BACKGROUND

1. Hepatorenal Impairment in pregnancy – Investigation and ManagementRagupathy K, Sidra L; Doncaster Royal Infirmary  BACKGROUND Acute fatty liver of pregnancy (AFLP) is a rare clinical entity with an incidence of 1in 7000 to 1in 16000, but a high mortality rate (30%) where diagnosis is delayed. We present a case report of AFLP and its management. PRESENTATION 24-year-old parous woman with a normal BMI presented to us at 38 weeks of gestation feeling unwell with a headache, malaise, epigastric pain, backache and generalized body pain. Her past medical and obstetric history was unremarkable. CLINICAL EXAMINATION Clinical examination revealed jaundiced sclera, borderline increased blood pressure (140-150/100 mm Hg), and absence of proterinuria. Symphisio-fundal height was appropriate for gestation. INVESTIGATIONS Initial bloods showed hepato-renal impairment with raised urea, creatinine, ALT, urates and conjugated bilirubin. Clotting was impaired with low platelets, prolonged prothrombin time and low fibrinogen levels. Though preeclampsia was the preliminary diagnosis, absence of proterinuria and overt jaundice prompted further investigations. Blood sugars showing persistent hypoglycaemia (<3g%) clinched the diagnosis of AFLP. MANAGEMENT Ten percent Dextrose infusion was commenced immediately to correct the blood sugars. Vaginally, the cervix was quite favourable and artificial rupture of membranes was done to expedite delivery An emergency lower segment caesarean section (LSCS) was done shortly thereafter when the CTG became suspicious in early labour and abruption noted. Baby was born in a good condition and LSCS was uncomplicated. POSTNATAL Post-natally she was cared for in high dependency unit and the physicians consulted as well. Improvement was seen clinically and biochemically on the first postoperative day. However, hypoglycaemia took a longer time to stabilise needing 48 hours of Dextrose infusion. Subsequent ultrasound of upper abdomen showed features compatible with fatty infiltration of liver. On the fourth post-natal day, her bloods had greatly improved with stabilisation of clotting parameters as well. She was discharged home with plan for follow up in the outpatient clinics (both obstetric and medical). Repeat bloods done 4 weeks later showed normal hepatic and renal function tests. Blood results of Hepatic/renal serology, viral screening were all normal. AFLP could manifest with common prodromal symptoms, but timely diagnosis avoids a fulminated clinical course. Index of suspicion should be high when women present with atypical pre-eclamptic picture.