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

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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

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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

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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%.

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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

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Acute fatty liver of pregnancy

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

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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

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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%)

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Nonalcoholic Steatohepatitis (NASH)

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

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NASH

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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)

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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

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Symptoms• None!

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Complications• None!

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

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

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Treatment• Treat underlying cause• Obesity• Diabetes• Hyperlipidemia

• Weight loss• Exercise• Check heart

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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

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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

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