Shahin Merat MD Professor of Medicine Digestive Disease Research Institute Tehran University of Medical Sciences 1 Case 1 23 yo female GA 32 wk First pregnancy Twin 37 kg before pregnancy ID: 1032965
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1. Fatty Liver and PregnancyShahin Merat, M.D.Professor of MedicineDigestive Disease Research Institute Tehran University of Medical Sciences1
2. Case 123 y/o female, GA 32 wkFirst pregnancy, Twin37 kg before pregnancySevere nausea and vomitingAST: 420, ALT: 350, AlkP: 382, Bil: 2.7/1.9Hgb: 11.2, WBC: 11,200, Plt: 107,000Urea: 50, creat: 2.1PreeclampticSono: increased echogenicity2
3. Case 234 y/o female, GA 2372 kg before pregnancyMild nausea and vomitingAST: 100, ALT: 130, AlkP: 340, Bil: 1.3/0.7Hgb: 11.2, WBC: 9,300, Plt: 249,000Urea: 22, creat: 0.7Diabetes of pregnancySono: increased echogenicity3
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5. Acute fatty liver of pregnancy Prevalence: 1 in 7000 to 1 in 20,000 deliveriesIn the second half of pregnancy, usually close to termSome patients may be diagnosed after delivery Over half of patients have preeclampsiaMaternal mortality: 18%Fetal mortality: 23%.Recurrent liver disease in up to 25%.5
6. Acute fatty liver of pregnancy Microvesicular fatty infiltration of hepatocytes without inflammation or necrosis, perhaps due mitochondrial injuryUltrasound detects the increased fat in liver.More frequent in multiple pregnancy, nulliparity, male fetus, or signs of toxemia.Maybe more frequent in underweight mothers6
7. Acute fatty liver of pregnancy 7
8. SymptomsNausea and vomiting (75%)Abdominal pain (50%), AnorexiaJaundice8
9. Lab DataBilirubin usually elevatedAbnormal LFT (up to 1000 IU/L)Platelet count may be decreased, especially if with DICIncreased WBCPT prolongationHypoglycemiaElevations in serum ammoniaARF in up to 60%HyperuricemiaOverlap with HELLPEvidence of liver failure (eg hypoglycemia, encephalopathy)9
10. ComplicationsInfectionIntraabdominal bleedingTransient central DIRenal dysfunctionPancreatitis10
11. TreatmentImmediate terminationSupportive careFFP, platelets, glucose, dialysisUsually stabilize in 7-10 days after deliveryNo liver sequelMight repeat in next pregnancy (up to 25%)11
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13. Nonalcoholic Steatohepatitis (NASH)Macrovesicular fatPart of the metabolic syndromeThree major factorsObesityDiabetes (or FHx of it)Hyperlipidemia (especially TG)13
14. NASH14
15. NAFLDSimple Fatty LiverOnly deposition of fat in liverNo inflammationNo fibrosisNot believed to progress to cirrhosisUp to 25 % of some populations!Non-Alcoholic Steatohepatitis (NASH)15/54
16. NASH - DefinitionModerate to gross macrovesicular fatty change with inflammation (lobular or portal) with or without Mallory bodies, fibrosis, or cirrhosisNegligible alcohol consumption (<40 g/wk)Absence of serologic evidence of infection with hepatitis B or hepatitis C16/54
17. SymptomsNone!17
18. ComplicationsNone!18
19. Lab DataElevated liver enzymes<300 IU/LALT > ASTNormal AlkP, bilirubin, PTMight have signs of impaired glucose toleranceHyperlipidimiaObesity19
20. TreatmentTreat underlying causeObesityDiabetesHyperlipidemiaWeight lossExerciseCheck heart20
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22. Case 123 y/o female, GA 32 wkFirst pregnancy, Twin37 kg before pregnancySevere nausea and vomitingAST: 420, ALT: 350, AlkP: 382, Bil: 2.7/1.9Hgb: 11.2, WBC: 11,200, Plt: 107,000Urea: 50, creat: 2.1PreeclampticSono: increased echogenicity22
23. Case 234 y/o female, GA 2372 kg before pregnancyMild nausea and vomitingAST: 100, ALT: 130, AlkP: 340, Bil: 1.3/0.7Hgb: 11.2, WBC: 9,300, Plt: 249,000Urea: 22, creat: 0.7Diabetes of pregnancySono: increased echogenicity23
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