Management of Acute Fatty Liver of Pregnancy: A Retrospective Study of 12 Cases Compared With Data in the Literature

Introduction

Acute fatty liver of pregnancy (AFLP) is a rare and potentially life-threatening obstetric condition marked by hepatic dysfunction due to fat accumulation in liver cells. It generally arises in the later stages of pregnancy or shortly after delivery. Clinical presentation is often nonspecific, with symptoms such as gastrointestinal discomfort, nausea, and increased thirst or urination. In more severe cases, signs of liver failure may develop, including jaundice, altered mental status, and coagulation abnormalities. Laboratory tests typically reveal elevated liver enzymes, impaired coagulation, and abnormalities in blood counts. The condition poses significant risks for both mother and fetus, and timely diagnosis and appropriate multidisciplinary management are essential for favorable outcomes.

Methods

The objective of our study was to analyze the management of this pathology in our intensive care unit and compare it with the literature. This is a retrospective, descriptive, and analytical study conducted in the intensive care unit of Souissi Maternity Hospital, including 12 cases admitted from January 1, 2023, to December 31, 2024. We used a data extraction sheet covering demographic, diagnostic criteria, complications, and maternal and obstetric management, to analyze the data collected from medical records of pregnant women.

Results

Our retrospective study of 12 AFLP cases revealed a mean patient age of 29.8 ± 5.24 years and an average gestational age of 34.8 weeks. Gravidity and parity medians were 2 and 2.5, respectively. Gestational hypertension was present in five of the patients (41.7%), with some complicated by preeclampsia or eclampsia. All 12 patients met the Swansea diagnostic criteria (more than six criteria for each patient), with jaundice in 11 patients (91.7%), nausea/vomiting in nine of them (75%), and epigastric pain in seven parturients (58.3%) being the most common clinical presentations. Laboratory findings showed elevated transaminases in 10 patients (83% >3x normal, mean aspartate aminotransferase (AST) of 683.36 IU/L, mean alanine aminotransferase (ALT) of 428 IU/L), and total bilirubin was elevated >14 µmol/L in all patients, mean 169 µmol/L). Coagulopathy was common, with eight patients (66%) having a prothrombin time (PT) < 70%. Maternal complications were frequent in 11 patients (95%), including renal failure in eight of them (72%), hemorrhagic complications in five patients (45%), often necessitating blood transfusions, altered consciousness, and sepsis. Fetal complications included four intrauterine fetal death (33%) and three acute fetal distress (25%). Management was multidisciplinary, focusing on prompt uterine evacuation, hemostasis correction, and management of renal, infectious, neurological, and respiratory complications. No patients in our cohort received plasmapheresis due to equipment unavailability.

Conclusion

Both the existing literature and our service’s protocol prioritize immediate fetal delivery as the definitive intervention to halt disease progression. While the literature explores adjunctive therapies such as N-acetylcysteine (NAC) and plasmapheresis, the core focus remains on meticulous supportive care to address the numerous complications arising from liver failure.