Atypical case of Acute Fatty Liver in pregnancy.

V. Kalogianni 1, F. Vlahos 2, I. Giannakikou 3

1St. Georges Hospital NHS Foundation Trust, London, United Kingdom,  2 University of Milano-Bicocca, Medicine, Milan, Italy, 3 Hygeia Hospital, Anesthesiology and Critical Care Medicine, Athens, Greece

Case Report

HPC: Female, 30s, G3P2 37/40 (PMH: Nil, NKDA)

2/7 history of general malaise, abdominal pain, nausea

On admission: proteinuria, hypertension, coagulopathy, AKI

Urgent C/S under GA for presumed preeclampsia

Hospital course: Post-op: not rousable. Remained intubated. ICU admission.

Causes of non-emergence considered (Table 1)

Post-op results: transaminitis, cholestasis, high LDH, worsening kidney function and lactic acidosis (Table 2)

Diagnosis: Acute Fatty Liver of Pregnancy (AFLP) with resulting multi-organ failure

Follow up course: Managed conservatively in the ICU

ICU discharge POD14, hospital discharge POD 18 with recovered organ function

Discussion

AFLP: rare obstetric emergency

- Fatty infiltration of liver parenchyma

- Defects in free fatty acid metabolism

- 3rd trimester

- Clinical overlap with HELLP syndrome and pre-eclampsia

- Rapid deterioration

- High maternal and fetal mortality

Clinical findings: Malaise, nausea, vomiting, polyuria, polydipsia, abdominal pain, jaundice, encephalopathy

Lab findings: - Renal dysfunction - Transaminitis - Coagulopathy

Diagnosis: Gold standard: liver biopsy (rarely performed)

Clinical diagnosis: liver dysfunction after 20 weeks pregnancy with supporting clinical and lab findings

- Swansea Diagnostic criteria (Table 3) - Increased uric acid - Increased bilirubin - Increased lactic acid

Management: Fetal delivery | Supportive care | Liver transplantation

Learning points

-Importance of also considering non-anaesthesia causes of delayed emergence from anesthesia.

-AFLP may be confused with or be concurrent with pre-eclampsia or HELLP syndrome

References

Lim E et al. Liver diseases in pregnancy. Clin Med (Lond). 2021 Sep;21(5):e441-e445. doi: 10.7861/clinmed.2021-0497. PMID: 34507927; PMCID: PMC8439517.

Tan J et al. Swansea criteria score in acute fatty liver of pregnancy. Chin Med J (Engl). 2022 Apr 5;135(7):860-862. doi: 10.1097/CM9.0000000000001821. PMID: 35671185; PMCID: PMC9276417

Cascella M, et al.Delayed Emergence from Anesthesia: What we know and how we act. Local and regional anesthesia 2020,13: 195-206. Doe: 10.2147?LRA.S230728. PMID: 33177867

Dey M, et al. Acute Fatty liver of pregnancy. N Am J Med Sci. 2012 Nov;4(11):611-2. doi: 10.4103/1947-2714.103339. PMID: 23181240; PMCID: PMC3503387.