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Devarbhavi H, Venkatachala PR, Devamsh GN, Shalimar, Aashik YS, Patil M, Acharya SK. Swansea criteria evaluation in acute fatty liver of pregnancy, hemolysis elevated liver enzyme and low platelet syndrome, pre-eclampsia, and viral acute liver failure in pregnancy. Int J Gynaecol Obstet 2023; 163:1030-1032. [PMID: 37753869 DOI: 10.1002/ijgo.15137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/18/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023]
Abstract
SynopsisNot only AFLP but also HELLP and acute liver failure due to viruses in pregnancy meet the Swansea criteria, meriting a reappraisal and a reevaluation of the criteria.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Preethi R Venkatachala
- Department of Obstetrics and Gynecology, St. John's Medical College Hospital, Bangalore, India
| | - G N Devamsh
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Y S Aashik
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Mallikarjun Patil
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Subrat K Acharya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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2
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Liu R, Yang L, Jiang T, Lu Y, Zhang L, Shen G, Wu S, Chang M, Hao H, Hu L, Gao Y, Xu M, Chen X, Yi W, Li M, Xie Y. Hepatitis B core-related antigen serum levels may be a predictor of acute flare of chronic hepatitis B among pregnant women in the immune-tolerant phase of chronic HBV infection after short-course antiviral therapy. Virulence 2023; 14:2186335. [PMID: 36864005 PMCID: PMC10012896 DOI: 10.1080/21505594.2023.2186335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Studies have shown acute flares of chronic hepatitis B (CHB) might be related to immunologic changes that occur during pregnancy. However, the indicators for predicting acute flares of CHB among pregnant women still need further study. We aimed to distinguish the relevance between serum levels of HBcrAg and acute flares of CHB in pregnant women in the immune-tolerant phase of chronic HBV infection after short-course antiviral therapy. METHODS A total of 172 chronic HBV-infected pregnant women who were judged to be in the immune-tolerant phase were recruited in our research. All patients received short-course antiviral therapy with TDF. The biochemical, serological, and virological parameters were measured using standard laboratory procedures. The serum levels of HBcrAg were tested by ELISA. RESULTS Fifty-two (30.2%) out of 172 patients had acute flares of CHB. At postpartum week 12 (TDF cessation), serum HBcrAg (OR, 4.52; 95% CI, 2.58-7.92) and HBsAg (OR, 2.52; 95% CI, 1.13-5.65) were associated with acute flares of CHB. The serum HBcrAg levels were beneficial for confirmation of patients with acute flares of CHB, with an area under the ROC curve of 0.84 (95% CI, 0.78-0.91). CONCLUSIONS For pregnant women with chronic HBV infection in the immune-tolerant phase, serum HBcrAg and HBsAg levels at postpartum week 12 were associated with acute flares of CHB after short-course antiviral therapy with TDF. The serum HBcrAg level can correctly identify acute flares of CHB and may be a predictor of the need for continuing antiviral therapy after 12 weeks postpartum.
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Affiliation(s)
- Ruyu Liu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Liu Yang
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Tingting Jiang
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yao Lu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Lu Zhang
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ge Shen
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Shuling Wu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Min Chang
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hongxiao Hao
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Leiping Hu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yuanjiao Gao
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Mengjiao Xu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xiaoxue Chen
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Wei Yi
- Department of Obstetrics and gynecology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Minghui Li
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yao Xie
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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3
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Williamson C, Nana M, Poon L, Kupcinskas L, Painter R, Taliani G, Heneghan M, Marschall HU, Beuers U. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. J Hepatol 2023; 79:768-828. [PMID: 37394016 DOI: 10.1016/j.jhep.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 07/04/2023]
Abstract
Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.
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Ristovska EC, Genadieva-Dimitrova M, Todorovska B, Milivojevic V, Rankovic I, Samardziski I, Bojadzioska M. The Role of Endothelial Dysfunction in the Pathogenesis of Pregnancy-Related Pathological Conditions: A Review. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:113-137. [PMID: 37453122 DOI: 10.2478/prilozi-2023-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
In the recent decades, endothelial dysfunction (ED) has been recognized as a significant contributing factor in the pathogenesis of many pathological conditions. In interaction with atherosclerosis, hypercholesterolemia, and hypertension, ED plays a crucial role in the pathogenesis of coronary artery disease, chronic renal disease, and microvascular complications in diabetes mellitus. Although ED plays a significant role in the pathogenesis of several pregnancy-related disorders such as preeclampsia, HELLP syndrome, fetal growth restriction, and gestational diabetes mellitus, the exact pathogenetic mechanisms are still a matter of debate. The increased prevalence of these entities in patients with preexisting vascular diseases highlights the essential pathological role of the preexisting ED in these patients. The abnormal uteroplacental circulation and the release of soluble factors from the ischemic placenta into the maternal bloodstream are the main causes of the maternal ED underlying the characteristic preeclamptic phenotype. Besides the increased risk for maternal and fetal poor outcomes, the preexisting ED also increases the risk of development of future cardiovascular diseases in these patients. This study aimed to look deeper into the role of ED in the pathogenesis of several pregnancy-related hypertensive and liver diseases. Hopefully, it could contribute to improvement of the awareness, knowledge, and management of these conditions and also to the reduction of the adverse outcomes and additional long-term cardiovascular complications.
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Affiliation(s)
- Elena Curakova Ristovska
- 1University Clinic for Gastroenterohepatology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Magdalena Genadieva-Dimitrova
- 1University Clinic for Gastroenterohepatology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Beti Todorovska
- 1University Clinic for Gastroenterohepatology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Vladimir Milivojevic
- 2Section for Internal Medicine, Medcompass Alliance, School of Medicine, Belgrade University, Belgrade, Serbia
| | - Ivan Rankovic
- 3Section for Internal Medicine, Medcompass Alliance, Belgrade, Serbia
| | - Igor Samardziski
- 4University Clinic for Gynecology and Obstetrics, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Maja Bojadzioska
- 5University Clinic for Rheumatology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
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5
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Kumari S, Lamichhane R, Karki P, Adhikari P. Acute fatty liver of pregnancy complicated by coagulopathy: A case report. Clin Case Rep 2023; 11:e7283. [PMID: 37151940 PMCID: PMC10160430 DOI: 10.1002/ccr3.7283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/01/2023] [Accepted: 04/15/2023] [Indexed: 05/09/2023] Open
Abstract
Key Clinical Message We present the case of a rare obstetric emergency, which is usually fatal. Our case highlights suspicion of AFLP in patients presenting with jaundice in the third trimester with good maternal and fetal outcomes after a timely intervention. Abstract Acute fatty liver of pregnancy (AFLP) is a rare, obstetric emergency characterized by maternal liver dysfunction that can lead to maternal and fetal complications. We report a case of 28-year-old primigravida 39 weeks gestation diagnosed with AFLP complicated by coagulopathy with good maternal and fetal outcomes after a timely intervention.
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Wang J, Bahabri A, Wong P, Anantharachagan A. An atypical presentation of pre-eclampsia (PET) in a patient diagnosed with Guillain-Barré syndrome: A case report. Case Rep Womens Health 2023; 37:e00489. [PMID: 36926548 PMCID: PMC10011183 DOI: 10.1016/j.crwh.2023.e00489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/04/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
Guillain-Barré syndrome (GBS) is an autoimmune neurological disorder with unknown aetiology. Given the incidence of GBS is between 1.2 and 1.9 cases per 100,000 people annually [1], it is extremely rare in pregnancy. We report a case with a challenging diagnosis of pre-eclampsia (PET) in a 34-year-old diabetic primigravida who was diagnosed with GBS at 30 weeks of gestation. At her initial presentation, she complained of progressive weakness of her limbs and facial muscles. This was associated with difficulty swallowing. The diagnosis of GBS was made based on electromyography (EMG) and clinical findings. She was managed conservatively with supportive management and was delivered by lower segment caesarean section at 34 weeks of gestation due to rapidly deteriorating liver function tests (LFTs) in the likely setting of PET.
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Affiliation(s)
- Jue Wang
- Corresponding author at: Recherche Medical Centre, 64 Windich St, Esperance, WA 6450, Australia.
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Medico legal and ethical aspects of surrogacy; A case report of a tragic maternal death from Sri Lanka. J Forensic Leg Med 2022; 91:102425. [PMID: 36058108 DOI: 10.1016/j.jflm.2022.102425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 11/20/2022]
Abstract
A case report from Sri Lanka on surrogacy leading to a tragic maternal death; medico-legal and ethical aspects. Surrogacy, with multiple ethical and legal issues associated with it, is practised worldwide. Although regulations are not available in Sri Lanka, we report a woman who had a tragic death as a complication of surrogate pregnancy. The body of a young mother with four living children was brought for autopsy examination. According to the documents provided, there was a controversy about the deceased's identity. A woman volunteered to show a pillow trapped in her abdomen, simulating a pregnancy. By surrogacy, her husband's sperm were inseminated in this woman's uterus artificially according to a contract. She was diagnosed and managed for pregnancy-induced hypertension in the second trimester. At 36 weeks of gestation, she was admitted to the hospital in labour. On admission, she was icteric with elevated blood pressure. A cesarean section delivered a baby, and it was noted that she had an abruption of the placenta. She developed a postpartum haemorrhage following delivery, and resuscitation failed, resulting in her death. She had elevated liver enzymes and low serum proteins before death. Autopsy findings included intense icterus, congested lungs, global ischemic changes in the myocardium, pale kidneys and fatty soft yellow liver. This case discusses many unanticipated legal and ethical issues related to surrogate pregnancy, especially in a lack of regulations regarding the practice and relatively cheap medical expenses.
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Asadikalameh Z, Maddah R, Maleknia M, Nassaj ZS, Ali NS, Azizi S, Dastyar F. Bioinformatics analysis of microarray data to identify hub genes, as diagnostic biomarker of
HELLP
syndrome: System biology approach. J Obstet Gynaecol Res 2022; 48:2493-2504. [DOI: 10.1111/jog.15363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/16/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Zahra Asadikalameh
- Assistant Professor of Obstetrics and Gynecology, Department of Gynecology and Obstetrics Yasuj University of Medical Sciences Yasuj Iran
| | - Reza Maddah
- Department of Bioprocess Engineering, Institute of Industrial and Environmental Biotechnology National Institute of Genetic Engineering and Biotechnology Tehran Iran
| | - Mohsen Maleknia
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
- Student Research Committee Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
| | - Zohre S. Nassaj
- Center for Health Related Social and Behavioral Sciences Research Shahroud University of Medical Sciences Shahroud Iran
| | - Neda Seyed Ali
- Shahid AkbarAbadi Clinical Research Development unit (SHACRDU) School of Medicine, Iran University of Medical Sciences Tehran Iran
| | - Sepideh Azizi
- Shahid AkbarAbadi Clinical Research Development unit (SHACRDU) School of Medicine, Iran University of Medical Sciences Tehran Iran
| | - Fatemeh Dastyar
- Department of Obstetrics and Gynecology, School of Medicine Bushehr University of Medical Sciences Bushehr Iran
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9
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Terrault NA, Williamson C. Pregnancy-Associated Liver Diseases. Gastroenterology 2022; 163:97-117.e1. [PMID: 35276220 DOI: 10.1053/j.gastro.2022.01.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 01/21/2022] [Accepted: 01/26/2022] [Indexed: 12/14/2022]
Abstract
The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.
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Affiliation(s)
- Norah A Terrault
- Gastrointestinal and Liver Disease Division, University of Southern California, Los Angeles, California, USA.
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10
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Meng Z, Fang W, Meng M, Zhang J, Wang Q, Qie G, Chen M, Wang C. Risk Factors for Maternal and Fetal Mortality in Acute Fatty Liver of Pregnancy and New Predictive Models. Front Med (Lausanne) 2021; 8:719906. [PMID: 34422871 PMCID: PMC8374939 DOI: 10.3389/fmed.2021.719906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Acute fatty liver of pregnancy (AFLP) is a rare but potentially life-threatening hepatic disorder that leads to considerable maternal and fetal mortality. To explore the risk factors for maternal and fetal mortality in AFLP and develop new predictive models, through this retrospective study, we analyzed the demographic characteristics, clinical symptoms, and laboratory findings of 106 patients with AFLP who were admitted to Shandong Provincial Hospital. Risk factors for maternal and fetal mortality were analyzed by univariate and multivariate logistic regression analysis. The new models based on the multivariate logistic regression analysis and the model for end-stage liver disease (MELD) were tested in AFLP. The receiver operating characteristic curve (ROC) was applied to compare the predictive efficiency, sensitivity, and specificity of the two models. Prenatal nausea (p = 0.037), prolonged prothrombin time (p = 0.003), and elevated serum creatinine (p = 0.003) were independent risk factors for maternal mortality. The ROC curve showed that the area under the curve (AUC) of the MELD was 0.948, with a sensitivity of 100% and a specificity of 83.3%. The AUC of the new model for maternal mortality was 0.926, with a sensitivity of 90% and a specificity of 94.8%. Hepatic encephalopathy (p = 0.016) and thrombocytopenia (p = 0.001) were independent risk factors for fetal mortality. Using the ROC curve, the AUC of the MELD was 0.694, yielding a sensitivity of 68.8% and a specificity of 64.4%. The AUC of the new model for fetal mortality was 0.893, yielding a sensitivity of 100% and a specificity of 73.3%. Both the new predictive model for maternal mortality and the MELD showed good predictive efficacy for maternal mortality in patients with AFLP (AUC = 0.926 and 0.948, respectively), and the new predictive model for fetal mortality was superior to the MELD in predicting fetal mortality (AUC = 0.893 and 0.694, respectively). The two new predictive models were more readily available, less expensive, and easier to implement clinically, especially in low-income countries.
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Affiliation(s)
- Zhaoli Meng
- Department of Critical Care Medicine, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, Jinan, China.,Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Mei Meng
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jicheng Zhang
- Department of Critical Care Medicine, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, Jinan, China.,Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Qizhi Wang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Guoqiang Qie
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Man Chen
- Department of Critical Care Medicine, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, Jinan, China.,Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chunting Wang
- Department of Critical Care Medicine, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, Jinan, China.,Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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11
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Trottmann F, Raio L, Amylidi-Mohr S, Mosimann B, Jarquin Campos A, Messerli FH, Risch L, Baumann MU. Soluble fms-like tyrosine kinase 1 (sFlt-1): A novel biochemical marker for acute fatty liver of pregnancy. Acta Obstet Gynecol Scand 2021; 100:1876-1884. [PMID: 34157141 DOI: 10.1111/aogs.14218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 05/31/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Acute fatty liver of pregnancy (AFLP) substantially contributes to maternal and neonatal morbidity and mortality. Other liver-associated pregnancy complications such as preeclampsia-associated HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome may be difficult to differentiate from AFLP as these diseases overlap with regard to multiple clinical and laboratory features. The aim of this study was to investigate angiogenic profiles by measuring soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) in pregnancies compromised by AFLP and to compare them with those complicated by HELLP syndrome. MATERIAL AND METHODS Pregnant women affected by AFLP or HELLP syndrome were enrolled. The study population of women with HELLP syndrome was part of a larger data collection obtained in our clinic that has been used for previous work. Patients' angiogenic profiles were assessed by measuring sFlt-1 and PlGF serum levels. To assess the diagnostic potential of these angiogenic markers in AFLP, as well as discriminating it from HELLP syndrome, non-parametric tests were used and receiver operating curves were calculated. RESULTS Six women with AFLP and 48 women with HELLP syndrome were included in the study. Patients with AFLP showed significantly higher sFlt-1 levels (median: 57 570 pg/mL; range 31 609-147 170 pg/mL) than patients with HELLP syndrome (9713 pg/mL; 1348-30 781 pg/mL; p < 0.001). PlGF serum levels were higher in patients with AFLP compared with those with HELLP syndrome (197 pg/mL; 127-487 pg/mL vs. 40 pg/mL; 9-644 pg/mL, respectively; p < 0.01). sFlt-1/PlGF ratios were not significantly different between AFLP and HELLP syndrome patients (192; 157-1159 vs. 232; 3-948, respectively; NS). In our study population, an sFlt-1 cut-off value of 31 100 pg/mL allowed differentiation between these two diseases with a sensitivity and specificity of 100%. A linear correlation was found between the cumulative numbers of Swansea criteria and sFlt-1 serum levels (r = 0.97; p < 0.01). CONCLUSIONS AFLP is associated with very high sFlt-1 serum levels in particular in women fulfilling eight or more Swansea criteria. Besides the suggested Swansea criteria to diagnose AFLP, an sFlt-1 value above 31 100 pg/mL may be an additional biochemical feature improving discrimination between AFLP and HELLP syndrome. However, because of the small number of pregnancies affected by AFLP included in this work further studies are needed to corroborate our findings.
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Affiliation(s)
- Fabienne Trottmann
- Department of Obstetrics and Gynecology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynecology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Sofia Amylidi-Mohr
- Department of Obstetrics and Gynecology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Beatrice Mosimann
- Department of Obstetrics and Gynecology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Araceli Jarquin Campos
- Center of Laboratory Medicine Dr. Risch, Vaduz, Liechtenstein.,Private University of the Principality of Liechtenstein, Triesen, Liechtenstein
| | - Franz H Messerli
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Risch
- Division of Clinical Chemistry, Labormedizinisches Zentrum Dr. Risch, Bern, Switzerland
| | - Marc U Baumann
- Department of Obstetrics and Gynecology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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12
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Comparison of maternal and neonatal outcomes between acute fatty liver of pregnancy and hemolysis, elevated liver enzymes and low platelets syndrome: a retrospective cohort study. BMC Pregnancy Childbirth 2021; 21:293. [PMID: 33845770 PMCID: PMC8042922 DOI: 10.1186/s12884-021-03761-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/30/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome are two uncommon disorders that mimic each other clinically, but are distinct pathophysiologically. This study aimed to compare maternal and neonatal outcomes between AFLP and HELLP syndrome. METHODS This retrospective cohort study was performed at a tertiary referral center in Taiwan between June 2004 and April 2020. We used the Swansea Criteria to diagnose AFLP, and the Tennessee Classification System to diagnose HELLP syndrome. Maternal characteristics, laboratory data, complications, and neonatal outcomes were compared. We analyzed the categorical variables with Chi-square test or Fisher's exact test and continuous variables with Student's t test or Mann-Whitney U test. Subsequent logistic regression analyses adjusting by potential confounding factors with significant difference were analyzed. RESULTS During the study period, 21 women had AFLP and 80 women had HELLP syndrome. There was a higher rate of preeclampsia (95.0 % versus 23.8 %) in the HELLP syndrome group compared to the AFLP group. However, the AFLP group had more other maternal complications including jaundice (85.7 % versus 13.8 %), acute kidney injury (61.9 % versus 15.0 %), disseminated intravascular coagulopathy (66.7 % versus 8.8 %), and sepsis (47.6 % versus 10.0 %) compared to the HELLP syndrome group. Nevertheless, higher rates of small for gestational age neonates (57.1 % versus 33.3 %), neonatal respiratory distress syndrome (39.2 % versus 8.3 %) and neonatal sepsis (34.2 % versus 12.5 %) were noted in the HELLP syndrome group. CONCLUSIONS AFLP is associated with a higher rate of multiple organ dysfunction in mothers, whereas HELLP syndrome is associated with a higher rate of neonatal morbidity.
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13
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Two Fatty Liver Conditions Masquerading as Autoimmune Hepatitis. Case Reports Hepatol 2021; 2021:8820350. [PMID: 33763269 PMCID: PMC7964110 DOI: 10.1155/2021/8820350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 01/28/2021] [Accepted: 03/02/2021] [Indexed: 11/17/2022] Open
Abstract
Acute fatty liver of pregnancy (AFLP) is a rare obstetric condition that classically presents in the third trimester or early postpartum period and can lead to liver failure and death. Only six second trimester AFLP cases have been reported in the English literature. We present the earliest case of AFLP at 15 weeks of gestation confounded by a high titer anti-nuclear antibody (ANA >1 : 1280) and concern for autoimmune hepatitis. Our patient had intrauterine fetal demise with prompt dilation and evacuation. Sepsis and multisystem organ failure ensued, and she was transferred to a liver transplant center where she expired without further intervention.
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14
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Wacker J, Tackenberg M, Pöschl J, Merle U, Morath C, Rath W. Vorzeitige Plazentalösung und HELLP-Syndrom in Zeiten von Corona – Cave stuporem coronae. Geburtshilfe Frauenheilkd 2021. [DOI: 10.1055/a-1210-7071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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15
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Donck M, Vercruysse Y, Alexis A, Rozenberg S, Blaiberg S. Acute fatty liver of pregnancy - A short review. Aust N Z J Obstet Gynaecol 2020; 61:183-187. [PMID: 33382079 DOI: 10.1111/ajo.13293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/29/2020] [Indexed: 12/17/2022]
Abstract
Acute fatty liver of pregnancy (AFLP) is a rare but dramatic condition associated with a high maternal and fetal morbidity and mortality. We present a short review of AFLP management, illustrated by a case report. We conducted a systematic literature search for 'acute fatty liver of pregnancy', concerning its management. We found initially 11 studies, and three of them met the selection criteria. Prompt diagnosis, maternal stabilisation and rapid delivery are mandatory. This illustrative AFLP case fulfilled nine out of 14 Swansea criteria. Caesarean section is often required (as illustrated in this case), reducing maternal and perinatal mortality rates.
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Affiliation(s)
- Marie Donck
- Department of Obstetrics and Gynaecology, University Hospital Saint-Pierre (Université Libre de Bruxelles), Brussels, Belgium
| | - Yoann Vercruysse
- Department of Anesthesiology, University Hospital Saint-Pierre (Université Libre de Bruxelles), Brussels, Belgium
| | - Alexandros Alexis
- Department of Anesthesiology, University Hospital Saint-Pierre (Université Libre de Bruxelles), Brussels, Belgium
| | - Serge Rozenberg
- Department of Obstetrics and Gynaecology, University Hospital Saint-Pierre (Université Libre de Bruxelles), Brussels, Belgium
| | - Samantha Blaiberg
- Department of Obstetrics and Gynaecology, University Hospital Saint-Pierre (Université Libre de Bruxelles), Brussels, Belgium
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16
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Preeclampsia, HELLP Syndrome, and Postpartum Renal Failure with Thin Basement Membrane Nephropathy: Case Report and a Brief Review of Postpartum Renal Failure. Case Rep Obstet Gynecol 2020; 2020:3198728. [PMID: 33224542 PMCID: PMC7673951 DOI: 10.1155/2020/3198728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 10/16/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022] Open
Abstract
A 36-year-old primigravida female from a birthing center was referred for elevated blood pressure to the hospital two days after normal spontaneous vaginal delivery with nausea, vomiting, and diarrhea. During this two-day period, she was experiencing persistent vaginal bleeding and lower abdominal pains for which she took six doses of 600 mg ibuprofen. Further laboratory evaluation reflected leukocytosis, anemia, thrombocytopenia, elevation of liver enzymes, and renal failure with hyperkalemia requiring emergent hemodialysis once in the Medical Intensive Care Unit (MICU). She was diagnosed with HELLP syndrome with underlying preeclampsia. A week later, due to hypertension controlled with medications and nonoliguric renal failure with no active urine sediments, a renal biopsy was indicated to direct management. The renal biopsy supported the diagnosis of diffuse severe acute tubulointerstitial nephritis with hypereosinophilia and thin basement membrane nephropathy (see figures). She was subsequently treated with high-dose steroids which resulted in the normalization of blood pressures and renal function returning to baseline. We report the first case of acute tubulointerstitial nephritis in an individual with thin basement membrane nephropathy secondary to postpartum complications.
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Ramadan MK, Khaza'al J, Cha'ar D, Bazzi Z, Bachnak R, Haibeh P. Second-trimester acute fatty liver disease of pregnancy: A brief review of the literature and a case report. J Obstet Gynaecol Res 2020; 47:34-43. [PMID: 33230970 DOI: 10.1111/jog.14577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 12/14/2022]
Abstract
Acute fatty liver disease of pregnancy (AFLP) is a rare life-threatening medical emergency unique to pregnancy. It is characterized by progressive microvesicular fatty infiltration of maternal hepatocytes, but the exact etiology has yet to be elucidated. AFLP typically manifests in late third trimester or immediately postpartum and seldom during second trimester. Prompt delivery, irrespective of gestational age or severity, is crucial for arresting the insult and permitting recovery. We hereby report a 21-year-old Lebanese second-gravid woman at 20 weeks' gestation diagnosed with AFLP depending on clinical features and compatible laboratory studies (score of 8 on Swansea criteria), in spite of early occurrence. A review and analysis of early AFLP (second trimester) compared to late (third trimester) was also presented. AFLP appearing during second trimester is as serious as the disease manifesting in late third trimester, with similar diagnostic difficulties, less association with hypertension, but with greater hesitation of obstetricians to affect prompt delivery and higher adverse perinatal outcome due to added effect of premature delivery in second trimester.
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Affiliation(s)
- Mohamad K Ramadan
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Makassed General Hospital, Beirut, Lebanon
| | - Janoub Khaza'al
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
| | - Dunia Cha'ar
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
| | - Zeinab Bazzi
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
| | - Ronza Bachnak
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
| | - Pierre Haibeh
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon.,Department of Obstetrics and Gynecology, Lebanese University, Beirut, Lebanon
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18
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Rath W, Tsikouras P, Stelzl P. HELLP Syndrome or Acute Fatty Liver of Pregnancy: A Differential Diagnostic Challenge: Common Features and Differences. Geburtshilfe Frauenheilkd 2020; 80:499-507. [PMID: 32435066 PMCID: PMC7234826 DOI: 10.1055/a-1091-8630] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/15/2019] [Accepted: 01/08/2020] [Indexed: 12/17/2022] Open
Abstract
HELLP syndrome and the less common acute fatty liver of pregnancy (AFL) are unpredictable, life-threatening complications of pregnancy. The similarities in their clinical and laboratory presentations are often challenging for the obstetrician when making a differential diagnosis. Both diseases are characterised by microvesicular steatosis of varying degrees of severity. A specific risk profile does not exist for either of the entities. Genetic defects in mitochondrial fatty acid oxidation and multiple pregnancy are considered to be common predisposing factors. The diagnosis of AFL is based on a combination of clinical symptoms and laboratory findings. The Swansea criteria have been proposed as a diagnostic tool for orientation. HELLP syndrome is a laboratory diagnosis based on the triad of haemolysis, elevated aminotransferase levels and a platelet count < 100 G/l. Generalised malaise, nausea, vomiting and abdominal pain are common symptoms of both diseases, making early diagnosis difficult. Clinical differences include a lack of polydipsia/polyuria in HELLP syndrome, while jaundice is more common and more pronounced in AFL, there is a lower incidence of hypertension and proteinuria, and patients with AFL may develop encephalopathy with rapid progression to acute liver failure. In contrast, neurological symptoms such as severe headache and visual disturbances are more prominent in patients with HELLP syndrome. In terms of laboratory findings, AFL can be differentiated from HELLP syndrome by the presence of leucocytosis, hypoglycaemia, more pronounced hyperbilirubinemia, an initial lack of haemolysis and thrombocytopenia < 100 G/l, as well as lower antithrombin levels < 65% and prolonged prothrombin times. While HELLP syndrome has a fluctuating clinical course with rapid exacerbation within hours or transient remissions, AFL rapidly progresses to acute liver failure if the infant is not delivered immediately. The only causal treatment for both diseases is immediate delivery. Expectant management between 24 + 0 and 33 + 6 weeks of gestation is recommended for HELLP syndrome, but only in cases where the mother can be stabilised and there is no evidence of foetal compromise. The maternal mortality rate for HELLP syndrome in developed countries is approximately 1%, while the rate for AFL is 1.8 – 18%. Perinatal mortality rates are 7 – 20% and 15 – 20%, respectively. While data on the long-term impact of AFL on the health of mother and child is still insufficient, HELLP syndrome is associated with an increased risk of developing cardiovascular, metabolic and neurological diseases in later life.
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Affiliation(s)
- Werner Rath
- Medizinische Fakultät, Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Panagiotis Tsikouras
- Democritus University of Thrace, Department of Obstetrics and Gynecology, Alexandroupolis, Greece
| | - Patrick Stelzl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
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19
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Acute Fatty Liver of Pregnancy: Pathophysiology, Anesthetic Implications, and Obstetrical Management. Anesthesiology 2020; 130:446-461. [PMID: 30707120 DOI: 10.1097/aln.0000000000002597] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A narrative review of the pathophysiology, diagnosis, management, delivery implications, obstetric anesthesia care, and potential critical care needs in patients presenting with acute fatty liver of pregnancy.
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20
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The interpretation of liver function tests in pregnancy. Best Pract Res Clin Gastroenterol 2020; 44-45:101667. [PMID: 32359686 DOI: 10.1016/j.bpg.2020.101667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/19/2020] [Accepted: 02/17/2020] [Indexed: 01/31/2023]
Abstract
Abnormal liver tests occur in 3-5% of pregnancies and show many different causes. Although alterations of liver enzymes could be a physiological phenomenon, it may also reflect potential severe liver injury, necessitating further assessment and accurate management. The work-up has to consider liver diseases specific of pregnancy and non pregnancy-related liver damage (coincidental and pre-existing to pregnancy). Pre-existing liver diseases during pregnancy are relatively uncommon, as pregnant women are generally young and healthy. Liver diseases unique to pregnancy are intrahepatic cholestasis of pregnancy, the HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) and acute fatty liver of pregnancy. These disorders may result in foetal distress, severe liver damage and sometime hepatic failure; for these reasons the diagnostic work-up and treatment must be very fast. This review focuses on the management of pregnant women with altered liver function tests. Furthermore, the main liver diseases specific of pregnancy are described.
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21
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Azzaroli F, Mazzella G, Marchesini G, Brodosi L, Petroni ML. Fatty liver in pregnancy: a narrative review of two distinct conditions. Expert Rev Gastroenterol Hepatol 2020; 14:127-135. [PMID: 31928239 DOI: 10.1080/17474124.2020.1715210] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Fatty liver is rather common in pregnancy, occurring in two totally different conditions, i.e. nonalcoholic fatty liver disease (NAFLD) in pregnancy and acute fatty liver of pregnancy (AFLP). The former is a common condition, resulting by chance association because of the epidemics of obesity and the older age of many pregnant women in Western countries; the latter is a rare disease whose pathophysiology is still incompletely understood.Areas covered: We reviewed the evidence-based knowledge on fatty liver in/of pregnancy. For NAFLD, a few large retrospective and prospective studies identify immediate and late risks for both the mother and the fetus. For AFLP, only small retrospective studies are available, indicating that prompt delivery and eventual referral to Liver Units for liver support or transplantation are mandatory to avoid maternal and fetal death.Expert opinion: The number of pregnant women with fatty liver is expected to increase in the next years. Pharmacologic treatment of NAFLD might be postponed, even when new drugs are approved by health authorities for the general population. In the case of AFLP, we need to improve our ability to correctly identify and treat the most severe cases not resolving with delivery.
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Affiliation(s)
- Francesco Azzaroli
- Department of Medical and Surgical Sciences, "Alma Mater" University, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Giuseppe Mazzella
- Department of Medical and Surgical Sciences, "Alma Mater" University, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Giulio Marchesini
- Department of Medical and Surgical Sciences, "Alma Mater" University, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Lucia Brodosi
- Department of Medical and Surgical Sciences, "Alma Mater" University, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Maria Letizia Petroni
- Department of Medical and Surgical Sciences, "Alma Mater" University, Sant'Orsola-Malpighi Hospital, Bologna, Italy
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22
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Chalifoux M, Blank H. Acute fatty liver of pregnancy and disseminated intravascular coagulation: A case report. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2020. [DOI: 10.4103/joacc.joacc_8_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Pishko AM, Levine LD, Cines DB. Thrombocytopenia in pregnancy: Diagnosis and approach to management. Blood Rev 2019; 40:100638. [PMID: 31757523 DOI: 10.1016/j.blre.2019.100638] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 02/06/2023]
Abstract
Thrombocytopenia during pregnancy presents unique challenges for the hematologist. Obstetricians generally manage many of the pregnancy-specific etiologies, ranging from the benign (gestational thrombocytopenia) to the life-threatening (preeclampsia; hemolysis, elevated liver enzymes and low platelets syndrome; and acute fatty liver of pregnancy). However, hematologists may be consulted for atypical and severe presentations and to help manage non-pregnancy specific etiologies, including immune thrombocytopenia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and antiphospholipid syndrome, among others, in which maternal and fetal risks must be considered. This review provides a general approach to the diagnosis and management of thrombocytopenia in pregnancy for the consulting hematologist.
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Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas B Cines
- Departments of Pathology and Laboratory Medicine and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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24
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Utility of MELD scoring system for assessing the prognosis of acute fatty liver of pregnancy. Eur J Obstet Gynecol Reprod Biol 2019; 240:161-166. [DOI: 10.1016/j.ejogrb.2019.06.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/24/2019] [Indexed: 12/13/2022]
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25
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Acute fatty liver of pregnancy in a Chinese Tertiary Care Center: a retrospective study. Arch Gynecol Obstet 2019; 300:897-901. [PMID: 31435779 DOI: 10.1007/s00404-019-05259-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/06/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To describe some prenatal clinical features and laboratory findings of AFLP and provide the clinicians with potential predictors in postpartum recovery time. METHODS Forty-four cases of AFLP previously treated in the First Affiliated Hospital of Zhengzhou University were retrospectively reviewed. RESULTS The maternal and fetal mortalities after treatment were both 18.2%. The main symptoms of AFLP were nausea and vomiting (63.6%), jaundice (61.4%). Moreover, the most common maternal complication was acute renal dysfunction (79.5%), followed by DIC (47.7%) and MODS (38.6%). The level of platelets, total protein and total bilirubin were found to be correlated with postpartum recovery time (Pearson correlation coefficient 0.434, P = 0.008; 0.466, P = 0.005; 0.484, P = 0.003). CONCLUSIONS AFLP is a rare, but lethal complication in the third trimester. Termination of pregnancy should be applied once AFLP was highly suspected. Prenatal platelets, total protein and total bilirubin may be potential predictors of postpartum recovery.
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26
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Fukushima R, Kamata K, Ariyoshi F, Yanaki M, Nomura M, Ozaki M. A case of chronic hepatitis B merged with acute fatty liver of pregnancy with severe coagulopathy. JA Clin Rep 2019; 5:1. [PMID: 32025900 PMCID: PMC6967006 DOI: 10.1186/s40981-018-0219-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 12/17/2018] [Indexed: 12/18/2022] Open
Abstract
Background Acute fatty liver of pregnancy (AFLP) is a life-threatening disorder, and its relevance to viral hepatitis B (HB) remains unknown. This case presents an initial experience of treating a patient with HB progressing to AFLP throughout pregnancy; anesthesiologists should also recognize its clinical feature for perioperative management. Case presentation A 28-year-old parturient was diagnosed as chronic HB (CHB) at 21 weeks gestation. Liver and kidney dysfunction appeared rapidly at 34 weeks gestation, suspected as acute exacerbation of either CHB or AFLP. Emergency cesarean section was carried out, after which maternal disseminated intravascular coagulation and hypothermia persisted. With multidisciplinary management, the patient and infant were discharged on postpartum days 64 and 12, respectively. Conclusions Active CHB develops into AFLP. Antiviral therapy should be considered for parturient patients with CHB, particularly for those with high viral load. The most favorable outcome is prompt and accurate diagnosis to establish suitable termination method.
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Affiliation(s)
- Risa Fukushima
- Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Kotoe Kamata
- Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Fumiko Ariyoshi
- Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masashi Yanaki
- Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Minoru Nomura
- Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Makoto Ozaki
- Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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27
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Suzuki H, Nagayama S, Hirashima C, Takahashi K, Takahashi H, Ogoyama M, Nagayama M, Shirasuna K, Matsubara S, Ohkuchi A. Markedly higher sFlt-1/PlGF ratio in a woman with acute fatty liver of pregnancy compared with HELLP syndrome. J Obstet Gynaecol Res 2018; 45:96-103. [PMID: 30141235 DOI: 10.1111/jog.13786] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/20/2018] [Indexed: 12/17/2022]
Abstract
AIM To compare serum levels of angiogenesis-related factors between 14 women with HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome and a woman with acute fatty liver of pregnancy (AFLP). METHODS Serum samples were collected in 2004-2008 and 2013-2016. The levels of soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) were measured by an automated electrochemiluminescence immunoassay using Elecsys sFlt-1 and Elecsys PlGF. After logarithmic transformation, levels of sFlt-1, PlGF and the sFlt-1/PlGF ratio in a woman with AFLP were compared with those in women with HELLP syndrome, using the one-sample t-test. RESULTS At 37 weeks of gestation, a patient was diagnosed with AFLP based on Swansea criteria (showing six features including elevated transaminases), and she also showed a duodenal ulcer with active bleeding, thrombocytopenia and hypertension. Her serum levels of sFlt-1 and sFlt-1/PlGF ratio were significantly higher than in those with HELLP syndrome (273 040 pg/mL vs 15 135 [mean], P < 0.001; 4236 vs 224, P < 0.001; respectively). However, her serum level of PlGF was not significantly different from those with HELLP syndrome. CONCLUSION Serum levels of sFlt-1 and the sFlt-1/PlGF ratio, but not PlGF, in a woman with AFLP were markedly higher than those in women with HELLP syndrome. AFLP may be a different clinical entity from HELLP syndrome based on angiogenesis-related factors. Clinically, the sFlt-1/PlGF ratio may be used to rapidly distinguish AFLP from HELLP syndrome.
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Affiliation(s)
- Hirotada Suzuki
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Shiho Nagayama
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Chikako Hirashima
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Kayo Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Manabu Ogoyama
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Manabu Nagayama
- Division of Gastroenterology, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Koumei Shirasuna
- Department of Animal Science, Tokyo University of Agriculture, Kanagawa, Japan
| | - Shigeki Matsubara
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Tochigi, Japan
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28
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Gao Q, Qu X, Chen X, Zhang J, Liu F, Tian S, Wang C. Outcomes and risk factors of patients with acute fatty liver of pregnancy: a multicentre retrospective study. Singapore Med J 2018; 59:425-430. [PMID: 29297090 DOI: 10.11622/smedj.2018001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Acute fatty liver of pregnancy (AFLP) frequently causes liver failure in pregnant women. A better understanding of the clinical characteristics, management, outcomes and risk factors of AFLP is required, given its relatively high mortality rate. We aimed to describe the characteristics of AFLP, and further assess its outcomes and potential risk factors from the perspectives of the mother and fetus. METHODS This was a retrospective cohort study of 133 patients with AFLP hospitalised at four tertiary hospitals in China between January 2009 and April 2014. RESULTS Among 133 patients, AFLP was diagnosed in the postpartum period for 13 (9.8%) patients. Potential factors influencing adverse maternal outcome were male fetus (p = 0.04), postpartum diagnosis of AFLP (p < 0.01), intrauterine fetal death (p = 0.04), disseminated intravascular coagulation (p < 0.01), prothrombin time (p < 0.01) and activated partial thromboplastin time (p = 0.04). The frequency of fetal distress (p = 0.03) and activated partial thromboplastin time (p < 0.05) were significantly higher in pregnancies with dead fetuses than in those where the fetuses survived. Independent risk factors for perinatal maternal mortality were history of legal termination of pregnancy (odds ratio [OR] 1.958, 95% confidence interval [CI] 1.133-3.385), total bilirubin (OR 1.009, 95% CI 1.003-1.014) and serum creatinine (OR 1.010, 95% CI 1.003-1.017). CONCLUSION Compared with total bilirubin and serum creatinine, history of legal termination of pregnancy appeared to be a greater risk factor for maternal mortality among patients with AFLP.
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Affiliation(s)
- Qiang Gao
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xin Qu
- Department of Neurosurgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Xiukai Chen
- Center for Critical Care Nephrology, University of Pittsburgh, School of Medicine, Pittsburgh, USA.,Department of Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jicheng Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Suochen Tian
- Department of Critical Care Medicine, Liaocheng People's Hospital, Liaocheng, China
| | - Chunting Wang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
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29
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MiRNA-21 has effects to protect kidney injury induced by sepsis. Biomed Pharmacother 2017; 94:1138-1144. [PMID: 28821165 DOI: 10.1016/j.biopha.2017.07.098] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/19/2017] [Accepted: 07/19/2017] [Indexed: 12/20/2022] Open
Abstract
To investigate the miRNA-21 over-expression in the acute kidney injury induced by sepsis, we developed a sepsis induced in vitro model by lip polysaccharide (LPS) and in vovo model by cecal ligation and puncture (CLP) surgery. LPS or CLP surgery induced kidney cell apoptosis increasing. However, the kidney injury indexes of miRNA groups which were transfected with miRNA-21 were significantly suppressed. In further study, the relative proteins expressions were evaluated to explain the miRNA-21 mechanism to improve sepsis induced kidney cell apoptosis. The results were shown that miRNA-21 over-expression had effects to protect kidney cell apoptosis induced by sepsis via PTEN/PI3K/AKT signaling pathway.
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30
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Affiliation(s)
- Adam Morton
- Mater Health and University of Queensland, Brisbane, Australia
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31
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Morikawa M, Suzuki H, Obata-Yasuoka M, Kasai M, Itoh H, Ohkuchi A, Hamada H, Aoki S, Kanayama N, Minakami H. Association of antenatal antithrombin activity with perinatal liver dysfunction: A prospective multicenter study. J Gastroenterol Hepatol 2017; 32:1378-1386. [PMID: 28012194 DOI: 10.1111/jgh.13714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 12/14/2016] [Accepted: 12/21/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Liver dysfunction with decreased antithrombin (AT) activity and/or thrombocytopenia is life threatening in pregnant women. Whether AT is clinically useful for prediction of liver dysfunction remains unclear. METHODS A total of 541 women were registered prospectively at gestational week 34.7 (20.0-41.4) with available data on antenatal AT and platelet count (PLC). RESULTS Liver dysfunction defined as serum aspartate aminotransferase > 45 IU/L concomitant with lactate dehydrogenase > 400 IU/L occurred in five women antenatally (≤ 2 weeks before delivery) and in 17 women post-partum (within 1 week post-partum). Median (5th-95th) antenatal value was 85 (62-110)% for AT and 202 (118-315) × 109 /L for PLC in the 541 women and was significantly lower in women with than without perinatal liver dysfunction; 75 (51-108) versus 86 (62-110)% and 179 (56-244) versus 203 (121-316) × 109 /L, respectively. Nineteen (86%) women with liver dysfunction showed AT ≤ 62% or thrombocytopenia (PLC ≤ 118 × 109 /L) perinatally, but five lacked thrombocytopenia throughout the perinatal period. The best cut-off (AT, 77%; PLC, 139 × 109 /L) suggested by receiver operating characteristic curve gave antenatal AT and PLC sensitivity of 59% and 41% with positive predictive value of 8.6% and 14%, respectively, and combined use of AT and PLC improved sensitivity to 73% (16/22) with positive predictive value of 9.2% for prediction of perinatal liver dysfunction. CONCLUSIONS Reduced AT not accompanied by thrombocytopenia can precede liver dysfunction. Clinical introduction of AT may enhance the safety of pregnant women.
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Affiliation(s)
- Mamoru Morikawa
- Department of Obstetrics, Hokkaido University Hospital, Sapporo, Japan
| | - Hirotada Suzuki
- Department of Obstetrics and Gynecology, Jichi Medical University Hospital, Shimotsuke, Japan
| | - Mana Obata-Yasuoka
- Department of Obstetrics and Gynecology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Michi Kasai
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Japan
| | - Hiroaki Itoh
- Department of Obstetrics and Gynecology, Hamamatsu University Hospital, Hamamatsu, Japan
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University Hospital, Shimotsuke, Japan
| | - Hiromi Hamada
- Department of Obstetrics and Gynecology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Japan
| | - Naohiro Kanayama
- Department of Obstetrics and Gynecology, Hamamatsu University Hospital, Hamamatsu, Japan
| | - Hisanori Minakami
- Department of Obstetrics, Hokkaido University Hospital, Sapporo, Japan
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32
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Anon B, Barbet C, Gendrot C, Labarthe F, Bacq Y. [Acute fatty liver of pregnancy and mitochondrial fatty acid oxidation. Consequences for the offspring]. Arch Pediatr 2017. [PMID: 28647472 DOI: 10.1016/j.arcped.2017.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute fatty liver of pregnancy (AFLP) is a rare liver disease unique to pregnancy that can lead to acute liver failure. The prognosis, initially often fatal for both mother and child, has been improved by prompt delivery. The diagnosis should be highly suspected if the mother presents epigastric pain, nausea and/or vomiting, or polyuria-polydipsia in the third trimester of pregnancy. AFLP has been found associated with a genetic deficiency of fatty acid beta-oxidation, which may cause sudden death in infancy. Consequently, the mother and her newborn should undergo screening for this deficiency.
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Affiliation(s)
- B Anon
- Service d'hépato-gastroentérologie, hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France.
| | - C Barbet
- Service de pédiatrie, hôpital Clocheville, CHRU de Tours, 37044 Tours cedex, France
| | - C Gendrot
- Laboratoire de biochimie et biologie moléculaire, hôpital Bretonneau, CHRU de Tours, 37044 Tours cedex, France
| | - F Labarthe
- Service de pédiatrie, hôpital Clocheville, CHRU de Tours, 37044 Tours cedex, France
| | - Y Bacq
- Service d'hépato-gastroentérologie, hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France
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Acute Fatty Liver Disease of Pregnancy: Updates in Pathogenesis, Diagnosis, and Management. Am J Gastroenterol 2017; 112:838-846. [PMID: 28291236 DOI: 10.1038/ajg.2017.54] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 02/03/2017] [Indexed: 12/11/2022]
Abstract
Acute fatty liver of pregnancy (AFLP) is an obstetric emergency characterized by maternal liver failure and may have complications for the mother and fetus, including death. This review examines recent literature on the epidemiology, pathogenesis, diagnosis, and treatment of acute fatty liver of pregnancy. Pathogenesis of this disease has been linked to defects in fatty acid metabolism during pregnancy, especially in the setting of fetal genetic defects in fatty acid oxidation. The value of screening all patients for these genetic defects remains to be determined. Distinguishing AFLP from other high-risk liver diseases of pregnancy that have overlap features, such as HELLP and preeclampsia, can be challenging. Although sensitive diagnostic tools such as the Swansea criteria have been developed, further work is needed to diagnose AFLP more quickly. Although survival rates have improved in the past 30 years, delay in diagnosis and treatment of AFLP has life-threatening consequences; an algorithmic approach to AFLP may be a valuable resource for clinicians. Future epidemiological and long-term studies will improve our prediction of women at risk for developing AFLP and determine the long-term consequences of this condition.
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Wang S, Li SL, Cao YX, Li YP, Meng JL, Wang XT. Noninvasive Swansea criteria are valuable alternatives for diagnosing acute fatty liver of pregnancy in a Chinese population. J Matern Fetal Neonatal Med 2017; 30:2951-2955. [PMID: 27923319 DOI: 10.1080/14767058.2016.1269316] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This study aims to assess the diagnostic and prognostic value of Swansea criteria in diagnosing acute fatty liver of pregnancy (AFLP) in a Chinese population. METHODS A retrospective study was conducted on 52 Chinese women diagnosed with AFLP. All selected cases were reassessed using the Swansea criteria with special focus on the noninvasive criteria, since performing a liver biopsy for this indication is rare in a Chinese population. RESULTS Ninety point four percent of patients fulfilled five or more of the Swansea criteria. Thirty-one cases were positive for six or more Swansea criteria, but there were no significance differences between patients when using a cutoff criteria <6 or >6. When patients were positive for less than seven criteria, frequency of stillbirth, continuous blood purification (CBP) treatment, hysterectomy, and postpartum hemorrhage were not increased. However, patients who were positive for seven or more criteria had a significantly higher risk of stillbirth and a higher rate of CBP treatment (p < 0.05). Areas under the receiver operating characteristic (ROC) curve of postpartum hemorrhage was 0.670, which reached a statistical significance (p = 0.040). We observed a significantly elevated postpartum hemorrhage along with positivity of the Swansea criteria (p = 0.040). CONCLUSIONS Swansea criteria without liver biopsy are good screening tools for AFLP diagnosis, and may be useful for assessing disease severity.
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Affiliation(s)
- Shan Wang
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
| | - Shan-Ling Li
- b Department of Obstetrics and Gynecology , Shandong Provincial Maternity and Childcare Hospital , Jinan , China
| | - Yan-Xia Cao
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
| | - Yan-Ping Li
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
| | - Jin-Lai Meng
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
| | - Xie-Tong Wang
- a Department of Obstetrics and Gynecology , Shandong Provincial Hospital affiliated to Shandong University , Jinan , China
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Gunaydin B, Tuna AT. Anesthetic considerations for liver diseases unique to pregnancy. World J Anesthesiol 2016; 5:54-61. [DOI: 10.5313/wja.v5.i3.54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/01/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Liver diseases that are most unique to pregnancy consist of hyperemesis gravidarum, acute fatty liver of pregnancy, intrahepatic cholestasis of pregnancy, and hemolysis, elevated liver enzymes and low platelets syndrome. In this review, risk factors, etiology, symptoms, diagnosis, prognosis and treatment of each entity followed by principles of anesthetic management based on the case reports or retrospective records will be addressed.
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36
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Kawabata K, Morikawa M, Yamada T, Minakami H. Isolated pregnancy-induced anti-thrombin deficiency in a woman with twin pregnancy. J Obstet Gynaecol Res 2016; 42:719-721. [DOI: 10.1111/jog.12951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/25/2015] [Accepted: 12/21/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Kosuke Kawabata
- Department of Obstetrics; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Mamoru Morikawa
- Department of Obstetrics; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Takahiro Yamada
- Department of Obstetrics; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Hisanori Minakami
- Department of Obstetrics; Hokkaido University Graduate School of Medicine; Sapporo Japan
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37
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Thomas MR, Robinson S, Scully MA. How we manage thrombotic microangiopathies in pregnancy. Br J Haematol 2016; 173:821-30. [DOI: 10.1111/bjh.14045] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 01/17/2016] [Accepted: 01/17/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Mari R. Thomas
- Department of Haematology; UCLH; Cardiometabolic programme- NIHR UCLH/UCL BRC; London UK
| | | | - Marie A. Scully
- Department of Haematology; UCLH; Cardiometabolic programme- NIHR UCLH/UCL BRC; London UK
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38
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AISF position paper on liver disease and pregnancy. Dig Liver Dis 2016; 48:120-37. [PMID: 26747754 DOI: 10.1016/j.dld.2015.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/29/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
Abstract
The relationship between liver disease and pregnancy is of great clinical impact. Severe liver disease in pregnancy is rare; however, pregnancy-related liver disease is the most frequent cause of liver dysfunction during pregnancy and represents a severe threat to foetal and maternal survival. A rapid differential diagnosis between liver disease related or unrelated to pregnancy is required in women who present with liver dysfunction during pregnancy. This report summarizes the recommendation of an expert panel established by the Italian Association for the Study of the Liver (AISF) on the management of liver disease during pregnancy. The article provides an overview of liver disease occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and an assessment of the available treatment options. The report contains in three sections: (1) specific liver diseases of pregnancy; (2) liver disease occurring during pregnancy; and (3) pregnancy in patients with pre-existing chronic liver disease. Each topic is discussed considering the most relevant data available in literature; the final statements are formulated according to both scientific evidence and clinical expertise of the involved physicians, and the AISF expert panel recommendations are reported.
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39
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Meng J, Wang S, Gu Y, Lv H, Jiang J, Wang X. Prenatal predictors in postpartum recovery for acute fatty liver of pregnancy: experiences at a tertiary referral center. Arch Gynecol Obstet 2015; 293:1185-91. [DOI: 10.1007/s00404-015-3941-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 10/23/2015] [Indexed: 12/19/2022]
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40
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Pulmonary embolism in the setting of HELLP syndrome. Int J Obstet Anesth 2015; 24:184-90. [PMID: 25794414 DOI: 10.1016/j.ijoa.2015.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/12/2015] [Accepted: 01/20/2015] [Indexed: 12/17/2022]
Abstract
HELLP syndrome (hemolysis, elevated liver enzymes and low platelets) complicates 0.5-0.9% of pregnancies and is frequently associated with multiorgan dysfunction. Treatment relies on prompt diagnosis, delivery and supportive care. The clinical presentation may make the concurrent diagnosis and management of other disease entities challenging. This case report describes a patient with postpartum HELLP syndrome complicated by severe multiorgan dysfunction and pulmonary embolism.
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41
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Barvalia U, Eliades M, Melhem L. Concomitant Pituitary Apoplexy and Acute Fatty Liver of Pregnancy Complicated With Disseminated Intravascular Coagulation. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14436.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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42
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Abstract
Acute fatty liver of pregnancy, although rare, is usually a third trimester of pregnancy occurrence that may be life threatening for both the pregnant woman and the fetus. Often, the onset resembles gastroenteritis or cholecystitis and correct diagnosis is delayed. Because it can also present with preeclampsia and eclampsia, it may be mistakenly diagnosed as hemolysis, elevated liver enzymes, low platelet syndrome. This article presents diagnostic differences between liver conditions that can complicate pregnancy and management strategies for treating and maintaining the well-being of pregnant women, fetuses, and infants who are affected by acute fatty liver of pregnancy. Early recognition and rapid intervention from antepartum diagnosis through delivery and the postpartum period are required by the nursing team and medical providers to reduce maternal and neonatal morbidity and mortality.
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43
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de Oliveira CV, Moreira A, Baima JP, Franzoni LDC, Lima TB, Yamashiro FDS, Coelho KYR, Sassaki LY, Caramori CA, Romeiro FG, Silva GF. Acute fatty liver of pregnancy associated with severe acute pancreatitis: A case report. World J Hepatol 2014; 6:527-531. [PMID: 25068005 PMCID: PMC4110545 DOI: 10.4254/wjh.v6.i7.527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 05/20/2014] [Accepted: 06/11/2014] [Indexed: 02/06/2023] Open
Abstract
Acute fatty liver of pregnancy is a rare disease that affects women in the third trimester of pregnancy. Although infrequent, the disease can cause maternal mortality. The diagnosis is not always clear until the pregnancy is terminated, and significant complications, such as acute pancreatitis, can occur. Pancreatic involvement typically only occurs in severe cases after the development of hepatic and renal impairment. To date, little knowledge is available regarding how the disease causes pancreatitis. Treatment involves supportive measures and pregnancy interruption. In this report, we describe a case of a previously healthy 26-year-old woman at a gestational age of 27 wk and 6 d who was admitted with severe abdominal pain and vomiting. This case illustrates the clinical and laboratory overlap between acute fatty liver of pregnancy and pancreatitis, highlighting the difficulties in differentiating each disease. Furthermore, the hypothesis for this overlapping is presented, and the therapeutic options are discussed.
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