- Presentation of two cases of acute liver failure of pregnancy - Causes of acute liver failure of pregnancy - Characteristics of each cause of acute liver failure of pregnancy - Management of acute liver failure of pregnancy - Summary of the general management of acute liver failure of pregnancy

1. Kingdom of Saudi Arabia
Ministry of Health
Directorate of Health
Affairs in Gurayat
Gurayat General Hospital
Acute Liver Failure in Pregnancy
Dr.Hisham Abid Aldabbagh
MSc. Internal Medicine

2. 07/05/1437DOACase I
No past liver or kidney diseaseGA 24th wG2,P027 yrM.M.SH
↓Alb
16
↓PLT
100.
↓HGB
8.2
WBC
11.8
↑PT>20
↑PTT >45
↑INR >2
↑ALT
↑AST
>250
↑DB
↑TB
>40
Was in
Tabarjal
hospital
Jaundice
legs
edema
07/05/37
2days ago
Vaginal
tear
OR↑Vaginal
Bleeding
Delivered
normally
Vaginal
bleedinghours
Vitally
stable
↓Alb
15
↓PLT
63.
↓HGB
7.8
↑
WBC
18.5
↑PT24
↑PTT 60
↑INR>5
↑↑ALT
↑↑AST
>1000
↑↑DB
↑↑TB
>100
↓BP
Drowsy
Rapid
deterioration
Insertion of 3 Foley catheters as
intrauterine balloon
Platelet
transfusion
FFP
infusion
Blood
transfusion
MethergSyntoIV fluid
perfusion
ICU, Intensive managementIntubated, Mechanical ventilationMore Deterioration
Dx: Acute fulminant liver failure
of pregnancy
ExpiredCPR , failedCollapsedWorse08/05/37

3. 09/05/37DOACase II
No past liver or
kidney disease
Gall
stones
GDMGA
35th w
G3
P1+
1
28
yr
H.A.A
Hep.
A,B,
C (-)
PLT
382
WBC
12.2
HGB
8.4
↑DB
40
↑TB
48
↑AST
640
↑ALT
242
Vital
signs:
WNL
09/05/37
Dizziness,Vomiting,
Lt.leg pain, swelling
INR
2.4
PTT
54.4
PT
29.5
↓Alb.
23.1
↑DB
111
↑TB
132
↑AST
976
↑ALT
1093
10/05/37
+abd.pain, agitation
INR
3
PTT
68.7
PT
38.3
↓Alb.
21
↑DB
133
TB
153
↑AST
1640
↑ALT
787
Post operative
Shifted to ICU
CS
done

4. INR
3.3
PTT
67.9
PT
42.2
↓Alb
24
↑DB
150
↑TB
200
↑AST
824
↑ALT
513
drowsiness11/05/37
NH3
91.7
PLT
283
WBC
22.1
HGB 8
Multiple consultations with
a higher center
Intubated and put on
mechanical ventilation
Severe drowsiness,
confusion
13/05/37
Conservative treatment(IV fluids, antibiotics, albumin, lactulose)
Conservative treatmentReferred to a higher
center by medivac for
LT
16/05/37
Full recovery
Dx: Acute liver failure with cholestasis of pregnancy
Extubated22/05/37

5. Acute Liver Failure in Pregnancy
Essentials
uncommonIncidence
rapid deterioration of liver functionPresentation
oagulopathy, ↑ INR
encephalopathy
etiology
early diagnosis
prompt management
early referral
Contributors
hypertension
ascites
Predictors

6. CAUSES OF ACUTE LIVER FAILURE IN PREGNANCY
I- Pregnancy associated acute liver disease
- Pre-eclampsia/eclampsia with liver infarction
- Syndrome of hemolysis, elevated liver enzymes, and low
platelets (HELLP syndrome)
- Acute hepatic rupture
- Acute fatty liver of pregnancy (AFLP)
- Intrahepatic Cholestasis of Pregnancy

7. II- Exacerbated by pregnant state
- Viral hepatitis
- Budd-Chiari syndrome (BCS) with portal vein thrombosis
- Gallstone disease
III- Unrelated to pregnant state
- Drug-induced liver disease
- Toxins
- Shock
- Trauma
- Decompensation of pre-existent liver disease

9. PREGNANCY ASSOCIATED ACUTE LIVER DISEASES
EclampsiaPre-eclampsia
+ neurologic symptomsmultisystem disorderCharacteristics
endothelial dysfunction
fibrin deposition
headacheshypertensionFeatures
visual disturbancesrenal failure
seizures or comahepatic dysfunction
nulliparityRisk factors
extremes of maternal age
insulin resistance/obesity
infection

10. HELLP syndrome
micro angiopathic hemolytic
anemia
Characteristics0.5–0.9% of all
pregnancies
Incidence
hepatic dysfunction10–20% with severe
pre-eclampsia
thrombocytopeniaantepartum 69%
right upper quadrant or epigastric
pain
Presentationspostpartum 31%
nausea and vomitingwhiteRisk factors
malaisenulliparous
nonspecific viral-like symptomsolder patients

11. HELLP syndrome
persistent bleedingLT IndicationsthrombocytopeniaLab.
abnormalities
extensive liver necrosis↑AST
liver failure↑LDH
DICComplicationsschistocytesPeripheral blood smear
abruptio placentaeburr cells
acute renal failureechinocytes
pulmonary edemaMortality
intracerebral hemorrhage1%Maternal
liver hematoma, rupture
and ALF
10-60%Infantile

12. LIVER RUPTURE
MortalityDiagnosisPresentationsIncidence
39%CT or MRIhypotensionright upper
quadrant pain
2% of HELLP
ComplicationsManagementhypovolemia3rd trimester
ARDSsurgicalpyrexiashoulder painRisk factors
acute
kidney injury
LT indicationanemiavomitingmultiparity
liver failureleucocytosisabdominal
distension
old age
hypovolemic
shock
liver necrosis↑↑AST
>3000
peritoneal signscocaine
abuse
uncontrollable
bleeding
hepatomegalytrauma

13. ACUTE FATTY LIVER OF PREGNANCY
ComplicationsFindingsPresentationsRisk factorsIncidence
sepsis↑AST > ALTcoagulopathynauseamultiparity5/100,000
renal failure↑ iliru iencephalopathyvomitingold age3rd trimester
circulatory
collapse
↑uri a idhypoglycemiaanorexiaprimiparitypathogenesis
pancreatitis↑WBCnormal
erythrocyte
morphology
lethargypreeclampsiafetal fatty acid
metabolism
GI bleeding↓PLTabdominal
pain
male fetusMortality
Management
↑amonianormal
haptoglobin
levels
underweight18% maternal
delivery+/- DICascitesAFLP history23% fetal
LT↑↑ jau di e

14. INTRAHEPATIC CHOLESTASIS OF PREGNANCY
ComplicationspresentationsRisk factorsIncidence
prematuritygeneralized
pruritus
multiparity1-2/1000
stillbirth↑↑ iliru iold age3rd trimester
Management↑AST,ALTpersonal historyEtiology
delivery↑↑↑ ile a ids
>100 fold
family historygenetic
ursodeoxycholic
acid
liver diseasehormonal (female
sex hormone)
Cholestyraminecholestasis
w/oral
contraceptives
exogenous
progesterone

15. VIRAL HEPATITIS
hepatitis A, B, and C is the same as it is for the general
population
Incidence
hepatitis E is much higher in pregnancy
as in general populationPresentations
no involvement of other organ systems
Complications
high rates of preterm labor and mortalityhepatitis E
stillbirthdead
fetus
abortionpreterm
labor
fetal
malformations
fulminant liver
failure

16. CIRRHOSIS AND PORTAL HYPERTENSION
ComplicationsFindings
variceal bleeding↓al u ispider angiomas
liver failure (24%)↑PTascites
encephalopathy↓PLTpalmar erythema
splenic artery aneurysmDx: Biopsysplenomegaly
malnutrition
as in non pregnant womenManagement

17. BUDD-CHIARI SYNDROME (Hepatic vein obstruction)
DiagnosisPresentationsCauses
doppler USascitesmyeloproliferative disorders
CT abdomenabdominal swelling or
stretching
chronic inflammatory
diseases
venographyRt. upper abdomen painautoimmune disease
TreatmenthematemesisRisk factors
controversialjaundicehypercoagulability
anticoagulationprotein C, protein S,
antithrombin III deficiency
LTpregnancy

18. GALL STONE DISEASE
↑BMIRisk Factors
↑ holesterol se retioPredisposing
factor
leukocytosisfevercholecystitisnauseaRt. upper
quadrant pain
Presentations
vomiting
USDiagnosis
surgicalconservativeTreatment

19. MANAGEMENT OF LIVERV FAILURE IN PREGNACY
Essentials
Combination and coordination
Early diagnosis
Determining the cause of liver failure
Diagnosis and etiology specific treatment

20. Correction of
metabolic
parameters
General management
Prevention/treatment of cerebral edema/intra-cranial
hypertension
HypoglycemiaSurveillance for infections and prompt antimicrobial
treatment
Electrolyte
disturbances
Correction of coagulopathy
Maintenance of optimum hemodynamics
Nutrition
supplementation
Volume replacement
Vasopressor support
Renal perfusion

21. Hints on treatment of ALF
Systolic and diastolic blood pressure of 90 and 65 mmHg, respectively, should
be targeted to maintain cerebral perfusion pressure
Anemia and coagulopathy need to be corrected with appropriate transfusion
of blood products
The recombinant factor VIIa may be used in patients with DIC and bleeding
The optimal treatment for maternal safety is an urgent delivery
Corticosteroids are administered to accelerate fetal lung maturity in
preparation for delivery 48 h later

22. Summary
The availability of expert care in transplant surgery, hepatology, intensive
care medicine, anaesthesiology, interventional radiology and neonatology
must be considered when one is presented with a pregnant patient in ALF
Speedy diagnosis and treatment are crucial for management, with
consultation regarding termination of the pregnancy
LT is increasingly being considered as a treatment option especially in PAALD
When ALF complicates pregnancy, mortality approaches 40%, and LT is the
only viable alternative
Management protocols need to be individualized for each case keeping in
mind the risk versus benefit to both the mother and the fetus

23. Hopefully Message
Dear Colleagues,
I Would Like to Express My Great
Appreciation for Your
Good Coordination in
Prompt Management of
Acute Liver Failure in Pregnancy

24. Thank You
Email: dr.hishamdabbagh@gmail.com