Endocrine Abstracts

Acute fatty liver of pregnancy (AFLP) is a rare obstetric metabolic emergency (UK incidence 1/20.000 maternities) which typically presents in 3^rd trimester or postpartum and has a high maternal and foetal mortality and morbidity (UK Maternal mortality 1.8%, perinatal mortality 104/1000 births). Diagnosis can be delayed due to lack of set diagnostic criteria, rarity and overlapping clinical presentation with many other obstetric metabolic pathologies. Urgent delivery and supportive care are the mainstay of treatment. We would like to present an interesting case of AFLP which was initially managed as diabetic ketoacidosis (DKA). A 20-year-old lady with a background of gestational diabetes on insulin presented at 32 weeks’ gestation in her second pregnancy with general malaise, reduced foetal movements, and anorexia and was found to be icteric with hyperglycaemia, severe metabolic acidosis and ketosis and deranged liver functions. She was started on fixed rate intravenous insulin infusion (FRII) and IV fluids with a diagnosis of DKA. She was transferred to ITU due to lack of response to treatment where intravenous bicarbonate was given with only transient improvement in her acidosis. Liver ultrasound showed uncomplicated gallstones with normal liver. Rest of the non-invasive liver screen was unremarkable. Foetus was being regularly monitored through cardiotocography with no concerns. She was being managed with inputs from obstetrics, diabetologists, gastroenterologists and intensivists in ITU for five days but despite appropriate management of DKA, there was no resolution of her metabolic abnormalities, at which point, expert opinion was sorted from maternal medicine department of the tertiary care centre who suggested a diagnosis of AFLP and advised urgent delivery. She underwent emergency caesarean section at 33 weeks’ gestation and all her biochemical abnormalities started to improve post-partum with complete resolution of acidosis in 48 hours and normalisation of LFTs in two weeks. The baby was admitted to NICU for two weeks and intubated and NG fed for first week and later on discharged with no complications. Both mother and baby are now healthy. AFLP is a rare obstetric emergency which requires a high index of suspicion for diagnosis. This case was especially challenging given the hyperglycaemia and ketosis at presentation; these are not widely recognized metabolic abnormalities in AFLP. Diabetologists would rarely be involved in the care of AFLP however this case shows the importance of suspecting an alternate diagnosis when a ’diabetic emergency’ does not respond to otherwise highly effective treatment modalities.