Abstract

Acute fatty liver of pregnancy (AFLP) is a life-threatening disorder characterized by maternal liver failure, and it occurs in the third trimester of pregnancy or postpartum period. The resultant effects include coagulopathy, electrolyte abnormalities, and the multiple organ dysfunction syndrome (MODS), which may require liver transplantation. Therefore, pregnant women having MODS should be managed in an intensive care unit (ICU) with multidisciplinary inputs to facilitate the appropriate supportive care. We present a successful case report of a pregnant women admitted to the ICU with jaundice and MODS without the need for liver transplantation and organ support therapies. A 20-year-old patient in her first pregnancy at 31 weeks gestation who presented with nausea, vomiting, and jaundice was admitted to our hospital. She was referred from a rural medical center (a center 608 kilometers away) to the ICU due to the possible diagnosis of acute liver failure requiring liver transplantation. Acute physiology and chronic health assessment score was 12, sepsis related organ failure score was 8, and Glasgow coma scale was 15 on ICU admission. AFLP was considered in the patient and an emergency delivery was performed by caesarean section. She recovered with intensive care support after pregnancy delivery without the need for liver transplantation. The patient was discharged from the ICU and hospital after 6 and 10 days, respectively. AFLP should be suspected in the differential diagnosis of a pregnant woman with jaundice and hyperbilirubinemia who is admitted to the ICU in the third trimester of pregnancy or postpartum period. Intensivist should not delay in the diagnosis of AFLP due to its morbid complications and high mortality. Early diagnosis, prompt pregnancy delivery, and intensive care support in the peripartum and postpartum periods may improve maternal and fetal outcomes.

Keywords: Jaundice, acute fatty liver of pregnancy, intensive care unit

References

  1. Sheehan H. The pathology of acute yellow atrophy and delayed chloroform poisoning. J Obstetrical Gyecol 1940;47:49-62.
  2. Liu J, Ghaziani TT, Wolf JL. Acute fatty liver disease of pregnancy: Updates in pathogenesis, diagnosis, and management. Am J Gastroenterol 2017;112:838-46.
  3. Stander H, Cadden B. Acute yellow atrophy of the liver in pregnancy. Am J Obstet Gynecol 1934;28:61-9.
  4. Hammad AI and Porter TF. Acute Fatty Liver of Pregnancy-Chapter 30. In: Phelan JP, Pacheco LD, Foley MR, Saade GR, Dildy GA, Belfort MA, editors. Critical Care Obstetrics. 6th ed. USA, CN: John Wiley and Sons; 2018. p. 471-7.
  5. Kushner T, Tholey D, Kaçma J, Saberi B, Schiano T, Terrault N. Outcomes of liver transplantation for acute fatty liver disease of pregnancy. Am J Transplant. 2019; 19: 2101-7.
  6. Kalpana SV, Veena RS and Geeta PP. Acute fatty liver of pregnancy: A case report of an uncommon disease. Indian J Crit Care Med 2009;13:34-6.
  7. Tran TT, Ahn J, Reau NS. ACG clinical guideline: Liver disease and pregnancy. Am J Gastroenterol 2016;111:176-94.
  8. Zhong Y, Zhu F and Ding Y. Early diagnostic test for acute fatty liver of pregnancy: a retrospective case control study. BMC Pregnancy Childbirth 2020; 20:162-7
  9. English N, Rao J. Acute fatty liver of pregnancy with hypoglycaemia, diabetes insipidus and pancreatitis, preceded by intrahepatic cholestasis of pregnancy. BMJ Case Rep 2015;2015:bcr2015209649. doi: 10.1136/bcr-2015-209649.
  10. Gorginzadeh M, Safari S, Alavian SM. Acute fatty liver of pregnancy: a life-threatening condition requiring a life-saving approach. Hepat Mon 2016; 16:e35256. doi: 10.5812/hepatmon.35256
  11. Westbrook RH, Dusheiko G, Williamson C. Pregnancy and liver disease. J Hepatol 2016;64:933-45.
  12. Brady CW. Liver disease in pregnancy: What’s new. Hepatol Commun 2020;4:145-56.
  13. Lee NM, Brady CW. Liver disease in pregnancy. World J Gastroenterol 2009;15:897-906.
  14. Watkins L, Soens M. Chapter 37 -Acute fatty liver of pregnancy. In: Van de Velde M, Scholefield H, Plante LA, editors. Maternal Critical Care: A Multidisciplinary Approach. 1st ed. Cambridge University Press; 2013. p. 418-27.
  15. Batinelli EM. TTP and pregnancy. Blood 2014;123:1624-5.
  16. Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol 2004;103:981-91.
  17. Naoum EE, Leffert LR, Chitilian HV, Gray KJ, Bateman BT. Acute fatty liver of pregnancy: Pathophysiology, anesthetic implications, and obstetrical management. Anesthesiology 2019;130:446-61.
  18. Nanchal R, Subramanian R, Karvellas CJ, Hollenberg SM, Peppard WJ, Singbartl K et al. Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU: Cardiovascular, endocrine, hematologic, pulmonary and renal considerations: Executive summary. Crit Care Med 2020;48:415-9.
  19. Yu CB, Chen JJ, Du WB, Chen P, Huang JR, Chen YM, et al. Effects of plasma exchange combined with continuous renal replacement therapy on acute fatty liver of pregnancy. Hepatobiliary Pancreat Dis Int 2014;13:179-83.
  20. Chen G, Huang K, Ji B, Chen C, Liu C, Wang X, et al. Acute fatty liver of pregnancy in a Chinese Tertiary Care Center: a retrospective study. Arch Gynecol Obstet 2019;300:897-901. 
  21. Gao Q, Qu X, Chen X, Zhang J, Liu F, Tian S,et al. Outcomes and risk factors of patients with acute fatty liver of pregnancy: a multicentre retrospective study. Singapore Med J 2018;59:425-430.

Copyright and license

Copyright © 2020 The Author(s). This is an open access article distributed under the Creative Commons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited.

How to cite?

1.
Yeşiler Fİ, Şahintürk H, Günakan E, Gedik E, Zeyneloğlu P. A Pregnant Woman with Jaundice in the Intensive Care Unit. Turk J Intensive Care. 2020;18(4):217-224. https://doi.org/10.4274/tybd.galenos.2020.07379