Anesthetic management of cesarean delivery in patients with acute fatty liver of pregnancy

Acute fatty liver of pregnancy is a rare, life-threatening disorder that typically presents during the third trimester and is associated with high maternal and perinatal morbidity and mortality. Reports of anesthetic management are scarce; the optimal technique is not established, and management should be individualized. We describe the anesthetic management and outcomes of cesarean delivery in patients with acute fatty liver of pregnancy.

We retrospectively reviewed the medical records of patients with acute fatty liver of pregnancy who underwent cesarean delivery at our hospital between January 2018 and June 2026. Swansea criteria were used to confirm the diagnosis. Data collected included baseline characteristics, clinical and laboratory findings, anesthetic technique, intraoperative management, postoperative course, and maternal and neonatal outcomes.

Twenty patients were identified; five were excluded and 15 patients were included in the analysis. Eleven patients received single-shot spinal anesthesia, one received continuous spinal anesthesia because of concurrent placenta accreta spectrum, and three received general anesthesia because of severe disease, severe thrombocytopenia, or emergency repeat cesarean delivery for twin gestation and advanced labor. One patient in the general anesthesia group died 16 h after delivery. In the single-shot spinal anesthesia group, one patient developed postpartum encephalopathy and transient diabetes insipidus, and another had persistent hyperbilirubinemia. All patients receiving spinal anesthesia had normal sensory and motor recovery.

Single-shot spinal anesthesia was feasible in patients with acute fatty liver of pregnancy, whereas general anesthesia was used in patients with more severe disease or emergency obstetric indications.