# Fetal and Neonatal Complications Associated With Acute Fatty Liver of Pregnancy

## TL;DR

This study examines fetal and neonatal complications linked to acute fatty liver of pregnancy, highlighting high perinatal mortality and factors contributing to poor outcomes.

## Contribution

The study identifies maternal predictors of adverse perinatal outcomes in acute fatty liver of pregnancy cases in a specific clinical setting.

## Key findings

- Perinatal mortality was 24.6% with 17.8% stillbirths and 6.8% early neonatal deaths.
- Lower gestational age, coagulopathy, and higher maternal bilirubin levels were linked to adverse outcomes.
- Early recognition and timely delivery are critical for improving fetal survival in AFLP cases.

## Abstract

Background

Acute fatty liver of pregnancy (AFLP) is a rare but life-threatening obstetric emergency that can quickly endanger both the mother and fetus, typically presenting in the third trimester. Although greater awareness and supportive management have improved maternal survival, perinatal outcomes remain poor, particularly in resource-limited settings. This study aimed to describe fetal and neonatal complications associated with AFLP and identify maternal factors contributing to poor perinatal outcomes.

Methods

This retrospective study analysed medical records of 73 women diagnosed with AFLP at the Department of Obstetrics and Gynaecology, Unit I, Dr Ruth K. M. Pfau Civil Hospital Karachi, Dow University of Health Sciences, from November 3, 2024, to April 3, 2025. Diagnosis was based on the Swansea criteria. Maternal demographics, presenting symptoms, laboratory parameters, and neonatal outcomes were reviewed. Poor perinatal outcome was defined as stillbirth, early neonatal death, or a neonatal intensive care unit (NICU) stay exceeding seven days. Multivariate logistic regression was used to identify maternal predictors of adverse outcomes.

Results

The mean maternal age was 29 years, with most women presenting at an average gestational age of 35 weeks. Nausea and vomiting were reported in 64 (87.7%), malaise in 56 (76.7%), and jaundice in 47 (64.4%). Coagulopathy occurred in 31 (42.5%), while acute kidney injury was noted in 17 (23.3%). There were 13 stillbirths (17.8%) and five early neonatal deaths (6.8%), resulting in a perinatal mortality of 18 (24.6%). Lower gestational age, coagulopathy, and higher maternal bilirubin levels were independently associated with adverse perinatal outcomes.

Conclusion

Despite improvements in maternal management, perinatal mortality in AFLP remains alarmingly high. Early recognition and timely delivery, ideally before the onset of severe hepatic dysfunction, are critical for improving fetal survival. Strengthening neonatal intensive care facilities, developing national AFLP registries, and establishing standardised management protocols can play a key role in enhancing both maternal and neonatal outcomes in Pakistan and similar settings.