title: Thromboelastometry-guided hemostatic therapy: an efficacious approach to manage bleeding risk in acute fatty liver of pregnancy: a case report.
abstract: BACKGROUND
  Acute fatty liver of pregnancy (AFLP) is a rare but life-threatening disease. AFLP is characterized by liver failure with different degrees of coagulopathy. Outcome and survival can be dramatically improved with prompt recognition and treatment. Thromboelastometry has been considered a point of care for the management of bleeding patients. It could, therefore, be an alternative tool to treat the complex cases of AFLP involving liver failure and coagulopathy. Through this study, we present our successful experience of an AFLP case that was submitted to an emergency cesarean section in which blood transfusion was guided by thromboelastometry.
  
  
  METHODS
  We report the case of a previously healthy 28-year-old woman, Afro-Brazilian, in her first pregnancy with no medical records until the 36(th) pregnancy week. She presented to our emergency department with an acute onset of abdominal pain, jaundice, nausea and vomiting. The laboratory examinations revealed metabolic acidosis, acute kidney injury (serum creatinine 3.4 mg/dL), platelets 97 × 10(3)/mm3, serum fibrinogen 98 mg/dL and increased international nationalized ratio (INR 6.9) without acute bleeding. An emergency cesarean section was indicated. Based on the results of the thromboelastometric tests EXTEM and FIBTEM, prothrombin complex concentrate and fibrinogen concentrate were administered at the beginning of the cesarean section, which succeeded with no major bleeding and without need of further transfusion.
  
  
  CONCLUSIONS
  Thromboelastometry may be considered a useful, feasible and safe tool to monitor and manage coagulopathy in obstetric patients with acute fatty liver of pregnancy, with the potential advantage of helping avoid unnecessary transfusion in such patients.
authors.affiliation: Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP, CEP: 05651-901, Brazil. tomaz.crochemore@einstein.br.
authors.forename: Tomaz
authors.initials: T
authors.lastname: Crochemore
authors.affiliation: Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP, CEP: 05651-901, Brazil. felipe.piza@einstein.br.
authors.forename: Felipe Maia
authors.initials: FM
authors.lastname: de Toledo Piza
authors.affiliation: Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP, CEP: 05651-901, Brazil. silva.eliezer@einstein.br.
authors.forename: Eliézer
authors.initials: E
authors.lastname: Silva
authors.affiliation: Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP, CEP: 05651-901, Brazil. thiago.correa@einstein.br.
authors.forename: Thiago Domingos
authors.initials: TD
authors.lastname: Corrêa
mesh_terms: D015746:Abdominal Pain / Q000209:etiology; D000328:Adult; D001779:Blood Coagulation Factors; D002585:Cesarean Section; D005234:Fatty Liver / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D005260:Female; D006490:Hemostatics; D006801:Humans; D007565:Jaundice / Q000209:etiology; D009325:Nausea / Q000209:etiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D011517:Prothrombin Time; D013916:Thrombelastography; D016896:Treatment Outcome; D014839:Vomiting / Q000209:etiology
chemical_list: D001779:Blood Coagulation Factors; D006490:Hemostatics; C025667:prothrombin complex concentrates