A case of a patient with suspected AFLP and poor outcome with the diagnosis confirmed at post-mortem is presented. This case highlights the importance of a high index of suspicion of the condition in women presenting with jaundice in pregnancy. Other differential diagnoses of jaundice occurring during pregnancy include viral hepatitis, preeclampsia, cholelithiasis and intrahepatic cholestasis of pregnancy (ICP) [
4]. The clinical presentation and laboratory findings of AFLP are vague and nonspecific, and pose a diagnostic challenge [
5]. It is important to always consider life threatening differentials which may require prompt delivery and intensive care. Whilst HELLP syndrome and AFLP usually complicate the third trimester of pregnancy, HELLP syndrome (1 in 5000) is seen more frequently than AFLP (1 in 13000) [
4,
6]. In our case, the patient was at risk for both conditions as she was young and nulliparous. The blood pressure was however normal and urinalysis was negative for proteinuria. Key features of jaundice, hepatic encephalopathy, and the episodes of hypoglycaemia, normal ALT, AST, PLT and a very high WBC as well as the coagulopathy shown by upper gastrointestinal bleeding made the diagnosis of AFLP more likely. Other tests that were not available to us were coagulation studies which would have aided in the diagnosis of the coagulopathy and timely supportive care with blood products. Viral hepatitis also presents with jaundice but is characterised by a generally unwell patient with fever, nausea, vomiting and markedly elevated aminotransferases. Patients with intrahepatic cholestasis of pregnancy commonly complain of pruritus and their serum bilirubin levels do not usually exceed 6 mg/dl [
2]. Ingestion of drugs and herbal remedies that could lead to hypoglycaemia were ruled out from the history. Patients with cholelithiasis, in addition to the jaundice, also have pain the right upper quadrant as well as fever and an ultrasound scan aids in the diagnosis. Cholelithiasis and viral hepatitis may occur at any time during pregnancy unlike AFLP which is usually diagnosed in the third trimester as noted earlier [
7]. Sepsis was unlikely as the patient had no tachycardia or hypotension and remained normothermic. Other differential diagnoses were excluded in our case based on the symptoms, the timing of the presentation and investigations that were available. Our patient had a profound fall in the haemoglobin. It was difficult to attribute this fall due to haemolysis alone as we were unable to get the results for bilirubin levels, reticulocyte count and a peripheral blood smear. Blood loss into the gastrointestinal tract may be difficult to ascertain but may account for the fall.
The definitive management of AFLP is rapid delivery of the foetus and supportive intensive care. As seen in our case, jaundice, liver dysfunction, and coagulopathy may progress for 1 to 2 days after delivery. The post mortem and histological features are supportive of a diagnosis of AFLP. Our patient presented 4 days after the onset of symptoms and even though she had delivered, the symptoms progressed unabated albeit due to lack of urgent comprehensive supportive care such as transfusion of blood products and dialysis. There is usually improvement of symptoms 1 to 2 days after delivery but for patients who are critically ill and in those in whom complications progress despite delivery, management should be carried out in the intensive care unit.