Acute Fatty Liver of Pregnancy Complicated by Pancreatitis and Multiorgan Failure

Abstract

Purpose: Introduction: Acute fatty liver is an uncommon but serious complication of pregnancy. It usually occurs in third trimester and was universally fatal until the advent of advanced supportive measures. Case: A 29 year old woman was transferred to our tertiary care center with multiorgan failure. She was found to be have liver failure, renal failure and coagulopathy when she first presented to a city hospital with nausea and vomiting in 32nd week of her first pregnancy. Vaginal ultrasonography revealed an intrauterine dead fetus which was evacuated by cesarean section. Upon arrival to our center, she had developed acute pancreatitis, disseminated intravascular coagulation, intraabdominal bleeding with hemorrhagic shock and hypoglycemia in addition to hepatic and renal failure. She was given aggressive supportive treatment and blood products replacement. Transjugular liver biopsy confirmed the diagnosis of acute fatty liver of pregnancy (AFLP). The patient went on to develop acute respiratory failure and sepsis and ultimately succumbed to multiorgan failure. Discussion: Liver dysfunction in pregnancy can range from benign cholestasis to severe preeclampsia, HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome and AFLP. AFLP usually begins in late third trimester with nausea, vomiting, anorexia and epigastric pain and can progress to jaundice, coagulopathy and hepatic encephalopathy. Key laboratory findings are hyperbilirubinemia with modest elevation in transaminases, leukocytosis, coagulopathy and hypoglycemia. It can be complicated by disseminated intravascular coagulation, sepsis, renal failure and, rarely, pancreatitis. It is challenging to differentiate AFLP from HELLP syndrome due to overlapping features and liver biopsy showing microvesicular steatosis is usually necessary to make the diagnosis of AFLP. Emergent delivery and aggressive supportive care is the key to successful outcomes. Resolution occurs spontaneously after termination of pregnancy. Conclusion: AFLP is a serious condition which usually presents with non specific symptoms. Prompt recognition, termination of pregnancy and advanced supportive care are critical determinants of disease outcome. Prognosis is guarded when it is complicated by multiorgan failure.