EP11.03: Plasmapheresis in pregnancy: a novel treatment for acute liver disease of unknown origin with favourable maternal and fetal outcomes

Therapeutic plasmapheresis has to date been used extremely rarely in pregnancy, predominantly in Acute Fatty Liver of Pregnancy and Hemolysis, Elevated Liver enzymes and Low Platelets syndromes. In the unique case report, we present the experimental plasmapheresis treatment of a previously healthy 39-year old in 23rd week of pregnancy with idiopathic acute liver disease. The multipara in 3rd pregnancy, with uncomplicated obstetrical history, presented to emergency department with acutely onset pruritus of hands and abdomen. Upon examination of yellowish discoloration of sclera and skin, the patient was hospitalised for jaundice differential diagnosis. Fetal anatomy, biometry and Doppler ultrasound (US) were normal. Alarming laboratory results of 432 μmol/l bile acids, 20 mg/dl bilirubin, 3050 U/l aspartate aminotransferase, negative viral and autoimmune tests and clear infection status, followed by an abdominal US and MRI with normal findings, led to urgent joint gastroenterology and nephrology consult. As initial treatment of ursodeoxycholic acid and prednisone had little effect, experimental plasmapheresis therapy was offered. After 11 plasmapheresis sessions, patient's condition improved markedly. Later, at 27 weeks of pregnancy upon cervical insufficiency, an emergency cervical cerclage was performed. The patient was readmitted at 36 weeks due to preterm premature rupture of the membranes. An elective Caesarean section was performed delivering a healthy in neurological examination boy, weighing 3290 grams, scoring 9/9/10 Apgar Scale. Mother and neonate were discharged after 8 days in good conditions. The novel experimental therapy of plasmapheresis in pregnancy may hold the answer to acute idiopathic liver diseases of pregnancy and should be considered if standard pharmacotherapy proves ineffective. Fetal biometry, Doppler and cervix US are crucial as FGR and cervical insufficiency may be observed in maternal liver dysfunction which may lead to preterm delivery.