A clinical case of a patient with liver cirrhosis in non-alcoholic fatty liver disease and pregnancy

Abstract

Introduction: Non-alcoholic fatty liver disease (NAFLD) is a significant health problem in society and it affects around a billion people on a global scale. NAFLD is the most common reason for liver damage worldwide and is considered the hepatic manifestation of the metabolic syndrome. NAFLD could be classified into two categories: non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH), which can progress to liver cirrhosis. There is limited literature on the occurrence of NAFLD in pregnant women and its effect on pregnancy. It is presumed that there is an increase in the frequency of gestational diabetes, premature birth, low birth weight, preeclampsia, more frequent delivery with Caesarean section, and more frequent occurrence of intrahepatic cholestasis. There is no data on the course of pregnancy in patients with NAFLD and cirrhosis, which is already formed.

Clinical case: We present the clinical case of a 30-year-old woman, who is pregnant in the VIII lunar month and was brought to the hospital due to heaviness, feeling of bloating, and swelling in the legs. Laboratory examination conducted a month before hospitalization revealed that: AST - 460 U/L, ALT - 980 U/L, GGT - 28.3 U/L, total bilirubin – 20.2, Hb - 138 g/L. The patient informed that she had had two miscarriages in the past. After the second miscarriage three years ago, she was hospitalized for the first time due to icterus and fever. For the first time, she was diagnosed with: liver cirrhosis caused by non-alcoholic steatohepatitis, active, decompensated, child stage B; portal hypertension; metabolic syndrome; hypertension; obesity class III. Autoimmune and viral etiology of cirrhosis was excluded. Hepatoprotective treatment was conducted. Following the first hospitalization at the Endocrinology Clinic, the patient was diagnosed with: impaired fasting glycemia; decreased glucose tolerance; metabolic syndrome; hypertensive disease stage II, moderate degree; obesity class III; dyslipidemia; Hashimoto's thyroiditis. Glucobay therapy, diet, and hypocaloric and exercise regimen were prescribed. The last hospitalization at the Endocrinology Clinic was during the VI lunar month of the current pregnancy. Insulin treatment was started. The results of the laboratory tests conducted during the last hospitalization in the Clinic are shown in Table 1. Ultrasound examination showed cirrhotic transformation of the liver, moderate ascites, splenomegaly, and pregnancy with coexisting live fetus. The presence of acute infection with hepatotropic and non-hepatotropic viruses was excluded. After consulting with a cardiologist and an echocardiography, the presence of heart failure was rejected. Hepatoprotective treatment and diuretics were carried out, which resulted in normalization of liver parameters and a slight reduction of ascites. The patient was discharged and referred for planned delivery by Caesarean section when the fetus reaches maturity.

Conclusion: The clinical case presents a patient with underlying hepatic cirrhosis in NAFLD and pregnancy, who developed transient hepatocytolysis and decompensation of cirrhosis with ascites during pregnancy, as well as diabetes mellitus on the background of previous impaired glucose tolerance. NAFLD is a disease, which could affect young patients in childbearing age. The presence of an advanced stage of NAFLD is associated with many complications during pregnancy, which requires follow-up by a gastroenterologist.