妊娠脂肪肝.ppt
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Acute Fatty Liver With Pregnancy
Dr.Mohammed Abdalla
Egypt. Domiat General Hospital
Historical points
? (AFLP) was first identified by Sheehan in 1940
? The name AFLP has replaced earlier terminologies, "acute yellow atrophy of pregnancy"
and "acute obstetric fatty metamorphosis of liver"
Incidence and Characteristics
once in every 7,000 to 11,000 deliveries
Incidence and Characteristics
? Acute fatty liver of pregnancy most frequently complicates the third trimester and is commonly associated (or complicated ) with preeclampsia (50 to 100 percent).
Incidence and Characteristics
Incidence : 1/7000 -11,000
Age, (mean, range) 26 (16-39)
Primiparous (%): 67
Male baby (%) :60
Onset week of pregnancy :33% (28-38)
Mortality (%): ( Maternal )18% - ( Fetal) 47%
Liver Function Tests
liver function tests" describes a panel of laboratory tests profiling discrete aspects of liver function
Liver Function Tests
? aspartate aminotransferase (AST)
? and alanine aminotransferase (ALT) evaluate Liver cell injury or necrosis
Liver Function Tests
evaluate liver synthetic function (are depressed in cirrhosis or severe acute liver disease)
Liver function tests
> alkaline phosphatase,>bilirubin,> gamma glutamyl transpeptidase
Pathogenesis
The etiology is not known precisely.
Pathogenesis
CLINICAL PRESENTATION
Vomiting 80
Abdominal pain52
Jaundice 93
Encephalopathy 87
Polydipsia 80
Pruritus 60
Ascitis 47
with or without polyuria, frequently is an early symptom in AFLP.
The patient may drink 2 or 3 liters of liquids overnight. it often exceeds the magnitude of vomiting. It has been interpreted as a transient diabetes insipidus.
? After hours or a few days, some patients become lethargic and may decline into hepatic coma, or milder degrees of mental impairment.
ascitis
Usually transient and rarely prominent.
After delivery, most patients improve slowly, and a full clinical and laboratory recovery may take from 1 to 4 weeks.
LABORATORY FEATURES
? Liver test abnormalities
> conjugated hyperbilirubinemia (usually between 5 and 15 mg/dL)
> increased alkaline phosphatase (normal <170)
> and modest increases in serum aminotransferases normal <50 (usually<1000 IU/L)
* Leukocytosis occurs commonly
* thrombocytopenia
* decreased clotting factors
* Hypoglycemia and renal dysfunction
Histopathology
fatty metamorphosis by liver biopsy:
Histopathology
In contrast with viral hepatitis and other common causes of fulminant hepatic failure, necrosis of hepatocytes is always minor .
Complications
* cerebral edema,* renal failure (60%),* hypoglycemia (53%),*infections (45%)
* gastrointestinal hemorrhage (33%),* coagulopathy (30%),* fetal death
* severe postpartum hemorrhage
The upper gastrointestinal hemorrhage may be caused by Mallory-Weiss syndrome, acute gastric or duodenal lesions (e.g., gastritis, duodenitis, peptic ulcers), or it can be a manifestation of a coagulopathy.
renal involvement is less severe than with toxemia
When renal failure is aggravated, it usually is impossible to distinguish from toxemia.
A severe hypoglycemia often appears at any stage of the disease, or even during clinical recovery.
Ascites, detected clinically or by ultrasound, is transient and rarely prominent.
Maternal mortality(18%) usually is attributed to one of its complications (gastrointestinal hemorrhage, bleeding disorder, renal failure, acute pancreatitis) but not to liver failure alone.
It often is impossible to immediately perform a liver biopsy in pregnant patients with severe coagulation abnormalities.
Therefore, in many cases, it is necessary to rely on the clinical and laboratory data and, in the physician's and obstetrician's experience,
the emergency therapeutic decisions usually are made without waiting for a histologically proven diagnosis.
Liver biopsy is not indicated for diagnosis
? Ultrasound is most important in the exclusion of biliary tract disorders, but its value and the value of CT and MR imaging, has been considered limited and not helpful for the diagnosis and management of patients with AFLP.
The mild jaundice.
and modest increase in serum aminotransferases are important signs
the mild increase in blood pressure, hyperuricemia, and the intense thirst are
No specific treatment
All patients should be hospitalized as soon as the diagnosis of AFLP is suspected
Moderate or severely affected patients (encephalopathic, deeply jaundiced, with a prothrombin time less than 40% of the control), or with any extrahepatic complications, should be attended in intensive care units.
it seems convenient to maintain glucose infusions . Because of the risk of a sudden hypoglycemia until a full metabolic recovery is obtained.
? Two laboratory tests: prothrombin time and blood glucose, should be repeated at least daily, Prothrombin time helps to assess the prognosis of liver failure, and blood glucose detects a severe hypoglycemia.
Pregnancy termination
(yesORno )
importance of interrupting pregnancy may seem questionable,
As it noticed in some patients that the disease does not immediately improve after delivery
AFLP should be suspected when persistent vomiting, malaise, encephalopathy or jaundice appear in the final weeks of pregnancy or in the early puerperium.
Diagnosis is mainly based onclinical and laboratory grounds.
Liver biopsy is usually confirmatory,if done..
AFLP is a medical and obstetric emergency because of the metabolic alterations and complications and because of the impending need to interrupt pregnancy.
close surveillance of future pregnancies in patients affected previously by this disease is recommended.
an impaired fatty acid metabolism during childhood. may affect babies born of pregnancies with AFLP.
Thank You
Dr.Mohammed Abdalla
EGYPT. Domiat general hospital
Acute Fatty Liver With Pregnancy
Dr.Mohammed Abdalla
Egypt. Domiat General Hospital
Historical points
? (AFLP) was first identified by Sheehan in 1940
? The name AFLP has replaced earlier terminologies, "acute yellow atrophy of pregnancy"
and "acute obstetric fatty metamorphosis of liver"
Incidence and Characteristics
once in every 7,000 to 11,000 deliveries
Incidence and Characteristics
? Acute fatty liver of pregnancy most frequently complicates the third trimester and is commonly associated (or complicated ) with preeclampsia (50 to 100 percent).
Incidence and Characteristics
Incidence : 1/7000 -11,000
Age, (mean, range) 26 (16-39)
Primiparous (%): 67
Male baby (%) :60
Onset week of pregnancy :33% (28-38)
Mortality (%): ( Maternal )18% - ( Fetal) 47%
Liver Function Tests
liver function tests" describes a panel of laboratory tests profiling discrete aspects of liver function
Liver Function Tests
? aspartate aminotransferase (AST)
? and alanine aminotransferase (ALT) evaluate Liver cell injury or necrosis
Liver Function Tests
evaluate liver synthetic function (are depressed in cirrhosis or severe acute liver disease)
Liver function tests
> alkaline phosphatase,>bilirubin,> gamma glutamyl transpeptidase
Pathogenesis
The etiology is not known precisely.
Pathogenesis
CLINICAL PRESENTATION
Vomiting 80
Abdominal pain52
Jaundice 93
Encephalopathy 87
Polydipsia 80
Pruritus 60
Ascitis 47
with or without polyuria, frequently is an early symptom in AFLP.
The patient may drink 2 or 3 liters of liquids overnight. it often exceeds the magnitude of vomiting. It has been interpreted as a transient diabetes insipidus.
? After hours or a few days, some patients become lethargic and may decline into hepatic coma, or milder degrees of mental impairment.
ascitis
Usually transient and rarely prominent.
After delivery, most patients improve slowly, and a full clinical and laboratory recovery may take from 1 to 4 weeks.
LABORATORY FEATURES
? Liver test abnormalities
> conjugated hyperbilirubinemia (usually between 5 and 15 mg/dL)
> increased alkaline phosphatase (normal <170)
> and modest increases in serum aminotransferases normal <50 (usually<1000 IU/L)
* Leukocytosis occurs commonly
* thrombocytopenia
* decreased clotting factors
* Hypoglycemia and renal dysfunction
Histopathology
fatty metamorphosis by liver biopsy:
Histopathology
In contrast with viral hepatitis and other common causes of fulminant hepatic failure, necrosis of hepatocytes is always minor .
Complications
* cerebral edema,* renal failure (60%),* hypoglycemia (53%),*infections (45%)
* gastrointestinal hemorrhage (33%),* coagulopathy (30%),* fetal death
* severe postpartum hemorrhage
The upper gastrointestinal hemorrhage may be caused by Mallory-Weiss syndrome, acute gastric or duodenal lesions (e.g., gastritis, duodenitis, peptic ulcers), or it can be a manifestation of a coagulopathy.
renal involvement is less severe than with toxemia
When renal failure is aggravated, it usually is impossible to distinguish from toxemia.
A severe hypoglycemia often appears at any stage of the disease, or even during clinical recovery.
Ascites, detected clinically or by ultrasound, is transient and rarely prominent.
Maternal mortality(18%) usually is attributed to one of its complications (gastrointestinal hemorrhage, bleeding disorder, renal failure, acute pancreatitis) but not to liver failure alone.
It often is impossible to immediately perform a liver biopsy in pregnant patients with severe coagulation abnormalities.
Therefore, in many cases, it is necessary to rely on the clinical and laboratory data and, in the physician's and obstetrician's experience,
the emergency therapeutic decisions usually are made without waiting for a histologically proven diagnosis.
Liver biopsy is not indicated for diagnosis
? Ultrasound is most important in the exclusion of biliary tract disorders, but its value and the value of CT and MR imaging, has been considered limited and not helpful for the diagnosis and management of patients with AFLP.
The mild jaundice.
and modest increase in serum aminotransferases are important signs
the mild increase in blood pressure, hyperuricemia, and the intense thirst are
No specific treatment
All patients should be hospitalized as soon as the diagnosis of AFLP is suspected
Moderate or severely affected patients (encephalopathic, deeply jaundiced, with a prothrombin time less than 40% of the control), or with any extrahepatic complications, should be attended in intensive care units.
it seems convenient to maintain glucose infusions . Because of the risk of a sudden hypoglycemia until a full metabolic recovery is obtained.
? Two laboratory tests: prothrombin time and blood glucose, should be repeated at least daily, Prothrombin time helps to assess the prognosis of liver failure, and blood glucose detects a severe hypoglycemia.
Pregnancy termination
(yesORno )
importance of interrupting pregnancy may seem questionable,
As it noticed in some patients that the disease does not immediately improve after delivery
AFLP should be suspected when persistent vomiting, malaise, encephalopathy or jaundice appear in the final weeks of pregnancy or in the early puerperium.
Diagnosis is mainly based onclinical and laboratory grounds.
Liver biopsy is usually confirmatory,if done..
AFLP is a medical and obstetric emergency because of the metabolic alterations and complications and because of the impending need to interrupt pregnancy.
close surveillance of future pregnancies in patients affected previously by this disease is recommended.
an impaired fatty acid metabolism during childhood. may affect babies born of pregnancies with AFLP.
Thank You
Dr.Mohammed Abdalla
EGYPT. Domiat general hospital
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