FFinalistSouthampton · 2027
Obstetrics & gynaecology
AKT · Obstetrics & gynaecology/Antenatal & medicallow yield

Acute fatty liver of pregnancy

Microvesicular fatty infiltration of the liver (3rd trimester)

Overview

A rare but life-threatening third-trimester liver failure from microvesicular fatty infiltration. It overlaps with the pre-eclampsia/HELLP spectrum but is distinguished by HYPOGLYCAEMIA, coagulopathy and frank liver failure. The treatment is prompt delivery.

Recognise

  • Third trimester: malaise, nausea/vomiting, abdominal pain, jaundice
  • Liver failure: HYPOGLYCAEMIA, coagulopathy (raised PT), encephalopathy
  • Often associated pre-eclampsia; raised transaminases, raised ammonia, AKI

Red flags

  • Hypoglycaemia, coagulopathy, encephalopathy → fulminant hepatic failure; maternal and fetal emergency

Differentials & how to tell them apart

HELLP / pre-eclampsiahaemolysis + low platelets + high LFTs, but glucose usually normal and no frank liver failure
Jaundice in pregnancyobstetric cholestasis = itch + raised bile acids, no liver failure/hypoglycaemia
Viral hepatitis / gallstonesserology/imaging; not pregnancy-specific

Investigations

LFTs (raised transaminases/bilirubin), glucose (LOW), clotting (deranged), U&E, ammonia, FBC; Swansea criteria support the diagnosis; exclude viral hepatitis.

Management

Stabilise (glucose, clotting) and DELIVER promptly; supportive intensive care

  1. 1Maternal stabilisation — correct hypoglycaemia and coagulopathy — and PROMPT DELIVERY regardless of gestation.Gate: Hypoglycaemia + coagulopathy in a jaundiced third-trimester woman points to AFLP over HELLP → urgent delivery + ICU
  2. 2Supportive liver care (usually resolves after delivery); monitor for postpartum deterioration; transplant rarely needed.
Supportive: IV glucose, correct coagulopathy — stabilise mother (glucose, blood products, ICU)

Key points

Distinguished from HELLP by hypoglycaemia and true liver failure. Definitive treatment is delivery; the liver usually recovers postpartum.

Monitor & prognosis

Glucose, clotting, LFTs, mental state; postpartum recovery.

Good with prompt delivery + intensive care; high mortality if missed.

Source: RCOG; Swansea criteria