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Renal diseases in pregnancy
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Acute fatty liver of pregnancy (AFLP) is not a common complication of pregnancy, but represents an obstetric emergency of the third trimester (70,71). The patients present with abdominal pain, nausea, vomiting, headache, malaise, anorexia, jaundice, and rarely with hepatic encephalopathy. The etiology could be related to a familial genetic defect in fatty acid metabolism (70). Up to 90% of the women with AFLP can develop ARF (70). Disseminated intravascular coagulopathy is usually present. Serum transaminases are generally not as severely elevated as they are in hepatitis. Most patients with renal failure have evidence of decreased renal perfusion similar to hepatorenal syndrome or acute tubular necrosis. Treatment again involves delivery of the baby.
Acute Fatty Liver of Pregnancy
Published in Sanjeewa Padumadasa, Malik Goonewardene, Obstetric Emergencies, 2021
Janaka de Silva, Sanjeewa Padumadasa
Acute fatty liver of pregnancy (AFLP) is a condition that is unique to pregnancy which may result in fulminant hepatic failure and, if untreated, carries a high risk of maternal and perinatal morbidity and mortality. First described by Sheehan in 1940 as ‘acute yellow atrophy of the liver’, it has an incidence of approximately 1 in 10,000–15,000 pregnancies. It typically occurs during the third trimester of pregnancy but may also occur as early as 26 weeks of gestation and as late as the immediate postpartum period. In the past, the maternal and perinatal mortality rates were reported to be over 75%. In recent times, the recognition of milder presentations, early intervention and delivery, and aggressive management of complications have reduced the maternal mortality rate to 10%–15% and perinatal mortality rate to approximately 20%.
Hypertension and pre-eclampsia (PET)
Published in Judy Bothamley, Maureen Boyle, Medical Conditions Affecting Pregnancy and Childbirth, 2020
It would be unusual for a woman with acute AFLP to be cared for by midwives in a maternity unit setting, admission to ICU is usual, and if necessary, transfer to a hospital with a liver unit may occur. However the midwife may be the first professional to see the woman on initial presentation, and her assessments and speedy referral may be critical in reaching a diagnosis as quickly as possible, as delay may lead to poor outcomes for the woman and baby48. Due to the uncertain diagnosis, a full range of vital signs should be undertaken and repeated frequently in order to obtain a trend. Close monitoring of oxygen saturations and respirations may indicate early deterioration of the woman’s condition. As with vital signs, a full range of blood tests is necessary, with particular attention to blood sugar (70% of women have profound hypoglycaemia [9]), liver function tests, renal function tests and clotting factors. A woman presenting with signs of AFLP will usually have a history of vomiting, and will need appropriate IV fluid replacement. However, as she may also have signs of polyuria and/or compromised renal function, close fluid balance is necessary in order to evaluate her condition. An indwelling urinary catheter with urometer for hourly measurement is usual.
Predictors of adverse maternal outcome in jaundiced pregnant women identified as having pregnancy-specific liver disease (P-sLD)
Published in Journal of Obstetrics and Gynaecology, 2022
Thendral Natarajan, Sasirekha Rengaraj, Latha Chaturvedula, Mukta Wyawahare
The clinical spectrum of P-sLD often overlap at initial presentation, and there is a general rule that these conditions resolve following delivery. However, if the disease is severe and associated with complications, there is a surge in maternal mortality and morbidity; this essentially explains the necessity of assessing its severity. Though there are many individual studies on maternal and foetal outcomes on HELLP syndrome, AFLP and PE with liver dysfunction, there are only a few studies on the predictors of survival among women with P-sLD in literature (Meng et al. 2016; Erkılınç and Eyi 2018; Gedik et al. 2017; Suresh et al. 2017). Insight into this condition has helped us to understand the importance of early delivery in the management of P-SLD which means a caesarean section in some situations. Of all the P-sLD the adverse maternal outcome is more in AFLP and HELLP syndrome than in IHCP or HG.
Liver failure in pregnancy: a review of 25 cases
Published in Journal of Obstetrics and Gynaecology, 2021
Mengyao Luo, Lei Gao, Junqi Niu, Chen Chen, He Wang, Ying Chen
Liver failure is a rare but potentially devastating disease with a high rate of short-term morbidity and mortality (Squires et al. 2018). Liver failure is usually characterised by hepatic encephalopathy, elevated aminotransferases and prolonged prothrombin time (PT) (Dayangan Sayan 2018). In pregnant women, the aetiology of liver failure may include acute fatty liver (AFL), haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome, intrahepatic cholestasis of pregnancy (ICP) or infection. However, the most common risk factors for liver failure in pregnant women and preventative measures that may reduce the burden of disease remain to be elucidated. Swansea criteria was published in 2002 and has been widely used to evaluate the diagnosis and severity of acute fatty liver of pregnancy (AFLP) (Al-Lamee et al. 2018), which is different from the Chinese Guidelines for Diagnosis of Liver Failure. In this study, the Chinese Guidelines is introduced as the criteria for inclusion, and the Swansea criteria were retrospectively used to assess the likelihood and risks of liver failure in pregnancy.
Managing ITP and thrombocytopenia in pregnancy
Published in Platelets, 2020
Renee Eslick, Claire McLintock
The most frequent cause of low platelets in pregnancy is gestational thrombocytopenia, a benign condition that typically induces a mild thrombocytopenia in late pregnancy and does not require any specific intervention. Obstetric causes account for approximately 20% of cases [7,8]. Preeclampsia is the most common obstetric cause of thrombocytopenia and is characterized by new onset hypertension above 140/90 after 20 weeks gestation, accompanied by at least one additional feature including proteinuria, renal insufficiency, impaired liver function, thrombocytopenia, pulmonary edema and/or new-onset headache unresponsive to simple analgesia [9,10]. Hemolysis with elevated liver enzymes and low platelets (HELLP) syndrome is a more severe form of preeclampsia, characterized by a rapidly falling platelet count accompanied by microangiopathic hemolysis and raised liver enzymes [11]. Acute fatty liver of pregnancy (AFLP) is an uncommon condition that typically presents in late pregnancy with abdominal pain, malaise, and vomiting [12,13]. Investigations are consistent with hepatic failure with elevated transaminases and bilirubin, coagulopathy and concurrent thrombocytopenia in 50–65% [13,14].