Acute fatty liver of pregnancy


  • Rare, potentially fatal complication that presents in second half of pregnancy or (less commonly) early postpartum
  • Exact etiology unclear, but thought to involve abnormal fetal fatty acid metabolism
  • Fat vesicles accumulate within hepatocytes, interfering with liver function

Clinical Features

Differential Diagnosis

3rd Trimester/Postpartum Emergencies


Differential diagnosis of hyperbilirubinemia.

Indirect Hyperbilirubinemia

Direct (Conjugated) Hyperbilirubinemia

Hepatocellular damage

Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase

Pregnancy Related

Transplant Related

Pediatric Related

Additional Differential Diagnosis


Only bilirubin stains the sclera

  • Carotenemia
  • Quinacrine ingestion
  • Dinitrophenol, teryl (explosive chemicals)



  • LFTs
    • ALT/AST usually in 300-500 range, alk phos usually elevated in pregnancy
    • Hyperbilirubinemia- more pronounced than in preeclampsia
  • BMP
  • DIC labs
  • CBC
  • UA
  • RUQ US
    • Non-specific; the liver can even be normal in echotexture
    • Useful to rule out other causes of obstructive biliary tract pathology.


  • Often initially misdiagnosed as preeclampsia/HELLP
    • Hypoglycemia, jaundice, ascites, hypofibrinogenemia all more common in AFLP

Swansea criteria[2]

At least six of the following findings, in the absence of another cause:

  • Vomiting
  • Abdominal pain
  • Polydipsia/polyuria
  • Encephalopathy
  • Elevated bilirubin
  • Hypoglycemia
  • Elevated urea
  • Leukocytosis
  • Ascites or bright liver on ultrasound scan
  • Elevated transaminases (AAT or ALT)
  • Elevated ammonia
  • Renal impairment: elevated creatinine
  • Coagulopathy: elevated prothrombin time or PT
  • Microvesicular steatosis on liver biopsy



  • Admit ICU or transfer to center with Ob

See Also

External Links


  1. Ko H, Yoshida EM (2006). Acute fatty liver of pregnancy. Canadian Journal of Gastroenterology. 20 (1): 25–30
  2. Dey M, Reema K. Acute Fatty liver of pregnancy. N Am J Med Sci. 2012;4 (11): 611-2. doi:10.4103/1947-2714.103339