Fatty Liver and PregnancyShahin Merat, M.D.Professor of MedicineDigestive Disease Research Institute Tehran University of Medical Sciences

1

Case 1• 23 y/o female, GA 32 wk• First pregnancy, Twin• 37 kg before pregnancy• Severe nausea and vomiting• AST: 420, ALT: 350, AlkP: 382, Bil: 2.7/1.9• Hgb: 11.2, WBC: 11,200, Plt: 107,000• Urea: 50, creat: 2.1• Preeclamptic• Sono: increased echogenicity

2

Case 2• 34 y/o female, GA 23• 72 kg before pregnancy• Mild nausea and vomiting• AST: 100, ALT: 130, AlkP: 340, Bil: 1.3/0.7• Hgb: 11.2, WBC: 9,300, Plt: 249,000• Urea: 22, creat: 0.7• Diabetes of pregnancy• Sono: increased echogenicity

3

4/54

Acute fatty liver of pregnancy • Prevalence: 1 in 7000 to 1 in 20,000 deliveries• In the second half of pregnancy, usually close to term• Some patients may be diagnosed after delivery • Over half of patients have preeclampsia• Maternal mortality: 18%• Fetal mortality: 23%.• Recurrent liver disease in up to 25%.

5

Acute fatty liver of pregnancy • Microvesicular fatty infiltration of hepatocytes without

inflammation or necrosis, • perhaps due mitochondrial injury

• Ultrasound detects the increased fat in liver.• More frequent in multiple pregnancy, nulliparity, male fetus,

or signs of toxemia.• Maybe more frequent in underweight mothers

6

Acute fatty liver of pregnancy

7

Symptoms• Nausea and vomiting (75%)• Abdominal pain (50%), • Anorexia• Jaundice

8

Lab Data• Bilirubin usually elevated• Abnormal LFT (up to 1000 IU/L)• Platelet count may be decreased, especially if with DIC• Increased WBC• PT prolongation• Hypoglycemia• Elevations in serum ammonia• ARF in up to 60%• Hyperuricemia• Overlap with HELLP• Evidence of liver failure (eg hypoglycemia, encephalopathy)

9

Complications• Infection• Intraabdominal bleeding• Transient central DI• Renal dysfunction• Pancreatitis

10

Treatment• Immediate termination• Supportive care• FFP, platelets, glucose, dialysis

• Usually stabilize in 7-10 days after delivery• No liver sequel• Might repeat in next pregnancy (up to 25%)

11

12/54

Nonalcoholic Steatohepatitis (NASH)

• Macrovesicular fat• Part of the metabolic syndrome• Three major factors• Obesity• Diabetes (or FHx of it)• Hyperlipidemia (especially TG)

13

NASH

14

NAFLD• Simple Fatty Liver• Only deposition of fat in liver• No inflammation• No fibrosis• Not believed to progress to cirrhosis• Up to 25 % of some populations!

• Non-Alcoholic Steatohepatitis (NASH)

15/54

NASH - Definition• Moderate to gross macrovesicular fatty change with

inflammation (lobular or portal) with or without Mallory bodies, fibrosis, or cirrhosis

• Negligible alcohol consumption (<40 g/wk)• Absence of serologic evidence of infection with hepatitis B or

hepatitis C

16/54

Symptoms• None!

17

Complications• None!

18

Lab Data• Elevated liver enzymes• <300 IU/L• ALT > AST

• Normal AlkP, bilirubin, PT• Might have signs of impaired glucose tolerance• Hyperlipidimia• Obesity

19

Treatment• Treat underlying cause• Obesity• Diabetes• Hyperlipidemia

• Weight loss• Exercise• Check heart

20

21/54

Case 1• 23 y/o female, GA 32 wk• First pregnancy, Twin• 37 kg before pregnancy• Severe nausea and vomiting• AST: 420, ALT: 350, AlkP: 382, Bil: 2.7/1.9• Hgb: 11.2, WBC: 11,200, Plt: 107,000• Urea: 50, creat: 2.1• Preeclamptic• Sono: increased echogenicity

22

Case 2• 34 y/o female, GA 23• 72 kg before pregnancy• Mild nausea and vomiting• AST: 100, ALT: 130, AlkP: 340, Bil: 1.3/0.7• Hgb: 11.2, WBC: 9,300, Plt: 249,000• Urea: 22, creat: 0.7• Diabetes of pregnancy• Sono: increased echogenicity

23

24