Case report
Acute fatty liver of pregnancy; three cases and discussion of analgesia and anaesthesia

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Summary

Acute fatty liver of pregnancy is a rare, potentially fatal, complication of late pregnancy. The incidence is estimated at 1:7000-1:15 000 pregnancies. Presentation is classically with malaise, nausea and vomiting, abdominal pain and rarely encephalopathy. Prolongation of laboratory clotting tests is an early feature. Ultrasound examination of the liver is performed to exclude biliary stasis. Rapid clinical deterioration may occur and urgent delivery should be organised. Anaesthetists form part of a multidisciplinary approach before, during and after delivery but there are few reports of anaesthetic involvement. One dilemma facing an anaesthetist called to assist in these cases is the potentially negative effect of general anaesthesia on hepatic encephalopathy versus the risks associated with regional anaesthesia in the presence of coagulopathy. Postoperative analgesia may also be complicated by impaired renal and hepatic function. We present three cases that occurred in our unit in a 6-month period illustrating the spectrum of disease severity and the successful use of different anaesthetic techniques to facilitate management including delivery.

Introduction

Acute fatty liver of pregnancy is a rare, potentially fatal, complication of late pregnancy. Co-pathologies include intrauterine death, coagulopathy and preeclampsia. Anaesthetists are part of a multidisciplinary team involved in the management of these conditions before and after delivery. We present three cases that occurred in our unit in a 6-month period illustrating the spectrum of disease severity and the successful use of different anaesthetic techniques to facilitate management including delivery.

Section snippets

Case 1

A 29-year-old Caucasian woman (G3, P0) with a twin pregnancy was admitted at 34 weeks’ gestation with a three-day history of nausea, vomiting and mild abdominal pain. The blood pressure was not elevated and urinanalysis revealed a trace of protein only. Apart from tachycardia and mild uterine tenderness, examination was unremarkable; in particular there was no jaundice or other signs of liver dysfunction. Intravenous fluids and cyclizine were prescribed for vomiting and then corticosteroids and

Case 2

A 29-year-old Asian woman (G1, P0) was admitted at 35 weeks’ gestation with a five-day history of upper abdominal pain and vomiting. She also complained of pruritus of both arms. She was apyrexial, normotensive with a heart rate 80 beats/min, and tender in the epigastrium and right upper quadrant. Blood test results showed a white count of 16.7 × 109/L, platelets 86 × 109/L, creatinine 209 μmol/L, bilirubin 98 μmol/L, ALT 90 units/L and urate 0.51 mmol/L. A focussed abdominal ultrasound showed a

Case 3

A 30-year-old woman (G2, P1) was admitted at 33 weeks’ gestation with a two-day history of nausea and vomiting and, on direct questioning, vague abdominal discomfort. Examination was unremarkable and vital signs were normal. Her blood test results including coagulation and platelet count were within the normal range except for a raised bilirubin of 65 μmol/L. AFLP was diagnosed provisionally and urgent caesarean delivery arranged. This was undertaken with a subarachnoid block, using a full

Discussion

Acute fatty liver of pregnancy was first described in 1934 by Stadder and Cadden as “acute yellow atrophy of the liver,”1 a rare and fatal complication of pregnancy. Subsequently the typical histological appearance of microvesicular fatty infiltration of the liver was described and an associated mortality of 70% reported.2 More recent studies have estimated an incidence of 1:10 000-15 000 pregnancies with a mortality of 10-20%.3 Castro et al. performed a retrospective study of 200 000 births in

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