Acute fatty liver of pregnancy complicating a twin pregnancy
A 37-year-old primigravida with twin gestation at 34-week was admitted with epigastric discomfort, abdominal pain, malaise and vomiting. Diagnosed with hypertension in third trimester, she was prescribed alpha methyldopa. Heart rate was 102/min and blood pressure was 170/90 mm Hg. Icterus was noticed later on the day. Foetal heart sounds were heard. Ultra sonography of abdomen showed fatty liver and twin pregnancy []. Investigations: haemoglobin - 10.7 g%, total count - 10,700/mm3, platelets - 2.6 lakhs, urea - 11 mg/dl, creatinine - 1.4 mg/dl, uric acid - 5.3 mg/dl, lactate dehydrogenase - 442 U/L, peripheral smear negative for haemolysis. Hepatitis B surface antigen, hepatitis C virus and human immunodeficiency virus negative, prothrombin time test 48 s control - 14 s, International Normalised Ratio - 4.0, total bilirubin - 7.8 mg/dl (0.3-1.0 mg/dL), direct bilirubin - 4.0 mg/dl (0z, serum glutamic oxaloacetic transaminase - 316 U/L (0-35 U/L), serum glutamic-pyruvic transaminase - 313 U/L (0-35 U/L), alkaline phosphatase 974 (30-300 IU/L), total protein - 5.3 U/L, albumin - 2.8 U/L, globulin - 2.5 U/L, plasma ammonia - 93 meq/d, urine albumin++, cardiotocography showed evidence of foetal distress. A presumptive diagnosis of pre-eclampsia and/or acute fatty liver of pregnancy (AFLP) was made. Emergency caesarean section was planned under general anesthesia. She was given vitamin K and fresh frozen plasma (FFP). Induction by rapid sequence using thiopentone, followed by suxamethonium, trachea intubated using size seven endotracheal tube. Anaesthesia maintained with oxygen: Nitrous oxide, sevoflurane, fentanyl and atracurium. Mannitol and albumin were transfused to prevent hepatorenal syndrome. Twin babies delivered were healthy. Extubation and recovery were uneventful. Cryoprecipitate and FFP were transfused in post-anaesthesia care unit. Broad spectrum antibiotics started. Magnesium sulphate was continued at 2 g/h. Serum magnesium levels monitored 6th hourly were normal. On the second post-operative day, liver function deteriorated further. On the 3rd post-operative day, she had two episodes of tonic clonic convulsions and respiratory distress. Chest X-ray was suggestive of acute respiratory distress syndrome. Mechanical ventilation initiated in synchronized intermittent mandatory ventilation mode with pressure support. Antibiotic was changed to tobramycin based on culture and sensitivity report. Computed tomography scan brain and electroencephalography were normal. Repeat ultra sound scan of abdomen showed ascites with hyperechoic features suggestive of haemorrhagic ascites as the patient already had coagulopathy. There were no gall stones or dilatation of biliary tract. Central venous pressure was maintained between 8 and 12 mm Hg. Weaned off on the 7th day but non-invasive ventilation was continued for three more days. Hepatic function gradually improved. Viral markers were negative on repeated tests. Coagulopathy was corrected with a total of 32 units of FFP, 4 units of platelets and 12 units of cryoprecipitate. Patient gradually improved with supports and was shifted out from post-operative intensive care unit on the 20th day.