A NEAR MISS! ACUTE FATTY LIVER OF PREGNANCY (AFLP)

Isanka S¹, Arulnesan AC¹, Fernando LGN¹, Senthilnathan PG¹

1-De Soysa Hospital for Women.Colombo.Srilanka

 

Introduction

AFLP is a rare and fatal disorder. The reported incidence and stillbirth rates are 1/7000–1/16000 and 9% respectively. Nulliparous, low BMI, and Multifetal pregnancies are identified as risk factors. We report a case of AFLP complicated with intrauterine fetal death (IUD), coagulopathy, post-partum hemorrhage (PPH), Acute Kidney Injury(AKI), Macroangiopathic hemolytic anemia (MAHA), and post-partum psychosis.

 

Case

A 30-year-old primigravida at 35 weeks of gestation was admitted with malaise, vomiting and jaundice.She didn’t have a fever or skin eruptions.CTG showed features of severe fetal acidosis and fetal heart sounds were absent by the time she transferred to the tertiary care center.Her BMI was 18kg/m² and GCS was 15/15. She was afebrile, icteric, and had a normal BP of 110/70mmHg.The USS confirmed IUD with an EFW of 2.9kg.

ABG showed severe metabolic acidosis with a pH of 7.1. Elevated K⁺ (5.57mmol/l), blood urea 88 mg/dl, and serum creatinine 302 µmol/l revealed an AKI. Urine albumin was negative. Her HGB was 11.8 g/dl, PLT 54000/µl, and WBC was 22000/µl.liver function tests showed ALT 288 U/L, AST 332U/L, ALP 519 U/,Total serum bilirubin of 11.8 mg/dl.Serum uric acid was 15.7mg/dl and LDH was1212U/L.INR 1.6, APPTT 45.9 (control 30.5 Sec), and PT was 16.3( Control 14 sec).She was normoglycemic throughout.

Multidisciplinary team (MDT) involved. Hemodialysis is done due to severe renal impairment. labour induced & the dead fetus was delivered on day 3 which was complicated by PPH.APTT risen to 100 Seconds and INR was 1.8. ROTEM confirmed impaired Intrinsic pathway of clotting. Blood products & Factor Vii concentrate transfusion, uterotonics, and Bukry balloon catheter successfully arrested the bleeding.

Grade 1 hepatic encephalopathy was diagnosed on day 5. Her HGB and PLT were dropping, and the blood picture revealed MAHA. 7 cycles of Plasma exchange were done. She was having disturbed behaviour and labile mood despite improving biochemical parameters. Symptoms improved with antipsychotic medications and post-partum psychosis was diagnosed. The patient was discharged on day 19 with a stable biochemical and mental state.

 

Discussion

AFLP makes a diagnostic dilemma with other liver diseases which can share most of the clinical features. The Swansea criteria guides to diagnose AFLP where this patient had 8 of the features. Despite multiple complications, the quick diagnosis and aggressive treatment saved the life of this young girl.

 

Conclusion

 

AFLP is an obstetric emergency. Diagnosing as early as possible, aggressive management with MDT involvement, expedited delivery, and careful follow-up are the four main rules in management.