Acute Fatty Liver of Pregnancy: Better Understanding of Pathogenesis and Earlier Clinical Recognition Results in Improved Maternal Outcomes

Acute fatty liver of pregnancy (AFLP) is an uncommon disorder affecting women in late pregnancy. It is increasingly recognised as an important cause of preventable maternal mortality across the world. The pathogenic mechanism of AFLP is now better understood; it appears that a compensated defective fatty acid oxidation becomes overt when metabolic stressors are superimposed on the increased energy demands of late pregnancy. The mother tends to rely more on fats as a source of energy in late pregnancy. This phenomenon may have an evolutionary basis and may explain why AFLP typically occurs in late pregnancy. The Swansea criteria have proven to be useful in early diagnosis of AFLP. Attempts to simplify these criteria further have proved helpful in early recognition of the disease. Although liver biopsy showing microvesicular steatosis of hepatocytes is the pathologic hallmark of AFLP, it is neither necessary nor safe in the antepartum setting. Current management strategies revolve around ensuring urgent delivery of the fetus and anticipating and managing complications of acute liver failure. While early recognition and multidisciplinary management have considerably improved maternal survival in AFLP, fetal outcomes remain poor. The authors postulate a therapeutic intervention to improve fetal outcomes in this disorder.