Fulminant hepatic failure in pregnancy: challenges, management strategies, prognosis and outcomes


  • Anant Parasher Department of Medicine, Guru Teg Bahadur Hospital, New Delhi, India
  • Vandana Mohan Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India




Acute fatty liver of pregnancy, Hepatic failure, Pre-eclampsia, Transplantation


Fulminant hepatic failure is defined as a sudden, severe impairment of hepatic function leading to an encephalopathy, which occurs within eight weeks of appearance of first symptoms in the absence of pre-existing liver disease. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver function leading to significant morbidity and even mortality. Hepatic dysfunction in pregnancy may be categorized into Pre-eclampsia-associated liver diseases such as pre-eclampsia/eclampsia, the HELLP syndrome and Acute fatty liver of pregnancy (AFLP), and other causes of hepatic dysfunction namely Hyperemesis gravidarum (HG) and Intrahepatic cholestasis of pregnancy (IHCP). For this review, a search was conducted for published articles, case reports and clinical trials in MEDLINE/Pubmed from 1970 to 2020 with the keyword’s fulminant hepatic failure, acute liver failure in pregnancy, pre-eclampsia, HELLP and AFLP. We concluded that fulminant hepatic failure is one of the most dreaded complications in pregnancy in obstetrical units worldwide. Mandatory screening for etiology, early diagnosis and initiation of supportive management as soon as possible are absolutely essential to ensure better maternal and fetal outcomes. Effective communication with the obstetrician regarding timely delivery/termination of pregnancy ensures a favourable prognosis in the majority of cases. Liver transplant is a definitive life-saving option for cases of severe fulminant hepatic failure in pregnancy, and management has to be suited to each patient individually, keeping in mind the well-being of both the mother, and the child.

Author Biographies

Anant Parasher, Department of Medicine, Guru Teg Bahadur Hospital, New Delhi, India

Medicine, Senior Resident

Vandana Mohan, Department of Obstetrics and Gynaecology, Guru Teg Bahadur Hospital, New Delhi, India

SR, Obs/Gyn


Bernuau J, Rueff B, Benhamou J. Fulminant and Sub fulminant Liver Failure: Definitions and Causes. Semin Liver Dis. 1986;6(2):97-106.

Trey C, Davidson CS. The management of fulminant hepatic failure. Prog Liver Dis. 1970;3:282-98.

Pandey C, Pandey V, Tandon M, Karna S. Acute liver failure in pregnancy: Challenges and management. Indian J Anaesth. 2015;59(3):144.

Hay J. Liver disease in pregnancy. Hepatology. 2008;47(3):1067-76.

Fleming WJ. Liver Disease in Pregnancy. Current Clin Med. 2010;558-63.

Joshi D, James A, Quaglia A, Westbrook RH, Heneghan MA. Liver disease in pregnancy. Lancet. 2010;375(9714):594-605.

Lana K, Wagner MD. Diagnosis and Management of Preeclampsia. First Choice Community Healthcare, Albuquerque, New Mexico. Am Fam Physician. 2004;70(12):2317-24.

Sibai BM. The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): much ado about nothing?. Am J Obstet Gynecol. 1990;162(2):311-6.

ACOG Committee on Practice Bulletins--Obstetrics. ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. Number 33, January 2002. Obstet Gynecol. 2002;99(1):159-67.

MacKay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from preeclampsia and eclampsia. Obstet Gynecol. 2001;97(4):533-8.

Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol. 2004;103(5):981-91.

Reyes H. Acute fatty liver of pregnancy. Clin Liver Dis. 1999;3:69-81.

Borwning MF, Levy HL, Wilkins HL, Larson C, Shih VE. Fetal fatty acid oxidation defects and maternal liver disease in pregnancy. Obstet Gynecol. 2006;107:115-20.

Martin S. Fatty Liver of Pregnancy Clinical advisor. Cancer Therapy Advisor. 2017.

Tran TT, Ahn J, Reau NS. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016;111(2):176-94.

Ablett J. Acute fatty liver of pregnancy guideline (GL780). Maternity Guidelines- Acute Fatty Liver of Pregnancy (GL780). 2016;1-5.

Brooks RR, Feller CM, Maye JP. Acute fatty liver of pregnancy: A case report. J Am Assoc Nurse Anesth. 2002;70(3):215-7.

WHO. Hepatitis E, 2018. Available at: https://www.who.int/newsroom/factsheets/detail/hepatitis-e. Accessed on 10 May 2021.

Singh S, Mohanty A, Joshi YK, Dwivedi SN, Deka D. Outcome of hepatitis E virus infection in Indian pregnant women admitted to a tertiary care hospital. Indian J Med Res. 2001;113:35-9.

Jilani N, Das BC, Husain SA, Baweja UK, Chattopadhya D, Gupta RK, et al. Hepatitis E virus infection and fulminant hepatic failure during pregnancy. J Gastroenterol Hepatol. 2007;22:676-82.

Remy P, Widjaja D, Anand B. Hepatitis E Treatment & Management: Medical Management, Diet and Activity. Medspace. 2019.

Kamar N, Bendall RP, Peron JM, Cintas P, Prudhomme L, Mansuy JM, et al. Hepatitis E virus and neurologic disorders. Emerg Infect Dis. 2011;17(2):173-9.

Norvell JP, Blei AT, Jovanovic BD, Levitsky J. Herpes simplex virus hepatitis: An analysis of the published literature and institutional cases. Liver Transpl. 2007;13:1428-34.

Darwish MS, Valla DC, Groen PC, Zeitoun G, Hopmans JA, Haagsma EB, et al. Determinants of survival and the effect of portosystemic shunting in patients with Budd-Chiari syndrome. Hepatology. 2004;39:500-8.

Bogin V, Marcos A, Shaw-Stiffel T. Budd-Chiari syndrome: in evolution. Eur J Gastroenterol Hepatol. 2005;17(1):33-5.

Hennes EM, Zeniya M, Czaja AJ, Pares A, Dalekos GN, Krawitt EL, et al. Simplified criteria for the diagnosis of autoimmune hepatitis. Hepatology. 2008;48:169-76.

Terrabuio DR, Abrantes LCP, Carrilho FJ, Cancado EL. Follow-up of pregnant women with autoimmune hepatitis: the disease behavior along with maternal and fetal outcomes. J Clin Gastroenterol. 2009; 43:350-6.

Westbrook RH, Yeoman AD, Kriese S, Heneghan MA. Outcomes of pregnancy in women with autoimmune hepatitis. J Autoimmun. 2012;38:239-44.

Peters MG. Management of Autoimmune Hepatitis in Pregnant Women. Gastroenterol hepatol. 2017;13(8):504-6.

Patra S. Management of Fulminant Hepatic Failure due to Hepatitis E in Pregnancy. AOGD Bulletin. 2018;18(3).

Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol. 2000;183(1):1-22.

Altman D, Carroli G, Duley L, Farrell B, Moodley J, Neilson J, Smith D, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet. 2002;359(9321):1877-90.

Shames BD, Fernandez LA, Sollinger HW, Chin LT, Alessandro AM, Knechtle SJ, et al. Liver transplantation for HELLP syndrome. Liver Transpl. 2005;11:224-8.

Ockner SA, Brunt EM, Cohn SM, Krul ES, Hanto DW, Peters MG. Fulminant hepatic failure caused by acute fatty liver of pregnancy treated by orthotopic liver transplantation. Hepatology. 1990;11:59-64.

Naeyer S, Ysebaert D, Utterbeeck M, Francque S, Palit G, Jacquemyn Y. Acute fatty liver of pregnancy and molecular absorbent recirculating system (MARS)-therapy: A case report. J Matern Fetal Neonatal Med. 2008;21:587-9.

Kamar N, Bendall R, Legrand AF, Xia NS, Ijaz S, Izopet J, et al. Hepatitis E. Lancet. 2012;379(9835):2477-88.

Shrestha MP, Scott RM, Joshi DM, Mammen MP, Thapa GB, Thapa N, et al. Safety and efficacy of a recombinant hepatitis E vaccine. N Engl J Med. 2007;356(9):895-903.

Zhu FC, Zhang J, Zhang XF, Zhou C, Wang ZZ, Huang SJ, Wang H, et al. Efficacy and safety of a recombinant hepatitis E vaccine in healthy adults: a large-scale, randomised, double-blind placebo-controlled, phase 3 trial. Lancet. 2010;376(9744):895-902.

Gerolami R, Borentain P, Raissouni F, Motte A, Solas C, Colson P. Treatment of severe acute hepatitis E by ribavirin. J Clin Virol. 2011;52(1):60-2.

Keefe EB, Dieterich DT, Han SHB, Jacobson IM, Martin P, Schiff ER, et al. A treatment algorithm for the management of chronic hepatitis B virus infection in the United States: an update. Clin Gastroenterol Hepatol. 2006;4:936-62.

Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH. AASLD guidelines for treatment of chronic hepatitis B. Hepatology. 2016;63:261-83.

Banait VS, Sandur V, Parikh F, Murugesh M, Ranka P, Ramesh VS, et al. Outcome of acute liver failure due to acute hepatitis E in pregnant women. Indian J Gastroenterol. 2007;26:6-10.

Scheinberg IH, Jaffe ME, Sternlieb I. The use of trientine in preventing the effects of interrupting penicillamine therapy in Wilson's disease. N Engl J Med. 1987;317:209-13.

Mahadevan U. American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy. Gastroenterol. 2006;131:283-11.

Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterol. 1989;97:439-45.

Valentine JM, Parkin G, Pollard SG, Bellamy MC. Combined orthotopic liver transplantation and caesarean section for the Budd-Chiari syndrome. Br J Anaesth. 1995; 75:105-8.

Anders M, Quinonez E, Goldaracena N, Osatnik J, Fernandez JL, Viola L, et al. Liver transplantation during pregnancy in a patient with acute liver failure. Acta Gastroenterol Latinoam. 2010;40(3):268-70.

Kimmich N, Dutkowski P, Krahenmann F, Mullhaupt B, Zimmermann R, Ochsenbein KN. Liver Transplantation during Pregnancy for Acute Liver Failure due to HBV Infection: A Case Report. Case Rep Obstet Gynecol. 2013; 356560.

Parhar KS, Gibson PS, Coffin CS. Pregnancy following liver transplantation: review of outcomes and recommendations for management. Can J Gastroenterol. 2012;26(9):621-6.

Coscia LA, Constantinescu S, Moritz MJ, Frank A, Ramirez CB, Maley WL, et al. Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl. 2009:103-22.






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