Acute Fatty Liver of Pregnancy: What to Do When Initial Stabilisation and Delivery Do Not Restore Hepatic Recovery
Clinical scenario
This protocol applies when a patient with acute fatty liver of pregnancy has undergone initial management — including correction of metabolic derangements and expedited delivery — yet has not achieved the expected early postpartum recovery of liver function.
Previous treatment — failure condition
The preceding step involved stabilisation and correction of coagulopathy, hypoglycaemia, and metabolic acidosis, followed by expedited delivery of the fetus — with the mode of delivery determined by the multidisciplinary team. The goals of this initial approach were not met: liver transaminases did not fall below 100 IU/L by the second or third day postpartum, and prompt recovery of renal function was not achieved. This failure of response triggers escalation to the next-line protocol described here.
Next-line approach (partial overview)
In women with persistent severe hepatic impairment following delivery, specific post-delivery extracorporeal interventions may be considered to support maternal recovery and reduce the duration of illness. For those requiring intensive care unit admission, a targeted pharmacological approach may also be applicable. The complete structured regimen — including eligibility criteria, sequencing, and monitoring — is available via the link below.
References
DOI: 10.1016/j.jhep.2023.03.006
- Based on limited data from small case series, the use of plasma exchange post-delivery may be considered to improve maternal disease severity and decrease the time to recovery in women with acute fatty liver of pregnancy and severe hepatic impairment.
- There are no existing data to support or refute the benefit of N-acetylcysteine treatment in the management of acute fatty liver of pregnancy. However, benefits have been demonstrated in other causes of non-paracetamol-induced liver failure and it can be considered in women requiring admission to intensive care units.
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