816: Hepatic and renal dysfunction with acute fatty liver of pregnancy: expected duration of recovery after delivery

Abstract

pregnancy: expected duration of recovery after delivery David Nelson, Nicole Yost, F. Gary Cunningham The University of Texas Southwestern Medical Center, Obstetrics and Gynecology, Dallas, TX OBJECTIVE: Acute liver and renal dysfunction are particularly problematic in women with acute fatty liver of pregnancy (AFLP). While recovery for both begins following delivery, the time required for either is not well characterized. Our aim was to assess and provide estimates of the duration required for resolution of hepatic and renal dysfunction in AFLP. STUDY DESIGN: Clinical and laboratory findings were reviewed for women with AFLP admitted to our obstetrics service from 1980 through 2010. The diagnosis was made when severe hepatocellular dysfunction was accompanied by characteristic clinical findings and evidence for renal, hemostatic, and/or hematological aberrations; imaging studies; and/or liver histopathology. Along with clinical resolution, we analyzed a number of serially determined laboratory findings beginning after delivery and then for varying intervals up to several weeks postpartum. RESULTS: A total of 50 women with AFLP were identified during the 30-year period. They had multi-organ system dysfunction of varying severity, and although there was only one maternal death, these women had numerous medical, surgical, and obstetrical complications as well as perinatal deaths. Management included supportive care and delivery. For this study, mean levels were calculated for four serum analytes determined serially and shown in the Figure. CONCLUSION: The degree of hepatic and renal insufficiency is quite variable in severity and concordance in women with AFLP. Ongoing hepatocellular damage appears to decrease soon following delivery as reflected by rapidly declining serum aspartate aminotransferase (AST) levels. Despite this, hepatic dysfunction reverses more slowly as indicated by the prolonged recovery of cholesterol production and bilirubin clearance. Similar trends were documented for plasma fibrinogen concentrations and prothrombin generation (data not shown). Our findings indicate that renal dysfunction is caused by prerenal factors and serum creatinine concentrations decrease in a linear fashion after delivery, and in most women these will be 1 mg/dL within a week. 817 Acute fatty liver of pregnancy: characterization of associated coagulopathies and duration of their persistence after delivery David Nelson, Nicole Yost, F. Gary Cunningham The University of Texas Southwestern Medical Center, Obstetrics and Gynecology, Dallas, TX OBJECTIVE: Acute fatty liver of pregnancy (AFLP) is frequently complicated by clinically significant coagulopathy. Delivery usually arrests hepatocellular damage with subsequent production of procoagulants. At delivery, especially cesarean, blood and coagulant replacement therapy is commonly required. Although coagulation persists after delivery, its duration has not been well characterized. Our purpose was to determine the severity, causes, and duration of hemostatic dysfunction. STUDY DESIGN: Clinical and laboratory findings were reviewed for women identified to have AFLP admitted from 1980 through 2010. The diagnosis was arrived at by confirmation of severe hepatocellular dysfunction accompanied by characteristic clinical findings; laboratory evidence for renal, hemostatic, and/or hematological aberrations; imaging studies; and/or liver biopsy. Selected indicators of hemostasis were analyzed to accomplish our goals. RESULTS: A total of 50 women had AFLP with multi-organ system dysfunction of varying degrees. Although there was only one maternal death, these women had numerous medical, surgical, and perinatal complications. Treatment included supportive care and effecting delivery. Pertinent to this study, four indicators of coagulation were determined at various intervals after delivery and plotted as a function of days postpartum (Figure). CONCLUSION: Although variable in severity, coagulopathy of AFLP results from increased consumption and decreased hepatic production of procoagulants. Both the intrinsic and extrinsic pathways are affected as evidenced by frequent prolongation of the PTT and/or the INR. Hypofibrinogenemia is common and often severe, and it usually is accompanied by abnormally increased serum levels of fibrin split products or D-dimers (data not shown). Thrombocytopenia is almost universal and in about 1/5 of women platelets decreased to less than 50,000 (10^9/L). After delivery, and related to their severity, some of these derangements persist for up to a week as hepatocellular repair progresses. Poster Session V Academic Issues, Antepartum Fetal Assessment, Genetics, Hypertension, Medical-Surgical-Disease www.AJOG.org