Snapshot A 30-year-old G1P0 presents to the emergency room with her husband. She is pregnant with twins at 36 weeks gestation. Earlier that night, her husband noticed that she suddenly seemed more yellow. She then complained of right upper quadrant pain, nausea, and general feeling of malaise. She had not taken any medications. On exam, she is alert and oriented only to person, and she is found to have elevated liver enzymes, coagulopathy, and hypoglycemia. A hepatic ultrasound rules out trauma but doesn’t yield much more information. She is taken to the operating room for a cesarean section immediately for suspected acute fatty liver of pregnancy. Introduction Overview acute fatty liver of pregnancy (AFLP) is a complication of pregnancy characterized by hepatic microvesicular steatosis and acute liver failure Epidemiology Incidence rare Demographics pregnant women Risk factors nulliparity multiple gestations ETIOLOGY Pathogenesis mechanism thought to be due to mitochondrial dysfunction of fatty acid beta-oxidation, leading to accumulation of fatty acids within hepatocytes and liver dysfunction Presentation Symptoms common symptoms nausea and vomiting malaise right upper quadrant pain upper gastrointestinal bleed fulminant liver failure sudden-onset jaundice Physical exam inspection hypertension altered mental status jaundice coagulopathy Imaging Hepatic ultrasound indications low sensitivity and thus not typically indicated findings decreased or diffuse attenuation Studies Serum labs liver injury ↑ AST/ALT ↑ bilirubin ↓ clotting factors may have ↓ glucose may have ↑ creatinine normal acetaminophen level negative viral serologies Invasive studies liver biopsy indications gold standard for diagnosis not often utilized due to risk of hemorrhage findings pericentral microvesicular steatosis minimal necrosis Differential Acetaminophen toxicity key distinguishing factor history of acetaminophen ingestion elevation in AST/ALT are typically significantly higher ↑ acetaminophen level HELLP syndrome key distinguishing factor characterized by hypertension, hemolysis, elevated liver enzymes, and low platelets Treatment Medical supportive care indications all patients repletion of coagulation factors indications coagulopathy Surgical immediate delivery of fetus indications all patients; this is the only treatment modalities induction of labor cesarean delivery Complications Maternal and fetal death Acute liver failure treatment liver transplant Acute renal failure Encephalopathy Prognosis High risk of maternal and fetal mortality After delivery, maternal prognosis is good