Acute tubular necrosis

WASHINGTON -- Acute fatty liver of pregnancy must be ruled out in any woman who presents in the third trimester with nausea, vomiting, epigastric pain, or malaise, Michael F. Fesenmeier, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The disorder is rare, estimated to affect only 1 in 7,000-16,000 pregnancies. But it is deadly. Maternal and neonatal mortality rates of 75% have been reported in some studies.

"Physicians must be diligent in diagnosing acute fatty liver of pregnancy, and be prepared for its high morbidity and mortality," said Dr. Fesenmeier of the University of Cincinnati Medical Center.

He and his associates assessed the clinical presentations and outcomes of all 16 women treated for acute fatty liver of pregnancy (AFLP) at three tertiary-care centers in Ohio and Kentucky between 1993 and 2003. The average gestational age at diagnosis was 35.2 weeks (range, 30.0-37.2 weeks). There were 13 singleton and 3 twin pregnancies.

Nausea and vomiting were the most common presenting symptoms, affecting 12 patients (75%). The average duration of nausea and vomiting before the women presented for emergency care was 3-4 days, but some women went undiagnosed for much longer, including one who was undiagnosed for 3 weeks. That patient died within a month of delivery.

Other symptoms included epigastric pain in seven patients (43%), jaundice in six (38%), malaise in five (31%), and loss of consciousness in one (6%), he said in a poster presentation at the meeting.

There were two maternal deaths from multiorgan failure (12.5% maternal mortality) and three fetal deaths (15% infant mortality). Ten women (62%) developed acute tubular necrosis, seven (43%) developed pulmonary edema, seven (43%) developed disseminated intravascular coagulation, and six (38%) developed pancreatitis.

The average length of stay was 15 days, with a range of 5-58 days. Three women were referred for liver transplantation at hospital discharge.

Clinical and laboratory findings of AFLP often overlap with those of HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), and pancreatitis. "We recommend that patients who present with nausea, vomiting, epigastric pain, or malaise in the third trimester should receive evaluation of liver enzymes, renal function, and a complete blood count to rule out the diagnosis of AFLP," Dr. Fesenmeier said.

BY MARY ANN MOON

Contributing Writer

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