Double Trouble of Liver in Pregnancy: A Boon in Disguise!

Abstract

Liver diseases unique to pregnancy are categorized based on the stage of pregnancy they occur. In the intensive care unit (ICU), common liver disorders encountered include intrahepatic cholestasis of pregnancy (ICP), acute fatty liver of pregnancy (AFLP), and hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. ICP is the most prevalent liver disorder during pregnancy and generally has a good prognosis after delivery. AFLP, on the other hand, is a potentially life-threatening condition that typically manifests in the second to third trimester of pregnancy. In this particular case, unique instance of AFLP and ICP overlap, with both the mother and fetus surviving. The patient initially presented with acute liver failure even after the delivery of the fetus, leading to a working diagnosis of AFLP based on clinical signs, symptoms, and laboratory reports. Subsequently, the patient developed multiorgan dysfunction syndrome (MODS) and required invasive ventilator support, renal replacement therapy, and measures to reduce intracranial pressure. Fortunately, the patient recovered from MODS; however, her liver function tests remained elevated. A liver biopsy was performed, revealing microvesicular fatty accumulation in hepatocytes and bile plugs in biliary ducts, confirming the diagnosis of AFLP with ICP. While the pathophysiology and clinical presentations of these conditions differ, there can be some overlapping and masked symptoms, particularly in critically ill patients. Although rare, there have been a few documented cases of simultaneous occurrence of ICP and AFLP in critically ill patients.