Table of contents
Acute fatty liver of pregnancy
What's new
Updated 2023 EASL guidelines for the management of acute fatty liver of pregnancy.
Background
Overview
Definition
AFLP is a rare, potentially life-threatening liver disorder that affects pregnant women in the third trimester.
1
Pathophysiology
AFLP is associated with defects in fatty acid oxidation secondary to various enzymatic deficiencies, leading to microvesicular fatty infiltration of the liver.
2
Epidemiology
The incidence of AFLP in Canada is estimated at 8 per 100,000 person-years.
3
Disease course
Clinically, AFLP can present with a range of symptoms, including nausea, vomiting, abdominal pain, and jaundice. In severe cases, it can lead to hepatic encephalopathy and multiorgan failure.
2
Prognosis and risk of recurrence
The prognosis largely depends on early diagnosis and prompt delivery. Prompt delivery is recommended, especially in cases of elevated lactate levels and hepatic encephalopathy.
4
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of acute fatty liver of pregnancy are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL 2023), the American Association for the Study of Liver Diseases (AASLD 2021), the Chinese Society of Obstetrics Gynecology (CSOG 2021), the American College of Gastroenterology...
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Screening and diagnosis
Indications for screening
As per CSOG 2021 guidelines:
Obtain prenatal screening for AFLP in outpatients at 35-37 weeks of gestation.
B
Obtain routine blood tests, liver function, and coagulation function as first-line screening indicators. Obtain testing immediately in pregnant patients with gastrointestinal symptoms, such as nausea and vomiting, and suspected AFLP. B
Obtain retesting within 24 hours to identify AFLP as soon as possible in patients with suspected AFLP based on initial screening.
B
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Diagnosis
Classification and risk stratification
Prognosis
As per CSOG 2021 guidelines:
Assess postoperative prothrombin activity, TBIL, platelet count, and serum creatinine as prognostic indicators.
B
Evaluate patients by a multidisciplinary team if the abovementioned indicators continue to be abnormal after delivery or the patient is not recovering by 1 week after delivery.
B
Diagnostic investigations
Abdominal imaging: as per AASLD 2021 guidelines, Obtain abdominal imaging to rule out hepatic hemorrhage, infarction, or rupture in patients with AFLP.
E
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Genetic testing
Medical management
Setting of care: as per EASL 2023 guidelines, Consider managing patients with AFLP developing encephalopathy, elevated serum lactate (> 2.8 mg/dL), a MELD score ≥ 30 or with a score > 7 on the Swansea criteria at level 2 or 3 care (ICU admission).
C
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N-acetylcysteine
Inpatient care
Therapeutic procedures
Liver support system: as per CSOG 2021 guidelines, Offer artificial liver treatment in patients with severe AFLP.
B
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Delivery
Plasmapheresis