What is the diagnosis and management of Acute Fatty Liver of Pregnancy (AFLP)?

From the Guidelines

Acute Fatty Liver of Pregnancy (AFLP) is a medical and obstetric emergency that requires prompt diagnosis and management, with early recognition and rapid delivery being critical to improve outcomes.

Diagnosis

The diagnosis of AFLP can be made using the Swansea criteria, which includes six or more of the following findings: vomiting, abdominal pain, polydipsia/polyuria, encephalopathy, elevated transaminases (AST or ALT >42 IU/L), elevated bilirubin (>0.8 mg/dL), hypoglycemia (<72 mg/dL), leukocytosis (>11 × 106/L), elevated uric acid (>5.7 mg/dL), elevated ammonia (>42 IU/L), ascites or bright liver on ultrasound, renal impairment (creatinine >1.7 mg/dL), coagulopathy (PT >14 seconds or partial thromboplastin time >34 seconds), or microvesicular steatosis on biopsy 1.

Management

The management of AFLP involves planning for delivery and timely evaluation for possible liver transplantation. Supportive care is the only other treatment required, and liver biopsy is rarely needed unless it will affect management 1. Daily aspirin prophylaxis for patients at risk for pre-eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome is advised beginning at week 12 of gestation 1.

• Key features of AFLP include:
  • Non-specific symptoms such as nausea and vomiting, abdominal pain, anorexia, and fatigue
  • Polyuria and polydipsia
  • Signs of liver decompensation (jaundice, encephalopathy, abdominal distension)
  • Risk factors include extremes of maternal age, low BMI, pregnancy-induced hypertension, multifetal pregnancy, FGR, and male fetus 1
• Liver transplantation evaluation should be considered in patients who progress to acute liver failure, especially those with suspected AFLP who have already given birth but do not improve clinically 1.

Important Considerations

• Early recognition and rapid delivery are critical to improve outcomes in AFLP 1
• Maternal mortality rates have improved to less than 10% in recent years with prompt diagnosis and management 1
• Intrahepatic hemorrhage or hepatic rupture can occur at a rate of less than 2% 1

From the Research

Diagnosis of Acute Fatty Liver of Pregnancy (AFLP)

• The diagnosis of AFLP is based on a combination of clinical presentation, laboratory findings, and imaging studies 2, 3, 4, 5, 6
• Common symptoms of AFLP include nausea, vomiting, epigastric distress, and jaundice in the third trimester of pregnancy 2, 3, 4
• Laboratory findings may include elevated liver enzymes, coagulopathy, and hypoglycemia 2, 3, 4, 5
• Imaging studies such as ultrasound may show enhanced echo or fatty liver 2

Management of Acute Fatty Liver of Pregnancy (AFLP)

• The management of AFLP involves prompt recognition, preparation for delivery, and supportive care such as reversal of coagulopathy 5
• Early termination of pregnancy, usually by cesarean section, is often necessary to improve maternal and fetal outcomes 2, 3, 4, 6
• Supportive care may include large dose infusion of fresh frozen plasma, management of hypoglycemia, and treatment of other complications such as renal failure and disseminated intravascular coagulation 3, 4
• Maternal and fetal outcomes can be improved with early diagnosis and prompt management of AFLP 2, 3, 4, 5, 6

Key Considerations in AFLP Management

• Prompt diagnosis and management are crucial to improve maternal and fetal outcomes 2, 3, 4, 5, 6
• A high index of suspicion is necessary to diagnose AFLP, especially in patients presenting with non-specific symptoms in the third trimester of pregnancy 4
• Multidisciplinary care, including obstetricians, hepatologists, and intensivists, may be necessary to manage complex cases of AFLP 5