This handout is for acute fatty liver of pregnancy (aflp). Your care team identified this based on: third-trimester onset of nausea, vomiting, malaise, ruq/epigastric abdominal pain — common aflp prodrome (knight ukoss 2008 pmid 18332072).
Other reasons your team may use this plan: new jaundice + dark urine in third-trimester pregnancy with prodrome — alarm finding for aflp (swansea criterion bilirubin > 14 µmol/l); unexplained maternal hypoglycemia (< 4 mmol/l / 72 mg/dl) in 3rd-trimester pregnant patient — swansea criterion; high specificity for aflp; coagulopathy (pt > 14 s, aptt > 34 s, low fibrinogen) + transaminitis (alt/ast > 42 iu/l) in 3rd-trimester pregnancy without dic explanation — aflp red flag.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| prompt delivery (vaginal preferred if feasible; cesarean if expedited delivery required) | — | — | — | PregCat: N/A — obstetric intervention, not a drug. | Lactation: N/A — delivery event; lactation establishes postpartum. | CORNERSTONE of AFLP management per Knight UKOSS 2008 (PMID 18332072); maternal hepatic recovery starts within hours of delivery once fetal/placental trigger is removed; vaginal preferred if cervix ripe + coagulopathy correctable; cesarean if expedited delivery required (after FFP + cryoprecipitate correction if possible). |
| glucose (D10W) | D10W 100 mL bolus IV for hypoglycemia < 4 mmol/L then infusion 100-200 mL/h titrated to glucose ≥ 4 mmol/L | IV | continuous infusion titrated | PregCat: N/A — labeling does not assign for IV dextrose; resuscitation fluid in routine clinical use throughout pregnancy. | Lactation: compatible — physiologic carbohydrate; lactation use not constrained. | Replace impaired hepatic glycogen output; hypoglycemia is a Swansea criterion and an immediately reversible cause of altered mental status; q2-4h glucose monitoring; titrate to glucose ≥ 4 mmol/L. |
| fresh frozen plasma (FFP) | 10-15 mL/kg IV; recheck PT/INR + fibrinogen after each unit batch | IV | as needed to correct coagulopathy | PregCat: N/A — blood product. | Lactation: N/A — does not affect breastfeeding. | Replace depleted clotting factors in hepatic failure; target INR < 2 pre-delivery if possible; combine with cryoprecipitate for fibrinogen and platelets for thrombocytopenia. |
| cryoprecipitate | 10 units IV; recheck fibrinogen 30 min later; redose if fibrinogen < 200 mg/dL | IV | as needed to target fibrinogen ≥ 200 | PregCat: N/A — blood product. | Lactation: N/A. | Pregnancy baseline fibrinogen 350-650; < 200 is critical; cryoprecipitate is first-line fibrinogen replacement; framework per Pacheco SMFM 47 obstetric MTP guidance. |
| platelet transfusion | 1 pheresis unit (or 6-pack pooled) IV; target > 50 K intrapartum; > 100 K with active hemorrhage | IV | as needed | PregCat: N/A. | Lactation: N/A. | Correct thrombocytopenia from DIC overlap or HELLP-AFLP overlap; framework per Pacheco SMFM 47. |
| massive transfusion protocol 1:1:1 PRBC:FFP:platelets | Per local MTP — activate with anticipated EBL > 1500 mL or active uncontrolled hemorrhage with DIC | IV | as needed | PregCat: N/A. | Lactation: N/A. | Activate early given coagulopathy + delivery setting; framework per Pacheco SMFM 47 obstetric MTP. |
| phytonadione | 10 mg IV slow push (or PO/SC) daily; recheck PT/INR 12-24 h later | IV/PO/SC | daily until INR < 1.5 or hepatic recovery | PregCat: former C — labeling categorises as C; benefit-risk overwhelmingly favors use in coagulopathic AFLP. | Lactation: compatible per LactMed — newborns routinely receive vitamin K at birth; small amounts in maternal milk acceptable. | Replace vitamin-K-dependent factors; lower-yield in severe AFLP than FFP since the deficit is largely synthetic failure not vitamin-K depletion alone, but still standard adjunct. |
| hepatology and transplant center referral | — | — | — | PregCat: N/A — care-pathway action, not a drug. | Lactation: N/A. | Transfer to liver transplant center if fulminant features (INR > 2 despite FFP, persistent encephalopathy, persistent hypoglycemia, ammonia > 150) — Casey 2020 PMID 31991493 ALFSG cohort had 16 % requiring liver transplant; pre-transplant evaluation; bridge therapies (plasmapheresis, MARS, NAC) per hepatology. |
| plasmapheresis or MARS molecular adsorbent recirculating system | Per hepatology / nephrology / critical care; typically daily or alternate-day sessions | extracorporeal | per protocol | PregCat: N/A. | Lactation: N/A. | Limited evidence base; case-series support as bridge to recovery or transplant in fulminant cases; not routine but selectively used in tertiary/transplant centers. |
| newborn LCHAD / MCAD / long-chain fatty acid oxidation defect screening | — | — | — | PregCat: N/A — neonatal screening. | Lactation: N/A — pertains to newborn. | MANDATORY — cord blood + acylcarnitine profile (newborn screen) + targeted genetic testing for LCHAD HADHA G1528C mutation; positive screen → pediatric metabolism + nutrition specialist + dietary management with MCT-based formula + avoidance of fasting. Maternal LCHAD heterozygosity confers ~ 20-70 % recurrence in subsequent pregnancy. |
| lactulose for hepatic encephalopathy | — | — | — | PregCat: former B — long pregnancy experience; minimal systemic absorption. | Lactation: compatible — minimal systemic absorption. | 30-45 mL PO q6h titrated to 3 soft BMs/day; reduces ammonia in hepatic encephalopathy; adjunct to definitive delivery. |
Plan: AFLP emergent delivery + ICU supportive care — prompt delivery cornerstone + D10W for hypoglycemia + MTP/cryoprecipitate/vitamin K for coagulopathy + hepatology / transplant referral if fulminant + mandatory newborn LCHAD screening (Knight UKOSS 2008 PMID 18332072 + Ch'ng 2002 PMID 12427793 + Wang 2017 PMID 27923319 + Casey 2020 PMID 31991493)
Call 911 or go to the nearest emergency room right away if you have:
Maternal liver typically recovers within 1-2 weeks post-delivery; full biochemical recovery within 4-6 weeks. NEWBORN: mandatory LCHAD/MCAD/long-chain FAO screening (newborn screen acylcarnitine profile + targeted genetic testing); positive screen → pediatric metabolism specialist + dietary management. MATERNAL genetic counseling — heterozygous LCHAD carrier status confers ~ 20-70 % recurrence in subsequent pregnancy + lifelong implications. Mental-health screen (peripartum PTSD + EPDS — survival from a near-fatal pregnancy event carries significant burden). Subsequent-pregnancy counseling — tertiary-center delivery + early-3rd-trimester surveillance + family planning input.
Guideline: Knight UKOSS 2008 (Gut) prospective national surveillance + Ch'ng 2002 (Gut) Swansea criteria-defining cohort + Wang 2017 (J Matern Fetal Neonatal Med) Swansea validation + Casey 2020 (Hepatology) US ALFSG cohort + obstetric MTP framework + LactMed for phytonadione