Introduction Acute Fatty Liver of Pregnancy (AFLP) is a life threatening condition occurring in the last trimester of pregnancy, its incidence is up to 1/1000 births1 and is commoner in primiparous women with male or twin pregnancies.2 It has features in common with HELLP syndrome, though coagulopathy, hypoglycaemia and polydipsia are commoner in AFLP and anaemia is not a feature.3 Liver biopsy confirms the diagnosis but a Swansea Score of 6 or above, in absence of another explanation, indicates AFLP.1 We aimed to review our experiences of AFLP to further our recognition and management of the condition.
Methods A retrospective review of 20 patients with suspected AFLP between 1993 and 2011, assessing patient demographics, Swansea score, biopsy results and complications.
Results Median age 26 (range 18–35), gestation age 36 (range 33–40), 3 twin pregnancies and 65% male births. Most were G1P0. Average Swansea score 9 (range 6–13). Commonest presentation was abdominal pain, malaise and vomiting. 60% had polydypsia, 25% had encephalopathy. 100% had raised transaminase, AST 231 u/l (range 84–4019), ALT 274 u/l (range 99–722). 95% had high urate 0.61 mmol/l (range 0.32–0.97), 85% had high bilirubin 62 umol/l (range 13–192) and 85% leucocytosis 19.4×109/l (range 12.8–74.5). 65% had renal impairment, Creatinine 141 umol/l (range 40–305), 55% had coagulopathy, PT 15 s (range 10–57), 40% had hypoglycaemia, glucose 3 mmol/l (range 1–6). 20% patients had high ammonia, average 58 (range 28–67), 65% patients did not have ammonia checked. Ultrasound scan (USS) was performed on 4/20 patients, 2 had steatosis. 50% patients had biopsy, done 2–13 days post partum. All had microvesicular steatosis, 2 cholestasis, 1 centrilobular necrosis and 1 hepatocyte inflammation. All bloods, where available, showed improvement in 7 days and normalised by 3 months. Complications occurred in 3 pregnancies; 2 intrauterine deaths and 1 prolonged ITU stay. No patients had recurrence of AFLP. No maternal deaths occurred.
Conclusion Male babies and twin pregnancies increased risk AFLP. A high index of suspicion is needed in patients with abdominal pain, malaise and high ALT in the last trimester, the Swansea score should be applied to aid diagnosis, higher Swansea scores indicate greater risk. Recent years have shown improved maternal and foetal survival2 but correct identification and early obstetric intervention prevents complications such as liver failure.
Competing interests None declared.
References 1. Ch'ng CL, Morgan M, Hainsworth I, et al. Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut 2002;51:876–80.
2. Knight M, Nelson-Piercy C, Kurinczuk JJ, et al. A prospective national study of acute fatty liver of pregnancy in the UK. Gut 2008;57:951–6.
3. Kingham JG. Liver disease in pregnancy. Clin Med 2006;6:34–40.