Plasma exchange-based artificial liver support for acute liver failure associated with early-onset intrahepatic cholestasis of pregnancy: a case report

Background Intrahepatic cholestasis of pregnancy (ICP) is typically benign, but progression to acute liver failure (ALF) is a rare, life-threatening complication. We report a case of ALF associated with early-onset ICP managed successfully with plasma exchange-based artificial liver support system (ALSS). Case presentation A 29-year-old Chinese woman (G2P1) presented with abnormal liver function at 20 weeks of gestation, characterized by markedly elevated aminotransferases but only mildly increased total bile acid (TBA, 12.4 µmol/L). Despite supportive care, she developed progressive cholestasis, hyperbilirubinemia, coagulopathy, and mild encephalopathy. Pregnancy was terminated at 23 weeks due to disease progression. Post-termination, TBA surged to 360.9 µmol/L, indicating persistent severe cholestasis. Given the poor response to conventional therapy, sequential ALSS combining Double Plasma Molecular Adsorption System (DPMAS) and plasma exchange was initiated. The patient exhibited rapid biochemical improvement and recovered fully without liver transplantation. Conclusions This case illustrates a rare clinical presentation of acute liver failure associated with early-onset intrahepatic cholestasis of pregnancy in the setting of multiple potential contributing factors. Plasma exchange-based artificial liver support may provide temporary extracorporeal support for selected patients with progressive pregnancy-associated hepatic dysfunction. Further studies are required to clarify the optimal timing, indications, and clinical benefits of this therapy.