on maternal risk. Possibility of termination of pregnancy was considered, but remained the choice for close follow up with strict control and maintenance of pregnancy. At 38 weeks, an elective C/S delivery was scheduled due iterativity and gestational thrombocytopenia. A healthy male newborn, 2360g Apgar score 9/10 who was discharged along with the mother on day 3. Discussion Although the outcome of last pregnancy has been favorable, it could have been dramatic. Hepatic disease poses a huge risk, what reinforces the importance of family planning counseling and contraceptive protocols – especially for long-acting reversible contraception – in women with potentially life-threatening conditions in order to reduce maternal mortality and finally achieve the Millennium Development Goal 5.