ACUTE FATTY LIVER
A 29 year-old primigravida is at 33 weeks’ gestation. She is brought to the
maternity unit by her husband who states she is becoming mentally
confused. He reports she started experiencing nausea and vomiting three
days ago which are becoming worse, associated with lack of appetite.
Fundal height is 30 cm. Fetal heart rate 145/min with non-reactive non-
stress test, BP 150/95 mm Hg, random blood glucose 52 mg/dL. Platelet
count is 75,000 and PTT is prolonged at 64.7 seconds. Creatinine is 2.1
mg/dL. Uric acid is 11.9 mg/dL, lactic dehydrogenase 1063 U/I, ALT 220
U/I, AST 350 U/I, total bilirubin 8.4 mg/dL. Serum ammonia is elevated.
Urine protein dipstick is 3+.Acute fatty liver is a rare, life-threatening complication of pregnancy that usually
occurs in the third trimester. Prevalence is 1 in 15,000. Maternal mortality rate is
20%. It is thought to be caused by a disordered metabolism of fatty acids by
mitochondria in the fetus, caused by deficiency in the long-chain 3-hydroxyacyl-
coenzyme A dehydrogenase (LCHAD) enzyme.
Clinical Findings. Symptom onset is gradual, with nonspecific flulike
symptoms including nausea, vomiting, anorexia, and epigastric pain.
Jaundice and fever may occur in as many as 70% of patients.
Hypertension, proteinuria, and edema can mimic preeclampsia.
This may progress to involvement of additional systems, including acute renal
failure, pancreatitis, hepatic encephalopathy, and coma. Laboratory findings
may include: moderate elevation of liver enzymes (e.g., ALT, AST, GGT),