Liver Failure In Pregnancy Research Articles

Early plasma exchange and continuous renal replacement therapy improve puerperal prognosis in hepatitis B virus-related acute-on-chronic liver failure in pregnancy

Background and aimHepatitis B virus (HBV)-related gestational acute-on-chronic liver failure (ACLF) is a severe condition with limited treatment options. This study aimed to evaluate the efficacy and ideal timing of plasma exchange and continuous renal replacement therapy (CRRT) in managing pregnant women with HBV-related ACLF. MethodsThis study retrospectively analyzed 51 eligible patients with HBV-related gestational ACLF between 2009 and 2020. Patients admitted to the study were divided into a conventional treatment group and a new treatment group according to whether they received the new management protocol, which included more aggressive plasma exchange (PE) and CRRT strategies. All 19 pregnant women with hepatic encephalopathy (HE) were divided into an early treatment group and a non-early treatment group according to whether PE therapy was initiated within three days. Our study had two primary objectives. Firstly, we aimed to evaluate the impact of PE and CRRT on puerperal survival. Secondly, we sought to assess the effects of early PE and CRRT regimens on puerperal survival in women with HE. ResultsThe levels of total bilirubin on the second day postpartum (D3), the third day postpartum (D4), and the fifth day postpartum (D6) were significantly lower in the new treatment group compared to the conventional treatment group (P = 0.02, 0.01, and 0.02, respectively). The ALT of D3 was significantly elevated in the new treatment group compared to the conventional treatment group (P = 0.02). The incidence of HE overall increased from prenatal to postpartum D4, peaked on D4, and then gradually decreased from the fourth day postpartum (D5) （P = 0.027）. The first week after delivery revealed a significant difference in survival rate between the two groups, the conventional treatment group had statistically higher mortality rates compared to the new treatment group (P = 0.002). Similarly, the entire puerperal period mortality rate of the conventional treatment group was statistically higher than the new treatment group (P = 0.002). Moreover, among all patients with HE, the non-early treatment group showed significantly higher puerperal mortality rates compared to the early treatment group (P = 0.006). ConclusionsEarly PE and CRRT conducted within three days post-childbirth, enhance puerperal prognosis for HBV-related gestational ACLF.

Acute liver failure in pregnancy.

Liver function abnormalities are noted in a minority of pregnancies with multiple causes for the same. A small proportion of these develop severe liver injury and progress to acute liver failure (ALF). There is a discrete set of etiology for ALF in pregnancy and comprehensive understanding will help in urgent evaluation. Certain diseasessuch as acute fatty liver of pregnancy, hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome and pre-eclampsia are secondary to pregnant state and can present as ALF. Quick and targeted evaluation with urgent institution of etiology-specific management, especially urgent delivery in patients with pregnancy-associated liver diseases, is the key to avoiding maternal deaths. Pregnancy, as also the fetal life, imparts a further layer of complication in assessment, prognosis and management of these sick patients with ALF. Optimal management often requires a multidisciplinary approach in a well-equipped centre. In this review, we discuss evaluation, assessment and management of pregnant patients with ALF, focussing on approach to pregnancy-associated liver diseases.

Swansea criteria evaluation in acute fatty liver of pregnancy, hemolysis elevated liver enzyme and low platelet syndrome, pre-eclampsia, and viral acute liver failure in pregnancy.

SynopsisNot only AFLP but also HELLP and acute liver failure due to viruses in pregnancy meet the Swansea criteria, meriting a reappraisal and a reevaluation of the criteria.

Fulminant hepatic failure in pregnancy: challenges, management strategies, prognosis and outcomes

Fulminant hepatic failure is defined as a sudden, severe impairment of hepatic function leading to an encephalopathy, which occurs within eight weeks of appearance of first symptoms in the absence of pre-existing liver disease. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver function leading to significant morbidity and even mortality. Hepatic dysfunction in pregnancy may be categorized into Pre-eclampsia-associated liver diseases such as pre-eclampsia/eclampsia, the HELLP syndrome and Acute fatty liver of pregnancy (AFLP), and other causes of hepatic dysfunction namely Hyperemesis gravidarum (HG) and Intrahepatic cholestasis of pregnancy (IHCP). For this review, a search was conducted for published articles, case reports and clinical trials in MEDLINE/Pubmed from 1970 to 2020 with the keyword’s fulminant hepatic failure, acute liver failure in pregnancy, pre-eclampsia, HELLP and AFLP. We concluded that fulminant hepatic failure is one of the most dreaded complications in pregnancy in obstetrical units worldwide. Mandatory screening for etiology, early diagnosis and initiation of supportive management as soon as possible are absolutely essential to ensure better maternal and fetal outcomes. Effective communication with the obstetrician regarding timely delivery/termination of pregnancy ensures a favourable prognosis in the majority of cases. Liver transplant is a definitive life-saving option for cases of severe fulminant hepatic failure in pregnancy, and management has to be suited to each patient individually, keeping in mind the well-being of both the mother, and the child.

Letter to the Editor: Response to Casey et al., Acute Liver Failure in Pregnancy: How Much Is Pregnancy‐Related?

I read with great interest the article "Acute Liver Failure (ALF) in Pregnancy: How Much Is Pregnancy-Related?" by Casey et al.1 An important contribution of the study is their result showing failure of the Swansea criteria to differentiate between AFLP and HELLP and other causes of ALF.

Liver failure in pregnancy: a review of 25 cases

We retrospectively reviewed the medical records from 25 pregnant women with liver failure from May 2009 to July 2019. Data describing clinical symptoms and manifestations, routine blood analyses, coagulation, and liver and kidney function were extracted. Swansea criteria were assessed to identify variables with prognostic significance for maternal mortality. The results showed that acute fatty liver was the primary cause of liver failure and 8 (88.89%) patients died within 7 days. Swansea diagnostic criteria for assessing the severity of liver failure were consistent with Chinese guidelines and were more systematic and convenient. The incidence of postpartum haemorrhage was 76%, and the velocity of bleeding was approximately 600 mL per hour. Increased Swansea score, hepatic encephalopathy and decreased PWR were important prognostic indicators for mortality. Recovery during the 7 days postpartum period was an important determinant of maternal outcomes. Impact statement What is already known on this subject? Liver failure in pregnant women is a rare but potentially devastating disease with a high rate of short-term morbidity and mortality. There are limited reports about clinical predictors of maternal–foetal outcomes and the dilemmas faced in the term of delivery. What the results of this study add? The incidence of postpartum haemorrhage was 76% in pregnant women with liver failure, but the velocity of bleeding was approximately 600 mL per hour. Our study revealed the Swansea score and the ratio of hepatic encephalopathy were significantly higher and platelet-to-white blood cell ratio (PWR) was lower in women who died compared to those who survived. During treatment period, 8 (88.89%) patients died within 7 days. What the implications are of these findings for clinical practice and/or further research? Swansea score, hepatic encephalopathy and PWR were important prognostic indicators for mortality in pregnant women with liver failure. Recovery during the 7 days postpartum period was an important determinant of maternal outcomes. Our findings may prompt researchers to conduct a large multicentre study to evaluate the prognostic indicators for mortality in pregnant women with liver failure.

Risk factors assessment in patients with acute fatty liver of pregnancy treated without plasma exchange or renal replacement therapy

Objective Acute fatty liver of pregnancy(AFLP) is a rare but very urgent obstetric disease in clinical. It is a common cause of liver failure in pregnancy and often needs to be admitted to the department of critical care medicine because of the rapid development of acute hepatic dysfunction and severe acute renal dysfunction. The etiology and pathogenesis of this disorder is not very clear although there have been many studies on it before. Meanwhile, the relatively high mortality requires a better recognition in order to better guide clinical decision making. Our previous multicentre retrospective study on AFLP demonstrated that total bilirubin and serum creatinine were independent risk factors for perinatal maternal mortality. And we aim to further assess maternal outcomes and risk factors in AFLP patients treated without plasma exchange or renal replacement therapy based on previous data we collected. Methods Retrospective cohort study of 133 hospitalized patients with AFLP was collected from four Chinese tertiary hospitals during the period between January 2009 and April 2014. One hundred thirty three patients were divided into two subgroups containing patients treated without plasma exchange (PE) or renal replacement therapy (CRT) and patients treated with PE or/and CRT. Logistic regression was used to analyze independent risk factors for maternal mortality of AFLP treated without PE or CRT. Results The maternal mortality rate was 12.0% in subgroup of patients treated without PE or CRT. And in subgroup of patients treated with PE or/and CRT, the maternal mortality rate was 26.8%. Independent risk factors for maternal mortality of AFLP treated without PE or CRT were direct bilirubin (OR = 1.012; 95% CI, 1.002–1.022) and serum creatinine (OR = 1.022; 95% CI, 1.007–1.036). Conclusion Although less liver and kidney damage in AFLP treated without PE or CRT, direct bilirubin and serum creatinine remained to be independent risk factors for maternal mortality. Thus, the level of bilirubin and serum creatinine might not be necessary for AFLP to decide whether to give plasma exchange or dialysis treatment.

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An atypical presentation of acute fatty liver of pregnancy

Acute fatty liver of pregnancy (AFLP) is an uncommon but life-threatening condition unique to pregnancy, affecting ~1 in 10 000 pregnancies, and is the most common cause of liver failure in pregnancy. Here the case is described of a 35-year-old patient who presented at 21 weeks’ gestation complaining of vomiting, epigastric pain and food intolerance. During the course of her hospital stay of 31 days, she developed electrolyte imbalances and derangement in liver functions, with coagulopathy and bicytopenia. While she was being investigated for the cause of the biochemical abnormalities, she developed sepsis and anasarca, with a deterioration of her general condition, and it was decided to eliver the fetus. A diagnosis of AFLP was made on histological evaluation of a liver biopsy performed 3 days prior to delivery.

Acute liver failure due to hepatitis E infection in pregnancy

Objetives: Hepatitis E virus (HEV) infection is usually self-limited, however in pregnancy can present an aggressive and sometimes fatal outcome. Material and methods: A 40 year-old female, from Angola, was admitted to the emergency department due to abdominal pain, nausea and vomiting. The patient was 25 weeks pregnant with an irregular prenatal care and history of hypertension, medicated with alpha-metildopa, fansidar (for malaria), fenobarbital and folic acid since the 1st trimester. Physical examination and serology revealed an acute hepatic failure with prompt emergency caesarean section and hepatic transplant, both without complications. Results and discussion: Gross examination revealed liver with 800g and a smooth, reddish and dull capsule. On cut section the hepatic parenchyma was reddish and soft, with multiple green nodules, with well-defined boundaries, all with less than 1cm. Histological evaluation showed massive hepatic necrosis mainly in acinar zones 2 and 3 without microvesicular steatosis; rare microvacuolar was observed (red oil). There was mild to moderate inflammatory infiltrate composed predominately by T-lymphocytes (CD3+) with a normal CD8+/CD4+ ratio. Gallbladder was normal. Serology showed HEV positivity. There was no vertical transmission to the newborn. Despite its rarity, HEV should be part of the differential diagnosis in acute liver failure in pregnancy, especially in patients with travel history to endemic countries.

Acute Liver Failure In Pregnancy

Acute Liver Failure In Pregnancy

Acute liver failure in pregnancy: causative and prognostic factors.

Background/Aims:Acute liver failure (ALF) in pregnancy is often associated with a poor prognosis. In this single-center observational study we aim to study the incidence, causes, and factors affecting mortality in pregnant women with ALF.Patients and Methods:Sixty-eight pregnant women reporting with clinical features of liver dysfunction were enrolled as cases. Their clinical course was followed and laboratory studies were performed. The presence of ALF was defined as the appearance of encephalopathy. The results were compared with a control group of 16 nonpregnant women presenting with similar complaints. The cases were further subdivided into two groups of survivors and nonsurvivors and were compared to find out the factors that contribute to mortality.Results:ALF was seen in significantly more number of pregnant women than the controls (P = 0.0019). The mortality rate was also significantly higher (P = 0.0287). Hepatitis E virus (HEV) caused jaundice in a higher number of pregnant women (P < 0.001). It also caused ALF in majority (70.3%) of pregnant women, but HEV infection was comparable between the survivors and nonsurvivors (P = 0.0668), hence could not be correlated with mortality.Conclusions:Pregnant women appear to be more susceptible for HEV infection and development of ALF. The mortality of jaundiced pregnant women increased significantly with appearance of ALF, higher bilirubin, lower platelet count, higher international normalized ratio, and spontaneous delivery.

Acute liver failure in pregnancy: Challenges and management.

Acute liver failure (ALF) in pregnancy negatively affects both maternal and foetal outcome. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver functions leading to significant morbidity and even mortality. In this comprehensive review, we searched articles published as review articles, clinical trials, and case series in the Medline from 1970 to 2012. The overall outcome of ALF in pregnancy depends on the aetiology, timely diagnosis, prompt management, and early referral to a centre equipped in managing medical or obstetric complication. The foetal outcome is affected by the stage of pregnancy in which the mother has a deterioration of the liver function, with a worst prognosis associated with first or second-trimester liver failure. When ALF complicates pregnancy, liver transplantation is the one of the viable options. Management protocols need to be individualised for each case keeping in mind the risk versus benefit to both the mother and the foetus.

An interesting presentation of acute liver failure in pregnancy - a case report

Acute liver failure in pregnancy is associated with significant morbidity and mortality. Often it can be challenging to diagnose and manage. This can be as a result of overlapping symptoms...

Acute Liver Failure in Pregnancy Due to Hepatitis B Flare after Withdrawal of Antiviral Therapy

Acute Liver Failure in Pregnancy Due to Hepatitis B Flare after Withdrawal of Antiviral Therapy

Hepatitis E-associated acute liver failure in pregnancy: An Indian puzzle

Hepatitis E-associated acute liver failure in pregnancy: An Indian puzzle

Acute liver failure in pregnancy associated with maternal MCAD deficiency

In recent years the association between severe pregnancy complications and fetal fatty acid oxidation (FAO) disorders has been reported. However, there are few descriptions of a maternal FAO disorder leading to these complications. We describe acute liver failure associated with an undiagnosed maternal medium-chain acyl-CoA dehydrogenase (MCAD) deficiency. The previously healthy proband presented at the 39th week with an itchy rash, palmar erythema and trace proteinuria; she was admitted onto a maternity ward. Acute fatty liver was suspected from the blood tests and a Caesarean section was performed, delivering a healthy boy. Cord blood samples were taken at delivery as part of an ongoing research project. The analysis of the cord blood sample showed a high concentration of octanoylcarnitine of 2.3 micromol/L (reference <0.1), suggesting a possible fatty acid oxidation disorder. However, subsequent acylcarnitine analyses of the baby's blood showed a normal pattern. The proband was further evaluated by urine organic acids and acylcarnitine profile. Elevated concentrations of hexanoylglycine in urine and octanoylcarnitine in blood spots were found, consistent with a diagnosis of MCAD deficiency. Mutation analyses confirmed that she was homozygous for c.985A>G (K329E). Even though these pregnancy complications are rare and it is not possible to affirm that the proband's acute liver failure was secondary to an undiagnosed MCAD deficiency, it seems likely.

Obstetric Acute Yellow Atrophy

Acute liver failure in pregnancy is rare. Mother and foetus usually die whether liver failure is due to acute viral hepatitis, hepa‐totoxic agents, eclampsia, or whether it is due to “obstetric acute yellow atrophy” in which there is no necrosis but a gross fatty change in the liver. Moore (1956) suggested the term “acute fatty liver of pregnancy” for this unusual appearance. It was, however, Sheehan in 1940 who first recognized “obstetric acute yellow atrophy” as a distinct clinical entity and since then just over 40 cases have been reported.SUMMARYThe case history of a patient who died from obstetric acute yellow atrophy is presented and discussed.

ACUTE LIVER FAILURE IN PREGNANCY; CASE REPORT WITH SURVIVAL OF MOTHER AND CHILD.

ACUTE LIVER FAILURE IN PREGNANCY; CASE REPORT WITH SURVIVAL OF MOTHER AND CHILD.