Aims: To summarize the clinical features, perioperative management and maternal and neonatal outcomes of patients with acute fatty liver of pregnancy (AFLP) and to discuss the management of anesthesia in these patients. Methods: This study was a retrospective review over a period of 5 years and 9 months; 28 cases from the Shanghai Public Health Clinical Center were included. Records were reviewed for symptoms, signs, laboratory findings, clinical courses, perioperative management and maternal and neonatal outcomes. Results: Of the AFLP cases analyzed in the present study, 75.0% occurred in primipara and 63.3% occurred with male fetuses. Prodromic symptoms included the sudden onset of fatigue, nausea, vomiting, anorexia and jaundice. Laboratory results indicated liver function abnormalities, coagulopathy, hypoglycemia, leukocytosis and negative urine bilirubin. There were 2 maternal deaths (7.1%) without fetal deaths. Cesarean sections were performed in 16 cases under neuraxial anesthesia and in 12 cases under general anesthesia with rapid-sequence induction. Conclusion: Early diagnosis, prompt delivery and intensive supportive treatment are critical for improving the prognosis of AFLP. Anesthesia selection should be individualized and general anesthesia with rapid-sequence induction may be the best choice for patients with severe coagulopathy.

1.
Knight M, Nelson-Piercy C, Kurinczuk JJ, Spark P, Brocklehurst P: A prospective national study of acute fatty liver of pregnancy in the UK. Gut 2008;57:951-956.
2.
Ch'Ng CL, Morgan M, Hainsworth I, Kingham JG: Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut 2002;51:876-880.
3.
Shekhawat P, Bennett MJ, Sadovsky Y, Nelson DM, Rakheja D, Strauss AW: Human placenta metabolizes fatty acids: implications for fetal fatty acid oxidation disorders and maternal liver diseases. Am J Physiol Endocrinol Metab 2003;284:E1098-E1105.
4.
Blish KR, Ibdah JA: Maternal heterozygosity for a mitochondrial trifunctional protein mutation as a cause for liver disease in pregnancy. Med Hypotheses 2005;64:96-100.
5.
Browning MF, Levy HL, Wilkins-Haug LE, Larson C, Shih VE: Fetal fatty acid oxidation defects and maternal liver disease in pregnancy. Obstet Gynecol 2006;107:115-120.
6.
Natarajan SK, Thangaraj KR, Eapen CE, Ramachandran A, Mukhopadhya A, Mathai M, Seshadri L, Peedikayil A, Ramakrishna B, Balasubramanian KA: Liver injury in acute fatty liver of pregnancy: possible link to placental mitochondrial dysfunction and oxidative stress. Hepatology 2010;51:191-200.
7.
Usta IM, Barton JR, Amon EA, Gonzalez A, Sibai BM: Acute fatty liver of pregnancy: an experience in the diagnosis and management of fourteen cases. Am J Obstet Gynecol 1994;171:1342-1347.
8.
Holzman RS, Riley LE, Aron E, Fetherston J: Perioperative care of a patient with acute fatty liver of pregnancy. Anesth Analg 2001;92:1268-1270.
9.
Castro MA, Goodwin TM, Shaw KJ, Ouzounian JG, McGehee WG: Disseminated intravascular coagulation and antithrombin III depression in acute fatty liver of pregnancy. Am J Obstet Gynecol 1996;174:211-216.
10.
Vigil-De Gracia P, Lavergne JA: Acute fatty liver of pregnancy. Int J Gynaecol Obstet 2001;72:193-195.
11.
Ko H, Yoshida EM: Acute fatty liver of pregnancy. Can J Gastroenterol 2006;20:25-30.
12.
Treem WR, Shoup ME, Hale DE, Bennett MJ, Rinaldo P, Millington DS, Stanley CA, Riely CA, Hyams JS: Acute fatty liver of pregnancy, hemolysis, elevated liver enzymes, and low platelets syndrome, and long chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency. Am J Gastroenterol 1996;91:2293-2300.
13.
Mabie WC: Obstetric management of gastroenterologic complications of pregnancy. Gastroenterol Clin North Am 1992;21:923-935.
14.
Na Q, Liu CX, Cui H, Chen J, Liu SS, Li QL: Successful treatment of two patients with postpartum disseminated intravascular coagulation complicated by abdominal compartment syndrome. Gynecol Obstet Invest 2012;73:337-340.
15.
Pereira SP, O'Donohue J, Wendon J, Williams R: Maternal and perinatal outcome in severe pregnancy-related liver disease. Hepatology 1997;26:1258-1262.
16.
Ockner SA, Brunt EM, Cohn SM, Krul ES, Hanto DW, Peters MG: Fulminant hepatic failure caused by acute fatty liver of pregnancy treated by orthotopic liver transplantation. Hepatology 1990;11:59-64.
17.
Corke PJ: Anaesthesia for caesarean section in a patient with acute fatty liver of pregnancy. Anaesth Intensive Care 1995;23:215-218.
18.
Antognini JF, Andrews S: Anaesthesia for caesarean section in a patient with acute fatty liver of pregnancy. Can J Anaesth 1991;38:904-907.
19.
Wu TJ, Ng CC, Lee FK, Sun HL: Anesthesia for emergency cesarean section in a parturient with undiagnosed acute fatty liver of pregnancy - a case report. Acta Anaesthesiol Taiwan 2007;45:223-227.
20.
Gregory TL, Hughes S, Coleman MA, De Silva A: Acute fatty liver of pregnancy; three cases and discussion of analgesia and anaesthesia. Int J Obstet Anesth 2007;16:175-179.
21.
Spence D: Case report: anesthetic management of acute fatty liver of pregnancy in the postpartum period. AANA J 2010;78:223-228.
22.
Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, Mulroy MF, Rosenquist RW, Rowlingson J, Tryba M, Yuan CS: Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003;28:172-197.
23.
Kennedy WJ: Effects of spinal and peridural blocks on renal and hepatic functions. Clin Anesth 1969;2:109-121.
24.
Frink EJ Jr, Morgan SE, Coetzee A, Conzen PF, Brown BR Jr: The effects of sevoflurane, halothane, enflurane, and isoflurane on hepatic blood flow and oxygenation in chronically instrumented greyhound dogs. Anesthesiology 1992;76:85-90.
25.
Crawford MW, Lerman J, Saldivia V, Carmichael FJ: Hemodynamic and organ blood flow responses to halothane and sevoflurane anesthesia during spontaneous ventilation. Anesth Analg 1992;75:1000-1006.
26.
Zaleski L, Abello D, Gold MI: Desflurane versus isoflurane in patients with chronic hepatic and renal disease. Anesth Analg 1993;76:353-356.
27.
Debaene B, Goldfarb G, Braillon A, Jolis P, Lebrec D: Effects of ketamine, halothane, enflurane, and isoflurane on systemic and splanchnic hemodynamics in normovolemic and hypovolemic cirrhotic rats. Anesthesiology 1990;73:118-124.
28.
Thomson IA, Fitch W, Campbell D, Watson R: Effects of ketamine on liver blood flow and hepatic oxygen consumption. Studies in the anaesthetised greyhound. Acta Anaesthesiol Scand 1988;32:10-14.
29.
Carmichael FJ, Crawford MW, Khayyam N, Saldivia V: Effect of propofol infusion on splanchnic hemodynamics and liver oxygen consumption in the rat. A dose-response study. Anesthesiology 1993;79:1051-1060.
30.
Wouters PF, Van de Velde MA, Marcus MA, Deruyter HA, Van Aken H: Hemodynamic changes during induction of anesthesia with eltanolone and propofol in dogs. Anesth Analg 1995;81:125-131.
31.
Demeure dit Latte D, Bernard JM, Blanloeil Y, Peltier P, Francois T, Chatal JF: Induction of anaesthesia by propofol and hepatic blood flow in the rabbit. Clin Physiol 1995;15:515-522.
32.
Peltz B, Sinclair DM: Induction agents for caesarean section. A comparison of thiopentone and ketamine. Anaesthesia 1973;28:37-42.
33.
Ngan Kee WD, Khaw KS, Ma ML, Mainland PA, Gin T: Postoperative analgesic requirement after cesarean section: a comparison of anesthetic induction with ketamine or thiopental. Anesth Analg 1997;85:1294-1298.
34.
Gholson CF, Provenza JM, Bacon BR: Hepatologic considerations in patients with parenchymal liver disease undergoing surgery. Am J Gastroenterol 1990;85:487-496.
35.
Tegeder I, Lotsch J, Geisslinger G: Pharmacokinetics of opioids in liver disease. Clin Pharmacokinet 1999;37:17-40.
36.
Haberer JP, Schoeffler P, Couderc E, Duvaldestin P: Fentanyl pharmacokinetics in anaesthetized patients with cirrhosis. Br J Anaesth 1982;54:1267-1270.
37.
Van de Velde M, Teunkens A, Kuypers M, Dewinter T, Vandermeersch E: General anaesthesia with target controlled infusion of propofol for planned caesarean section: maternal and neonatal effects of a remifentanil-based technique. Int J Obstet Anesth 2004;13:153-158.
38.
Hunter JM, Parker CJ, Bell CF, Jones RS, Utting JE: The use of different doses of vecuronium in patients with liver dysfunction. Br J Anaesth 1985;57:758-764.
39.
Lebrault C, Berger JL, D'Hollander AA, Gomeni R, Henzel D, Duvaldestin P: Pharmacokinetics and pharmacodynamics of vecuronium (ORG NC 45) in patients with cirrhosis. Anesthesiology 1985;62:601-605.
40.
Magorian T, Wood P, Caldwell J, Fisher D, Segredo V, Szenohradszky J, Sharma M, Gruenke L, Miller R: The pharmacokinetics and neuromuscular effects of rocuronium bromide in patients with liver disease. Anesth Analg 1995;80:754-759.
41.
Khalil M, D'Honneur G, Duvaldestin P, Slavov V, De Hys C, Gomeni R: Pharmacokinetics and pharmacodynamics of rocuronium in patients with cirrhosis. Anesthesiology 1994;80:1241-1247.
42.
Thomas SD, Boyd AH: Prolonged neuromuscular block associated with acute fatty liver of pregnancy and reduced plasma cholinesterase. Eur J Anaesthesiol 1994;11:245-249.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.