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+We report the case of a previously healthy 28-year-old woman, Afro-Brazilian, in her first pregnancy.
+Our patient had no medical records until the 36th pregnancy week and reported allergy to diclofenac.
+She presented to our emergency department with an acute onset of abdominal pain, jaundice, nausea and vomiting, with no signs of encephalopathy.
+Her arterial blood pressure was 110/60mmHg, heart rate was 98bpm, axillary temperature was 35°C, she was severely dehydrated and with decreased peripheral perfusion.
+The laboratory examinations revealed hemoglobin 12.3g/dL, leukocytes 13 × 109/mL, platelets 97 × 103/mm3, international nationalized ratio (INR) 6.9, fibrinogen 98mg/dL, total bilirubin 14.2mg/dL, serum creatinine 3.4mg/dL, serum aspartate aminotransferase (AST) 306U/L, serum alanine aminotransferase (ALP) 302U/L, arterial bicarbonate 11mEq/L, arterial pH 7.21, blood glucose 65mg/dL and ionic calcium 1.02mmol/L.
+An abdominal ultrasound depicted fatty infiltration of the liver and confirmed fetal viability.
+Our patient received an initial fluid load with crystalloids.
+The calcium, glucose and hypothermia were reversed.
+The diagnosis of AFLP was confirmed following the Swansea’s criteria [9].
+Therefore, a cesarean section was indicated.
+A thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany) was performed at the beginning of the surgery.
+The thromboelastometry analysis showed an intense kinetic and structural hypocoagulable state (Fig.1 and Table 1).
+The FIBTEM revealed an impairment in fibrinogen function quality while the EXTEM depicted a coagulation factor deficiency (Fig.1a-c and Table 1).
+Based on, respectively, FIBTEM maximum clot firmness (MCF) (0mm; Table 1) and EXTEM clotting time (CT) (228s; Table 1), 4.0g of fibrinogen concentrate (Haemocomplettan® P, CSL Behring, Marburg, Germany) and 1000UI of prothrombin complex concentrate (Beriplex® P/N 500UI, CSL Behring, Marburg, Germany) were administered at the beginning of the cesarean section.
+The fluid input (crystalloids) and output during the caesarian section were, respectively, 2000mL and 200mL.
+The cesarean section succeeded with no major bleeding after the hemostatic therapy.
+Additional hemocomponent transfusion, such as fresh frozen plasma (FFP), cryoprecipitate, platelets or blood concentrates, was not necessary.
+A second thromboelastometry analysis was performed at the end of surgery (Fig.1d-e and Table 1), showing a mild hypocoagulation state.
+The patient was admitted to the intensive care unit (ICU) and remained stable, with no bleeding during the recovery phase.
+She was discharged from the ICU 3 days after admission and then 3 days later she was discharged from the hospital.