Acute fatty liver of pregnancy (AFLP) is a condition characterized by microvesicular fatty infiltration of the liver, developing in the latter half of pregnancy. The incidence is approximately 1: 12,000 deliveries. Clinical disease severity varies with some patients having only mild right-upper quadrant discomfort associated with prodromal nausea and vomiting. Others develop fulminant liver failure leading to coma. A depressed level of consciousness may arise from either hypoglycemia or the onset of hepatic encephalopathy. Hypoglycemia is a common feature of AFLP and should alert the clinician to the possible diagnosis. More than 50% of affected patients will have mild hypertension and pro-teinuria, making the distinction from HELLP syndrome difficult. Jaundice is often present at the time of diagnosis. Liver enzymes are increased and transaminases may rise above 1000 IUl"1 in severe cases. Liver failure leads to severe coagulo-pathy and a prolonged partial thromboplastin time and INR. Disseminated intravascular coagulation with microangiopathic hemolytic anemia develop together a mild neutrophil leucocytosis (Rahman andWendon, 2002; Strauss et al., 1999).
Management principles include delivery of the fetus and treatment of the acute liver failure. Coagulopathy may complicate the delivery and must be corrected beforehand. Management of liver failure also includes maintenance of the blood glucose level, the use oflactulose to limit the effects of intestinal bacteria and administration of vitamin K to mother and baby. Intubation and ventilation may be necessary in the comatose mother who cannot protect her airway. Associated complications of renal failure and pancreatitis need to be managed individually.
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