(773) A Rapid Diagnosis of Acute Fatty Liver of Pregnancy

Introduction: Acute fatty liver of pregnancy (AFLP) is a rare but potentially fatal occurrence that is typically seen in the third trimester to early postpartum period. The pathogenesis is unclear but it has been linked to abnormal fetal fatty acid metabolism. Presentation in these patients can be ambiguous and mirror that of pre-eclampsia, but it should not be missed due to possible fatal complications such as disseminated intravascular coagulation (DIC).

Description: The patient is a G1P1 33 year old female with a past medical history of hypothyroidism who was initially admitted to the hospital due to active labor at 38 weeks of pregnancy. She was found to have elevated LFTs 8-9x the upper limit of normal along with abnormal kidney function. Given these findings, she underwent a cesarean section and was subsequently admitted to the ICU. Following delivery, the patient developed altered mental status, worsening transaminitis, uptrending bilirubin, leukocytosis, elevated ammonia, lactic acidosis, downtrending hemoglobin and platelets. The patient was never hypertensive. Imaging at the time also revealed evidence of ascites. These findings were consistent with AFLP and she required close monitoring in the ICU given signs of multisystem-organ dysfunction along with evidence of ongoing hemolysis concerning for DIC. She subsequently received empiric antibiotics, supportive care, and serial labs; ultimately this led to significant clinical and laboratory improvement in the patient.

Discussion: The approach to critical illness in obstetric and postpartum patients can be challenging given the tenuous and dynamic nature of the patients condition. AFLP is a rare and emergent condition in which a high degree of suspicion is necessary for diagnosis. The disease process at hand was unknown at the time of admission to the ICU and the Swansea criteria was a tool utilized to aid in making the diagnosis. This criteria utilizes clinical symptoms and laboratory values and a score of 6+ is supportive for the diagnosis of AFLP. In this case, the patient initially had a Swansea score of 2 and developed a score of 9 following delivery. The patient's clinical picture evolved rapidly following delivery and immediate supportive care in the ICU allowed for a favorable outcome.