My life or baby's: Unpacking acute fatty liver of pregnancy

Writhing in pain, 28-year-old Anita* sits in her ward at Moi Teaching and Referral Hospital (MTRH), after being admitted for the last two weeks. She is six months pregnant, and unlike many women expecting bundles of joy, all she feels is pain and mental anguish.

Questions race through her mind, as she holds on to dear life, hoping that the doctors would probably change their minds about saving her baby’s life instead of hers. She has been given her an ultimatum: terminate the pregnancy to save her own life.

For the last six months, Anita has suffered from severe vomiting to severe nausea and abdominal pains, what doctors diagnosed as acute fatty liver disease in pregnancy—a rare condition that affects pregnant women. To save her life, the pregnancy has to be terminated, an option she is not willing to take.

Acute Fatty Liver of Pregnancy (AFLP), a condition that develops in approximately one in 10,000 pregnancies globally, according to recent studies published in the Journal of Clinical Medicine. “Liver disease in pregnancies is quite rare, but when it occurs, particularly in the case of acute fatty liver of pregnancy, it can be life-threatening for both mother and baby,” explains Dr Moses Obimbo, a leading gynecologist and researcher.

He outlines two main categories of liver diseases that can affect pregnant women. The first is cholestasis, a condition where bile flow is impaired. “Cholestasis of pregnancy presents primarily with intense itching all over the body,” he explains. “While not immediately fatal, it can lead to adverse pregnancy outcomes, including stillbirth.”

The second, more severe category, includes viral hepatitis (types A, B, and C) and the rare, but dangerous acute fatty liver of pregnancy (AFLP). According to the World Health Organisation’s latest maternal health report, AFLP, though rare, carries a mortality rate of 18 per cent for mothers and up to 23 per cent for fetuses when not treated promptly.

AFLP typically develops in the third trimester, presenting with symptoms that can be mistaken for normal pregnancy discomfort, severe nausea, vomiting, abdominal pain, and jaundice. Research published in the International Journal of Women’s Health indicates that early detection is crucial for survival. “The challenge with AFLP is that it can progress rapidly to liver failure,” he warns. “When diagnosed late in pregnancy, as in this case at MTRH, medical teams often face difficult decisions about timing delivery to save both lives,” he continues.

In Kenya, precise data on AFLP cases is limited due to underreporting and diagnostic challenges. However, the Ministry of Health’s 2023 report on maternal mortality indicates that liver-related complications contribute to approximately two per cent of maternal deaths nationwide. “In centres without sufficient neonatal intensive care facilities, the chances of survival for these early preterm babies are minimal,” Dr Obimbo notes.

This highlights the crucial role of well-equipped healthcare facilities in managing such cases.

Managing AFLP requires a delicate balance between maternal and fetal wellbeing. According to recent clinical guidelines published in the American Journal of Obstetrics and Gynecology, delivery is often the definitive treatment, regardless of gestational age.

“When both lives are in danger, we consider the mother’s life first,” Dr Obimbo emphasises. “However, with modern neonatal care facilities, babies delivered as early as 27 to 28 weeks have increased chances of survival,” he adds.

The management of AFLP cases requires a comprehensive team approach. “We involve gynecologists, psychiatrists, internal medicine specialists, and social workers,” Dr Obimbo explains, adding, “This multidisciplinary team works together with the patient and family to make informed decisions about care.”

The post-delivery period is equally critical. Patients may require intensive care unit management, and some cases progress to require liver transplantation.

A study in the Lancet showed that with prompt intervention, maternal survival rates have improved from 60 per cent in the 1980s to over 85 per cent today. While AFLP cannot be prevented entirely, maintaining a healthy lifestyle during pregnancy may help reduce risks. “We advise proper diet and avoiding alcohol and smoking. However, being a rare disease, it’s hard to predict who will develop it,” Dr Obimbo says.

For women who have experienced AFLP, future pregnancy decisions require careful consideration. Studies indicate a recurrence risk of approximately 25 per cent in subsequent pregnancies, emphasising the need for close monitoring in future pregnancies.

Recovery from AFLP extends beyond physical healing. “The psychological impact is significant,” Dr Obimbo notes.