Interpretations
The observed NAFLD prevalence of 51.3% in early pregnancy seems higher than the previously reported values for Sri Lanka (18.2%)20, Canada (17.6%) 25, Korea (18.4%) 11,38, and USA (14.3-16.7%)10. However, the prevalence in this study is not significantly different from the comparison group of non-pregnant reproductive age women from same geographical location. Irrespective of pregnancy, this high prevalence of fatty liver in this rural young woman (mean age 28.8 years) needs to be taken seriously as a major predicter of future NCDs.
NAFLD is considered as a hepatic manifestation of metabolic syndrome39. According to the multiple hit hypothesis proposed by Elenza et al. increasing oxidative stress, inflammation, endothelial dysfunction can lead to development of NAFLD 40. These underlying issues leading to NAFLD may have other effects on the mother and child which has not been fully evaluated yet. One of the most important findings of this study was the unprecedented observation of FL as a major risk factor for mid-pregnancy miscarriages with an odds ratio of 8.4. Liu Y et al. showed that abortions in women with NAFLD were higher than those without NAFLD (72.4% vs. 69.3%, age-adjusted P=0.001) 41. The pathophysiology behind this association is still not very clear. However, we can assume that the oxidative stress, endothelial damage and inflammation may predispose to development of early pregnancy loss 40. This observation with high effect size is of significant public health importance in predicting mid-trimester miscarriages and probably formulating new guidelines for pregnancy care programmes.
Current evidence on diabetes clearly shows that South Asians are at an increased risk of all metabolic derangements, including NAFLD, DM and GDM 42. Combining this knowledge with public health service provisions could be a practical and comprehensive approach in pregnancy care programmes. USS has been used for many years for pregnancy care, especially in the first trimester, as a “dating scan”. A simple added step in dating scans to screen for fatty liver during pregnancy may show the risk of developing hyperglycaemia and mid-pregnancy miscarriage. Our study shows that NAFLD is a better predictor of these conditions than the traditional “risk factors” considered in pregnancy. Beyond pregnancy, the diagnosis of NAFLD in pregnant women would be an early life opportunity to screen for fatty liver to prevent future non-communicable diseases.