RECURRENT PREGNANCY AFTER ACUTE FATTY LIVER: SAFE OR SORRY?

Barton and colleagues report the first documented case of recurrent acute fatty liver of pregnancy (AFLP). The patient initially presented at 28 wk gestation complaining of nausea, vomiting, and right upper quadrant pain (Mabie et al., Am J Obstet Gynecol, 158: 142–145, 1988). Her blood pressure was 120/80 mm Hg, and she had mild conjunctival icterus. Laboratory results included a bilirubin of 5.6 mg/dl, alkaline phosphatase of 553 U/L, aspartate aminotransferase of 946 U/L, and prothrombin time of 15.4 s. The urine was free of protein. Hepatitis B serology and hepatitis A IgM were negative. The patient became hypertensive and hypoglycemie during labor, and was delivered of a stillborn infant. A percutaneous liver biopsy revealed microvesicular steatosis consistent with a diagnosis of acute fatty liver of pregnancy. All abnormalities subsequently resolved, and the patient was discharged. Sixteen months later, The patient, again pregnant, returned at 30 wk gestation with complaints of nausea, vomiting, anorexia, fever, and epigastric pain. She offered that her symptoms were identical to those she bad experienced during her previous pregnancy. Her blood pressure was 110/80 mm Hg and She had mild conjunctival icterus. Laboratory values were as follows: bilirubin 3.3 mg/dl, alkaline phosphatase 362 U/L, aspartate aminotransferase 790 U/L, alanine aminotransferase 865 U/L, and prothrombin time 13.0 s. Hepatitis B serology, hepatitis A IgM, and dip‐stick test for urinary protein were negative. The patient again became hypertensive and hypoglycemic, and a 990‐g viable infant was delivered by cesarean section. Liver biopsy again demonstrated microvesicular steatosis, supporting a diagnosis of AFLP. Electron micrographs were also typical of this disorder.