1. Fatty Liver and Pregnancy Shahin Merat, M.D. Professor of Medicine Digestive Disease Research Institute Tehran University of Medical Sciences 1

2. 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

3. 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. 4/54

5. 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

6. 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

7. Acute fatty liver of pregnancy 7

8. Symptoms Nausea and vomiting (75%) Abdominal pain (50%), Anorexia Jaundice 8

9. 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

10. Complications Infection Intraabdominal bleeding Transient central DI Renal dysfunction Pancreatitis 10

11. 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. 12/5 4

13. Nonalcoholic Steatohepatitis (NASH) Macrovesicular fat Part of the metabolic syndrome Three major factors Obesity Diabetes (or FHx of it) Hyperlipidemia (especially TG) 13

14. NASH 14

15. 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) 15/5 4

16. 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 16/5 4

17. Symptoms None! 17

18. Complications None! 18

19. Lab Data Elevated liver enzymes <300 IU/L ALT > AST Normal AlkP, bilirubin, PT Might have signs of impaired glucose tolerance Hyperlipidimia Obesity 19

20. Treatment Treat underlying cause Obesity Diabetes Hyperlipidemia Weight loss Exercise Check heart 20

21. 21/5 4

22. 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

23. 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

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