INCIDENCE

HEPATIC RUPTURE /
INFARCT. IN PREGN.
1 : 40.000-250000
>75% Elderly Multigr. +PE
MMR : 59-70%
PMR : > 75%

ACUTE FATTY LIVER

IN PREGNANCY
1 : 13.000
AFLP + PE ( > 50% )
MMR : 18%
PMR : 23%

FULMINANT HEPATIC FAILURE

SEVERE COMPLICATION
Lost of 80-90% Liver cell function

MMR }
: 80%
PMR }

( HUNT & SHARARA , 1999 )

COMMON CAUSES

ACUTE FATTY LIVER IN PREGNANCY

PARACETAMOL OVERDOSE
IDIOSYNCRATIC REACTION TO MEDICATION
( TETRACYCLIN, TRIGLUTAZONE )

SEVERE ALCOHOLIC HEPATITIS

VIRAL HEPATITIS A / B
( HEP-C VERY RARE )

ASPIRIN INTOXICATION
( REYE SYNDROME )

WILSONS DESEASE
( HERIDITARY COPPER ACCUMULATION RARE )

( LARSEN et al., 2002 ; OGRADY, 2005 )

COMPLICATION

HEPATIC ENCEPHALOPATHY
IMPAIRED PROTEIN SYNTHESIS
( ALBUMIN

AND PROTHROMBIN TIME

( OGRADY, 1993 )

CLINICAL SIGN

CLINICAL SIGN
OF UNDERLYING
LIVER DESEASES
ACUTE HEPATIC FAILURE
( EPIGASTRIC PAIN / RUQ )
ACUTE FULMINANT
HEPATIC FAILURE
COMA / ENCEPHALOPATHY
SEVERE COAGULOPATHY
HYPOGLYCEMIA
DEATH

CLINICAL SIGN
UNDIAGNOSED
AFLP IN PE
PROGRESSIVE
ACUTE FULMINANT
HEPATIC FAILURE
DEATH
FETUS/MOTHER

CLASSIFICATION
FIRST SIGN OF LIVER DESEASES
1 WEEK : HYPERACUTE
8 28 DAYS : ACUTE
4 12 WEEKS : SUBACUTE

( OGRADY, 2005 )

CLINICAL
CONSEQUENCES
CEREBRAL OEDEMA
( ENCEPHALOPATHY )
COAGULOPATHY
RENAL FAILURE ( > 50 % )
INFLAMMATION / SIRS ( 60 % )
METABOLIC DERANGEMENT
HEMODYNAMIC & CARDIORESP.
( ARDS / PLEURAL EFFUSION > 50% )
ADRENAL INSUFFICIENCY ( 60% )

( HARRY el al., 2002; POLSON et al.2005 ; OGRADY 2005 )

LIVER FAILURE IN REGNANCY

AFLP
Onset
Clinical Sympt.

Other Feature
LAB.FINDINGS
AST
Bilirubin
Hemolysis
Leucocytosis
Thrombopenia
FDP
Amnonia
DIC
Hypoglycemia
Diagnosis
Histology
periTreatment

Third Trimester
Nausea, Vomiting
Abd. Pain , Coma

( RIELY & FALLON, 2004 )

Fulminant Hep.
Third Trimester
Nausea Vomiting
Abd. Pain, Hepatic
Encephalopathy

PE/E
Third Trimester
Nausea, Vomiting
Abdominal Pain
Convulsion

Ht, Oedema
Proteinuria

Hep. A or B
serologic finding

Ht, Oedema
Proteinuria

< 1000
2 10 mg/dL
Occasional
90 100%
Rare
Often
Increase
Common
Occurs
Liver Biopsy
if Coag. Normal
Centrilobular

500 3000
20 30
Usual
Variable
50%
Occasional
Increase
Occasional
Rare
Hepatitis studies
Biopsy if possible
Multiloblar collaps

Usually < 2000

16
Usual
Not found
90 100%
Usual
Normal
Usual
No
Response to Del.
Biopsy as needed
Fibrin thrombi,

microvesicular fat
Prompt delivery
Fresh frozen plsm.

and necrosis
Deliv. for fetal surv.

portal hemorrhage
Control PE/E, DIC
Prompt delivery

LAB. EVALUATION
PROTHROMBIN TIME
COMPLETE BLOOD COUNT
AST ; ALT ; GGT; ALK.PHOSP.
TOTAL BILIRUBIN ; ALBUMIN
RENAL FUNCTION TEST
ELECTROLYTE
( Na, K, Mg, Cl, Ca )
BLOOD GAS ( Arterial ), LACTATE
BLOOD TYPE & SCREEN
GLUCOSE, AMYLASE, LIPASE
TOXICOLOGY SCREEN
( Paracetamol level )
VIRAL HEP. SEROLOGY & HIV
AUTOIMMUNE MARKER
( ANA, ASMA, LKMA )
CERULOPLASMIN LEVEL
( Wilsons Desease )
AMONIA ( Arterial )

( POLSON et al., 2005 )

MANAGEMENT
HOSPITAL ADMITTANT
ICU SUPPORTIVE TX NUTRITION
FLUID BALANCE
MECHANICAL VENTILATION
INTRACRANIAL PRESSURE MONITORING
( in severe Encephalopathy )
ELIMINATION OF UNDERLYING CAUSED
( NAC for Paracetamol intoxication )
DRAINAGE OF ASCITES & PLEURAL EFF.
LIVER TRANSPLANTATION
( in severe condition )

( OGRADY, 1989 )

MANAGEMENT
KING COLLEGE HOSPITAL CRITERIA
FOR LIVER TRANSPLANTATION IN
FULMINANT HEPATIC FAILURE
( ACUTE LIVER FAILURE )

PATIENS WITH PARACETAMOL INTOXICATION

pH. < 7,3

PROTHROMBIN TIME > 100 sec.

SERUM CREATININ > 3,2 mg/dL
ENCEPHALOPATHY GRADE III / IV

( OGRADY, 1989 )

MANAGEMENT

KING COLLEGE HOSPITAL CRITERIA

FOR LIVER TRANSPLANTATION IN
FULMINANT HEPATIC FAILURE
( ACUTE LIVER FAILURE )

OTHERS
Prothrombin Time > 100 sec.
OR
3 of the following variables
Age < 10 yrs or > 40 yrs
Caused : - non A, non B Hepatitis
- Halothane Hepatitis
- Drug reaction
Duration of jaundice
before encephalopathy < 7 days
Prothrombin Time > 50 sec.
Serum Bilirubin level > 17,6 mg/dL
( OGRADY, 1989 )

PROGNOSIS
@ BEFORE LIVER TRANSPLANT ---- MMR 80 %
@ MULTIDISCIPLIN , ICU AND LIVER TRANSPL.
IMPROVE THE PROGN.SIGNIFICANTLY
THE OVERALL SHORT TERM SURVIVAL 65 %
@ PROGN. SCORING SYSTEM TO PREDICT MMR
AND IDENTIFY WHO WILL REQUIRED TRANSPL.
- King College Hosp. Criteria
- MELD Score
- APACHE Score
- CLICHY Criteria

( OSTAPOWICS et al., 2002 )

PROGNOSIS

THE BEST PROGNOSIS

THE HYPERACUTE GROUPS

( SASS & SHAKIL, 2005 )