What is Fatty Liver in Pregnancy?
Liver disease related to pregnancy is a term that covers different liver problems that can occur at various times during pregnancy. These include acute fatty liver of pregnancy, liver problems related to pre-eclampsia (a pregnancy complication that involves high blood pressure), and HELLP syndrome, a serious condition which stands for Hemolysis (breaking down of red blood cells), Elevated Liver enzymes (which indicates liver damage), and Low Platelets count (cells that help your blood clot).
Acute fatty liver of pregnancy is a fairly uncommon complication that occurs in about 5 out of every 100,000 pregnancies. This condition usually develops later in pregnancy and can lead to complications for both the mother and the baby. It causes the liver to dysfunction due to the buildup of fat in the liver cells, potentially causing blood clotting problems, electrolyte imbalance (when the levels of certain minerals in your body are too high or too low), and failure of multiple organs. It’s vital to quickly recognize and treat this condition as it can cause serious health problems and pose a risk to life. Treatment typically involves looking after the mother’s health and also delivering the baby, which is the only surefire way to treat this condition.
What Causes Fatty Liver in Pregnancy?
During the later stages of pregnancy, a woman’s body experiences an increase in free fatty acids – which are important for the growth of the baby and the placenta. Acute Fatty Liver of Pregnancy (AFLP) is a condition that may occur when there are problems with how these fatty acids are processed in the body. Unfortunately, we are not fully sure why this disease happens.
The theory is that, if there are issues with how these fatty acids are broken down, they build up inside liver cells, causing damage. A particular deficiency of an enzyme called long-chain 3 hydroxy acyl CoA dehydrogenase (LCHAD) has been identified as a key issue linked with AFLP. In fact, it is believed to be a factor in about 20 percent of all AFLP cases.
A specific genetic defect, called a G1528C mutation, is most frequently associated with AFLP; although, other alterations in the same enzyme, or even in other enzymes that are responsible for managing free fatty acids, could potentially lead to the same condition.
Risk Factors and Frequency for Fatty Liver in Pregnancy
Acute fatty liver of pregnancy is a rare problem that happens in about 1 out of every 7,000 to 20,000 pregnancies. Certain conditions can make someone more likely to develop this issue. The key one is a problem with the body’s ability to break down certain fats, known as a feta long-chain 3 hydroxy acyl CoA dehydrogenase deficiency. There are also other factors that can increase the risk.
- Having had acute fatty liver of pregnancy in a previous pregnancy
- Having conditions such as HELLP syndrome or preeclampsia
- Being pregnant with multiple babies at the same time
- Carrying a male fetus
Signs and Symptoms of Fatty Liver in Pregnancy
Pregnant women can develop acute fatty liver during the last part of their pregnancy, particularly between the 30th and 38th week. Symptoms include:
- Nausea
- Vomiting
- Lack of appetite
- Abdominal pain
Some of these women may show signs of high blood pressure and abnormal levels of protein in their urine, often due to a condition called HELLP syndrome or pre-eclampsia. If left unchecked, this can quickly develop into an acute liver failure. This condition is characterized by:
- Yellowing of the skin and eyes (jaundice)
- Fluid build-up in the abdomen (ascites)
- Blood clotting disorders
- Confusion
If not treated promptly, it can even lead to multiple organ failure. A physical exam is crucial for diagnosis, where doctors may notice signs of jaundice, tenderness in the abdomen, and confusion in the patient.
Testing for Fatty Liver in Pregnancy
If you are pregnant and your doctor suspects that you might have a condition known as acute fatty liver of pregnancy, you will probably need to have a few tests. These typically include a complete blood count, liver function tests, checks for levels of specific enzymes called aspartate and alanine aminotransferase, a creatinine test which checks your kidney function, and urine protein assessment.
In patients with acute fatty liver of pregnancy, usually, the levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) will be increased. There might be other abnormalities as well, like a high bilirubin level in the blood, low blood sugar, low platelets, high ammonia, high white blood cell count and problems with blood clotting. These could show up as prolonged prothrombin time, an abnormally high international normalized ratio (both measure how long blood takes to clot), and low fibrinogen (a protein that helps blood clot).
When it comes to checking the liver through imaging techniques like ultrasounds, CT scans or MRIs, these tests often do not show clear signs of the disease. The ultrasound might show fat accumulating in the liver, but this is not always the case. It’s also important to note that CT scans can have harmful effects on the unborn child, so they are usually not used in this case.
A liver biopsy, which involves taking a tiny piece of the liver and examining it in a lab, is usually not needed. If doctors feel that the patient’s signs and symptoms point to acute fatty liver of pregnancy, they can start treatment without waiting for a biopsy result. It might be needed occasionally, like when the liver function does not go back to normal after delivery, or to confirm the diagnosis in very early stages of the disease.
In cases where the patient has problems with their liver, doctors need to rule out other possible causes of these issues like viral hepatitis, drug-induced liver disease, and poisoning from too much acetaminophen. Acute fatty liver of pregnancy can be suspected in a pregnant woman with typical symptoms and significant liver problems after other causes have been ruled out. The disease can sometimes be confused with HELLP syndrome or severe preeclampsia, but the approach to treatment for these conditions is largely the same, so it would not be delayed while waiting for a certain diagnosis.
The “Swansea criteria” is a list of signs and symptoms that can help doctors diagnose acute fatty liver of pregnancy. If a woman has six or more of the listed symptoms and there’s no other known cause for her liver problems, she could be diagnosed with this disease according to the criteria.
The Swansea criteria include symptoms like vomiting, changes in brain function (encephalopathy), excessive thirst and urination, abdominal pain, high bilirubin, low blood sugar, high white blood cell count, elevated AST or ALT, high ammonia, high uric acid, kidney injury or high creatinine, problems with blood clotting or an unusually long prothrombin time, fluid in the abdomen (ascites) or a bright liver on ultrasound scan, and fatty changes in the liver when examined under a microscope.
Treatment Options for Fatty Liver in Pregnancy
If a pregnant woman has AFLP, which stands for Acute Fatty Liver of Pregnancy, it’s vital for both her health and the baby’s health that the baby is delivered promptly. Despite the medical evidence being of a very low level, there is a strong recommendation that the woman should not continue with the pregnancy due to the risk of serious complications.
Initially, efforts will be focused on stabilizing the expectant mom and taking care of her immediate health needs. This might involve balancing her electrolyte levels which are essential minerals in the body and also managing any low blood sugar (hypoglycemia), problems with blood clotting (coagulopathy) conditions. The mother and the baby’s health will be closely monitored with a particular focus on the baby’s heartbeat. If she loses any fluids, these will be replaced.
How the baby is delivered will depend on a few factors such as the health of the mother and the baby, as well as whether there are any reasons that would make a vaginal birth risky. If there are no medical reasons to avoid a natural birth, labor can be artificially started (induced) or proceed naturally. In some cases, however, a C-section may have to be performed due to worsening health of the mom or the baby. If a C-section is needed to deliver the baby, the mother may need to be given a transfusion of platelets, a component of blood that helps it to clot. Mothers less than 32 weeks pregnant may also be given a drug called magnesium sulfate to prevent a condition called cerebral palsy developing in the baby.
Once the baby is born, the mother will continue to be closely monitored for complications such as bleeding, low blood sugar (hypoglycemia), or kidney problems. If her liver function doesn’t improve quickly after pregnancy, a liver transplant may need to be considered as a potentially life-saving measure. The newborn baby should also undergo a special type of DNA test for a condition called LCHAD deficiency, as babies of mothers with AFLP are at risk of inheriting this condition. This would also include regular medical checks for signs of low blood sugar and fatty liver.
What else can Fatty Liver in Pregnancy be?
Acute fatty liver of pregnancy can sometimes be hard to diagnose, as it may resemble other conditions like HELLP syndrome and severe preeclampsia. These illnesses can even occur together in the same patient, which makes diagnosis even more difficult.
However, certain signs indicate acute fatty liver of pregnancy rather than other conditions. These include:
- Signs of liver failure, such as impaired blood clotting (coagulopathy) and widespread clotting within the blood vessels (disseminated intravascular coagulation)
- Low blood sugar (hypoglycemia)
- High levels of liver enzymes (transaminase)
- Excess bilirubin in the blood (hyperbilirubinemia)
These symptoms are usually more severe in cases of acute fatty liver of pregnancy compared to HELLP syndrome or preeclampsia.
What to expect with Fatty Liver in Pregnancy
In most situations, when a woman experiences acute fatty liver during pregnancy, her liver function typically returns to normal within one week to 10 days after she gives birth. Acute fatty liver is a condition where there is a rapid build-up of fat in the liver, which can affect its function.
Moreover, the maternal death rates related to this condition have significantly improved. They have dropped to less than 5 percent now, whereas previously, they were more than 75 percent. ‘Maternal mortality rate’ refers to the number of deaths that happen during pregnancy or within a certain period after pregnancy, often due to complications.
Possible Complications When Diagnosed with Fatty Liver in Pregnancy
Acute fatty liver of pregnancy, also known as AFLP, can lead to a serious condition called pulmonary edema, which is the accumulation of excess fluid in the lungs. This happens due to a decrease in plasma oncotic pressure. It’s estimated that this condition affects around 14% of patients diagnosed with AFLP.
In addition, AFLP can result in liver failure. This condition can be accompanied by pancreatitis, a disease characterized by inflammation of the pancreas, and disseminated intravascular coagulation, a condition that causes clotting and bleeding problems. Metabolic acidosis, a condition that happens when there’s an excessive amount of acid in the body, can also occur. These diseases could lead to severe health problems for both the mother and the baby, and in extreme cases, they can be fatal.
Therefore, it’s very important for doctors to detect AFLP as early as possible. Once detected, steps should be taken to stabilize the patient, and delivery should be considered afterward.
Potential Risks:
- Pulmonary edema
- Liver failure
- Pancreatitis
- Disseminated intravascular coagulation
- Metabolic acidosis
- Maternal or fetal health deterioration
- Potential fatality
Preventing Fatty Liver in Pregnancy
Patients who have had a sudden onset of fatty liver disease during pregnancy should get tested for a condition known as LCHAD deficiency, along with their newborn. Fatty liver disease can occur in later pregnancies, even if the test for LCHAD deficiency comes out negative. So, if you’re planning to get pregnant again, it might be helpful to see a specialist just to be on the safe side.
