Professor Lin Qiaozhi of modern Obstetrics and Gynecology in China
Many years ago it was proposed:
Pregnancy is not a disease, pregnancy should be prevented.
I've been an obstetrician for over thirty years.
I realized more and more the depth and importance of this sentence.
Pregnant in October, she gave birth.
During pregnancy,
People who are otherwise healthy may also have some diseases,
Or unpredictable anomalies can occur.
In the era of backward medical conditions,
A woman who is pregnant and gives birth is a ghost door.
Today, with the advancement of medical treatment,
Perinatal care is like a protective net,
It allows the vast majority of people to safely pass the pregnancy and childbirth.
What we healthcare workers do,
It's to weave this protective net a little tighter,
Less let the disease take advantage of the loophole.
But there are a small number of pregnant women,
Unfortunately, it will be targeted by the "cunning and sinister" pregnancy complications,
If early detection and early intervention are not possible,
The consequence could be a tragedy for the whole family.
"Acute fatty liver in pregnancy"
A rare but highly fatal complication in the third trimester.
This disease peculiar to pregnancy,
Even many medical staff do not understand,
However, once ignored,
The lives of both the pregnant woman and the fetus may not be insured.
The disease "Acute Fatty Liver In Pregnancy (AFLP)" is cunning and sinister:
First, because its symptoms are too atypical: nausea, vomiting, fatigue in the third trimester of pregnancy, it is easy to be mistaken for a normal reaction during pregnancy;
Second, the disease progresses rapidly, with acute renal insufficiency, disseminated intravascular coagulation, and multi-organ dysfunction occurring about two weeks after the onset of the disease.
Knowledge extension
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According to the first "Guidelines for the Clinical Management of Acute Fatty Liver Disease in Pregnancy" in Mainland China (which was first published in the Journal of Maternal-Fetal Medicine (English) in the 4th issue of 2021):
Acute fatty liver disease (AFLP) during pregnancy is a rare but critically ill disease endemic to pregnancy.
It generally occurs in the 30th to 38th week of pregnancy, mostly in the first trimester around 35 weeks of pregnancy, with an incidence rate of 1/7000 to 1/20000, and the maternal and infant mortality rate once reached 75% to 85% [1,2].
The occurrence and development of this disease is extremely fast, and the harm to the mother and fetus is huge.
The most serious maternal consequences are: acute liver failure, acute renal failure, multi-organ failure, DIC (diffuse intravascular coagulation), and even death; the most serious fetal consequences are: intrauterine fetal distress, fetal brain injury, intrauterine fetal death, etc.
Foreign studies have shown that patients have a mortality rate of 30% from the onset of symptoms to the onset of illness for more than 2 weeks [3].
Behind these words and figures above, there is a lot of blood lessons.
The following case occurred in an era when medical conditions were not so developed, and it makes me sad whenever I think about it.
More than 20 years ago, our hospital emergency department admitted a pregnant woman with twins in the third trimester.
At that time, when the pregnant woman turned from the outer courtyard, the general condition was already very poor, nausea and fatigue, and the skin was yellow.
The fetal heart of one fetus is no longer audible, and the other is beginning to slow down. After blood is drawn to check liver function, the diagnosis is "acute fatty liver in pregnancy".
Although the doctor on duty arranged emergency surgery at the first time, it was found that the mother's blood had not coagulated, severe liver and kidney failure, and the whole department fought up and down, and finally the pregnant woman and the fetus could not be rescued.
I often think that if I had just developed symptoms of nausea and fatigue two weeks ago, A pregnant woman would have been able to go to the hospital.
If the primary receiving doctor can recognize the disease, check her liver function, find abnormal liver function, and then do a caesarean section and terminate the pregnancy in time, then the outcome will be completely different.
Pathogenesis characteristics and high-risk groups of acute fatty liver disease during pregnancy:
Unlike other gestational liver diseases, the onset of acute fatty liver disease during pregnancy often occurs only in pregnant women during pregnancy, and after termination of pregnancy, the disease can often be effectively relieved, and the degree of liver damage can be completely reversed.
The specific pathogenesis of the disease is currently unclear.
According to the available evidence, some people are at high risk of the occurrence of this type of disease, including a history of acute fatty liver disease during the previous pregnancy, advanced first birth, multiple births, diabetes mellitus, and preeclampsia.
Last year, the doctors in our department met a pregnant woman who was 35 weeks pregnant at the outpatient clinic and was uncomfortable because of nausea.
Because the doctor is very familiar with the disease of "acute fatty liver in pregnancy", he is highly alert when he sees that the pregnancy and symptoms are very consistent.
It was already afternoon when the pregnant woman came to the doctor, although it was not on an empty stomach, but the doctor immediately arranged for her to have a blood biochemical examination.
As expected, liver function showed abnormalities, and blood clotting function began to appear a little abnormal.
After the diagnosis of the disease is clear, all that remains is to explain the condition to the patient and his family, arrange emergency surgery, and grab time with the disease.
Because this disease is only related to pregnancy, as long as it can be detected early, after the end of pregnancy, the patient's clinical symptoms generally recover within 3-4 days, and most of the liver and kidney dysfunction returns to normal in about 7 days [4].
When the receiving doctor informed the family of the diagnosis and severity of the disease, the patient's husband seemed to be a little indifferent, and several doctors were changed to communicate, and the family was still very calm.
It turned out that he himself was relatively fat, and he had also found fatty liver during the physical examination, so from the bottom of his heart, he felt that "his wife had only a common disease, and the doctor was a bit fussy."
But what he didn't know was that the fatty liver of ordinary people and the "acute fatty liver of pregnancy" were two completely different diseases.
Fortunately, after our explanation, the family realized the seriousness of the disease, and the patient underwent a caesarean section in time and underwent symptomatic treatment, and finally the mother and child were safe.
Treatment of acute fatty liver in pregnancy:
Acute fatty liver disease during pregnancy is a disease that progresses rapidly, and termination of pregnancy is currently the only effective means to slow the progression of the disease and improve the prognosis.
Therefore, if you find acute fatty liver during pregnancy, do not terminate the pregnancy as soon as possible, and one-sidedly feel that the current condition of the pregnant woman is still stable, the fetal gestational age is small, and take a relatively conservative symptomatic treatment, often miss the best treatment time for the pregnant woman, resulting in a poor mother-child prognosis.
First, the obstetrician responsible for pregnancy health care is reminded that if a pregnant woman has non-specific symptoms such as nausea, vomiting, fatigue, and thirst in the third trimester (especially at 35 to 37 weeks of pregnancy), it is necessary to check blood biochemistry (liver function) to exclude "acute fatty liver during pregnancy".
Second, pregnant women themselves should also have a string, do not mistakenly think that the month is too old to be easy to fatigue, do not alleviate after rest to pay attention to, the third trimester of pregnancy appears nausea and discomfort and other discomfort, must be treated as soon as possible, check a blood biochemistry to understand the liver and kidney function.
High-quality pregnancy health care is not only the first-class medical environment and services, but more importantly, whether some high-risk factors and critical diseases can be identified and intervened early.
In the more than 70 years since the founding of New China, the maternal mortality rate on the mainland has dropped from 15 million/100,000 to 16.9/100,000, which is something that every woman and child can be proud of.
Keeping every pregnant woman healthy and safe is our obstetrician's greatest wish.
bibliography
[1] Maternal-Fetal Medicine Committee, Chinese Society of Obstetrics and Gynecology, Chinese Medical Association; Li P, Chen Y, Zhang W, Yang H. CSOG MFM Committee Guideline: Clinical Management Guidelines for Acute Fatty Liver of Pregnancy in China (2021). Maternal Fetal Med 2021;3(4):238–245. doi: 10.1097/FM9.0000000000000121.
Obstetrics and Gynecology Branch of Chinese Medical Association. Guidelines for the clinical management of acute fatty liver disease during pregnancy (2022)[J]. Chin J Obstetrics & Gynecology, 2022, 57(1):12.
[3] Reyes H, Sandoval L, Wainstein A, et al. Acute fatty liver of pregnancy: a clinical study of 12 episodes in 11 patients[J]. Gut,1994,35(1):101-106.
[4] Nelson D B, Yost N P, Cunningham F G. Acute fatty liver of pregnancy: clinical outcomes and expected duration of recovery[J]. Am J Obstet Gynecol,2013,209(5):451-456.
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