Acute fatty liver disease a rare serious condition

1. Acute fatty liver disease • a rare • serious condition • uncertain etiology it is part of the pre-eclampsia spectrum. • Women with a raised body mass index (BMI), primigravidae and women with a multiple pregnancy appear to be at risk.

2. -Five out of the following symptoms • -usually present after 30 weeks of pregnancy: • -nausea, vomiting, polyuria, polydipsia, fever, headache, encephalopathy, pruritus, abdominal pain, tiredness, confusion, jaundice, anorexia, ascites, coagulopathy, hypertension, proteinuria, liver failure and hepatic encephalopathy

3. - deteriorate rapidly, especially liver function, affecting both maternal and fetal morbidity and mortality. • - Te woman must be referred to a specialist hepatologist for further investigation and to exclude alternative diagnoses such as HELLP.

4. -Management is to hasten the birth of the baby ,prepare the woman for a preterm birth. • - Careful fluid balance • - DIC is a significant risk. • -Following the birth the woman is likely to be transferred to an ICU/HDCU where her condition should begin to improve after 48 hours

5. Metabolic disorders • Obesity • -one of the most significant health concerns affecting society, with significant impact on the maternity services • - serious morbidity or mortality is related to increasing weight & development of disease e.g. cardiovascular disease, certain cancers and type 2 diabetes mellitus.

6. -The increasing prevalence of obesity is commonly called an epidemic , although obesity does not resemble an infectious disease; • - Using BMI classification, statistics demonstrate 25% of adults over 16 years are obese (BMI ≥30 kg/m2) of which 18.5% are women of childbearing age

7. 5% of the population having a BMI ≥40 kg/m2 Classifying size using body mass index (BMI) • -Obesity is diagnosed using the BMI as a measure of fatness, • - assessing a person's level of body fat than measuring solely height and weight • - Obesity is defined as a BMI ≥30 kg/m2 and can be subdivided into classes I, II and III

8. - As a screening tool for fatness, the BMI is considered accurate body fat distributions, muscle and bone density, ethnic variations, gender specifics or age effect.

9. - As a screening tool for fatness, the BMI is considered accurate body fat distributions, muscle and bone density, ethnic variations, gender specifics or age effect.

10. W HO int e r na t io na l bo dy m a ss inde x ( BM I ) cla ssifica t io ns ( kg / m 2 ) • Under-weight = <18.5 • Normal range = 18.5–24.9 • • Pre-obese = 25.0–29.9 • Obese = ≥30.0 • Obese Class I = 30.0–34.9 • Obese Class II = 35.0–39.9 • Obese Class III = ≥40.0

11. Distribution of body fat and disease • -a disordered glucose tolerance which ohen contributes to medical complications such as type 2 diabetes mellitus. • - visceral fat (fat retained abdominally) is metabolically more active, contributing to metabolic syndrome which is directly associated with cardiovascular disease and type 2 diabetes

12. Obesity as a concept • - risk of developing chronic disease • - Social scientists would agree that obesity is not a disease, but is a social construct defined as a disease, because it is considered abnormal in current Western culture • - significant stigma and discrimination the cause of obesity is multifactorial:

14. genetics, biology and behaviour on a background of cultural, environmental and socialfactors, where the individual plays a passive role within an obesogenic society

15. Obesity demographics • - increased rates of obesity in poorer societal groups, especially younger age groups. • -Children born into lower social class families are likely to become obese • more in women than in men, probably because of the complexity of the role of women in society .

16. Pathophysiology of obesity • increasing their risk of developing metabolic syndrome. • - central obesity, causes metabolic dysfunction involving primarily lipids and glucose, results in organ dysfunction within many of the body systems, especially the cardiovascular system. • - Other risk factors for metabolic syndrome include family history, poor diet and a sedentary lifestyle.

17. -Metabolic syndrome is thought to be caused by visceral adipose tissue causing the release of pro-inflammatory cytokines, known as adipokines, which promote insulin resistance. • - This causes a systemic inflammatory response, which over time results in microvascular and endothelial dysfunction in all of the body systems.

18. -The individual will have atherogenic dyslipidaemia, identified by: • @ low high density lipoprotein (HDL) • @ raised triglycerides • @, hypertension • @raised fasting blood glucose levels. • - As well as insulin resistance, such individuals develop a prothrombotic state with raised fibrinogen and plasminogen-activator-inhibitor levels

19. Nutritional needs in pregnancy • -Weight gain is usual at certain times in a female's life,; • - e.g. during infancy • -between the ages of 5 and 7 years • - adolescence • - pregnancy • - menopause.

20. -Maternal over nutrition has permanent effects on a fetus, that is, a higher birth weight tends to result in a higher BMI as an adult • - Physiological changes in pregnancy predispose to weight gain, essentially to provide energy for labour and lactation, and this storage is facilitated by the effect that increases in estrogen, progesterone and human placental lactogen (HPL) have on glucose metabolism • -Women with a raised BMI should be advised and encouraged to lose weight pre-conceptually to optimize pregnancy outcomes

21. -A woman's basal metabolic rate (BMR) increases during pregnancy due to : • *the increased metabolic activity of the maternal and fetal tissues. • *The increased body weight • * the increased maternal cardiovascular, renal and respiratory load influence a rise in the basal metabolic rate (BMR), but in part this is counterbalanced by a general decrease in activity.

22. -The resulting increase in required calorie intake is therefore relatively small; an extra 200 kcal per day are required during the third trimester for most women • -Weight gain in pregnancy is dependent on factors: • diet, activity and maternal wellbeing

23. Antenatal care • The BMI is routinely calculated at the initial visit with the midwife (booking) • - a raised BMI are ohen referred to a multiprofessional antenatal clinic, which involves specialist midwives, obstetricians and dieticians ( • - lifestyle interventions were introduced for obese and overweight women during pregnancy, the gestational weight gain was reduced, along with a reduction in the prevalence of gestational diabetes.

24. -Obesity is a significant risk factor for maternal mortality • & poor perinatal outcomes, • -Women with obesity might find some minor disorders of pregnancy, such as back pain and fatigue, are exacerbated

25. Risks a sso cia t e d wit h o be sit y in pr e g na ncy Maternal • Miscarriage and stillbirth • Gestational diabetes: offered a glucose tolerance test (GTT) at 24–28 weeks if BMI ≥30 • Hypertension: ensure correct size cuff and increase surveillance if BMI ≥35; increase antenatal appointments to screen for PET to every 3 weeks between 24 and 32 weeks and refer to specialist care if one or more additional risk factors are present, e.g. first baby, raised BP at booking

26. Venous thromboembolism: assess risk at every visit; prophylaxis is recommended if two or more risk factors are present • Prolonged pregnancy: risks associated with induction of labour • Presence of pre-existing medical conditions, e.g. ischaemic heart disease • Poorer mental health, e.g. depression

27. Fetal • Neural tube defects (NTDs): all women should take 5 mg folic acid daily • Macrosomia • Preterm labour • Lower Apgar scores • Late stillbirth • Neonatal mortality

29. Maternity services • Increased hospital admissions • Increased costs associated with managing complications • Increased length of hospital stay • Increased neonatal care requirements

30. report of psycho-social issues related to their increased BMI. • - worry about weight gain • - a variety of feelings towards their body image, but generally feel less stigma and discrimination, as weight gain is more socially acceptable while pregnant .

31. -ensure suitable equipment and staffing levels are available, e.g. suitable beds and chairs, large BP cuffs, sufficient operating department staff in respect of caring for women with obesity. • Risk assessments for labour should be undertaken antenatally for each woman

32. Intrapartum care • - encouraging mobility and an upright position. • Box 13.10 • I nt r a pa r t um r isks a sso cia t e d wit h o be sit y • Prolonged pregnancy and induction of labour • Prolonged labour: labour is slower and there is often a delay between 4–7 cm with syntocinon use being higher. There should be close observation of progress in labour with one-to-one care for women with a BMI ≥40 • Complications, e.g. shoulder dystocia • Emergency caesarean birth: if a woman has a BMI >40 the incidence is almost 50%. • There is an increased risk of malpresentation, e.g. occipito-posterior (OP) position and vaginal birth after caesarean (VBAC) is less successful

33. Primary postpartum haemorrhage (PPH): venous access and active management of the third stage of labour is recommended for women with a BMI ≥40 • there may be difficulties in assessing maternal and fetal wellbeing during labour, e.g. ensuring a good quality cardiotocograph (CTG) recording, undertaking vaginal examinations and performing manoeuvres in an emergency such as shoulder dystocia • difficulties in managing intraoperative complications such as controlling haemorrhage.

34. Risks a sso cia t e d wit h o be sit y in t he po st na t a l pe r io d • Maternal • Venous thromboembolism: early mobilization following birth encouraged. • Prophylaxis considered even following vaginal birth • Longer postoperative recovery • Increased postoperative complications, e.g. wound dehiscence and infection • Tendency to retain pregnancy weight gain • Lowered rates of breastfeeding duration • Reduced contraception choices: depending on presence of co-

36. Postnatal care • Neonatal • Increased risk of congenital abnormality, e.g. heart defects • Macrosomia: increased risk of trauma from birth; practical difficulties associated with undertaking the neonatal examination • Low birth weight: e.g. increased rates of cardiovascular disease and diabetes mellitus in middle age

37. Breastfeeding reduce the weight a woman has gained in pregnancy • -It is known that obese women have delayed lactogenesis and a lowered response of prolactin to suckling, leading to reduced milk production and premature cessation of breastfeeding. • However, the response to prolactin is reduced over time so extended support from midwives skilled at supporting the continuance of breastfeeding is especially important in this group of women.

38. -Weight gained in pregnancy is difficult to lose postnatally due to a number of factors such as : • 1-the demands of caring for a new baby, • 2- eating irregular meals • 3- an inability to exercise as frequently. This may result in higher rates of obesity in later life (Gardner et al 2011). Women who were obese during pregnancy also exhibit a tendency to retain

39. -weight reduction has been shown to improve outcomes in any subsequent pregnancy Discussions around weight, activity and healthy lifestyle modification behaviours by healthcare professionals during the 6–8 weeks postnatal examination are recommended.

40. -If co-morbidities such as gestational diabetes have been diagnosed during pregnancy a glucose tolerance test (GTT) should be undertaken at the postnatal examination and the woman should continue to have annual cardiometabolic screening

41. Obstetric cholestasis • Obstetric cholestasis (OC) is also known as intrahepatic cholestasis of pregnancy • - specific to pregnancy • -a disruption and reduction of bile products by the liver. • raised serum bile acids and usually appears aher the 28th week gestation, • resolving 2 weeks following the birth of the baby. • c\p: • intense itching (pruritus) that mainly affects the soles of the feet, hands and body

42. worse at night, • -no visible rash. • loss of sleep. • Urinary tract infections (UTI) are common • jaundice may occur, with the woman stating that her faecal stools are pale. • Treatment: topical creams, • -ursodeoxycholic acid and chlorampheniramine may be prescribed. • - oc: causes severe liver impairment and increases perinatal morbidity and mortality (Saleh and Abdo 2007). Timing of the birth depends on gestational age and fetal wellbeing, which is monitored through fetal growth and biophysical profiles, fetal movements and CTG. • -Birth before 38 weeks is usually advocated • - increased risk of postpartum haemorrhage (PPH) due to coagulation disruption. • -Oral vitamin K 10 mg is ohen prescribed to lessen the risk • - active management of the third stage of labour is advised. • - Postnatal care is based on ensuring liver function tests (LFTs) return to normal. • - Recurrence in a subsequent pregnancy is high, at around 90%.