Acute fatty liver of pregnancy — structured SAQ (15 marks)

(a) Diagnosis and criteria (3 marks)

One mark each for diagnosis, criteria name, and the count.^[1][2]

• Acute fatty liver of pregnancy (AFLP) — third-trimester microvesicular liver failure, distinguished from HELLP by hypoglycaemia, encephalopathy and coagulopathy with normal blood pressure and normal platelets.
• Swansea criteria — six or more of fourteen features in the absence of another explanation.
• Counting this patient: (1) vomiting, (2) abdominal pain, (3) encephalopathy, (4) elevated bilirubin, (5) hypoglycaemia, (6) elevated urate, (7) leucocytosis, (8) ascites/bright liver on USS, (9) elevated transaminases, (10) elevated ammonia, (11) renal impairment, (12) coagulopathy. Twelve of fourteen — well above the threshold of six.^[1]

(b) Immediate supportive management (5 marks)

One mark per named intervention with drug, dose and rationale.^[2][4]

• Call for help. Consultant obstetrician and anaesthetist, haematology, hepatology or specialist liver unit, major-haemorrhage protocol, neonatal team. Declare the diagnosis.
• Treat hypoglycaemia. IV dextrose — 50 mL of 50% dextrose as a bolus (or 100 mL of 25%), then a 10% dextrose infusion titrated to keep capillary glucose above 4 mmol/L. Hypoglycaemia causes seizures and death.
• Correct coagulopathy. Fresh frozen plasma 12-15 mL/kg to normalise INR; cryoprecipitate (or fibrinogen concentrate) to keep fibrinogen above 1.5-2 g/L. Vitamin K 10 mg IV once daily for three days to support hepatic synthesis. Have crossmatched blood in the room before delivery.
• Manage encephalopathy. Lactulose 15-30 mL orally or via NG two to three times daily; elevate the head of the bed 30 degrees; avoid sedatives.
• Admit to ICU/HDU. Continuous monitoring, fluid balance, treat AKI, prevent the lethal triad (warm the patient, correct acidosis, replace factors).^[2][4]

(c) Definitive management plan (3 marks)

One mark per element.^[2][4]

• Delivery is the treatment. Once stabilised, expedite delivery regardless of gestational age; vaginal induction preferred where delivery can be achieved within hours; caesarean for obstetric indications, an unfavourable cervix when delivery cannot be safely delayed, or deteriorating maternal/fetal condition.
• Anaesthetic review. Consultant anaesthetist; regional anaesthesia only if coagulopathy corrected; general anaesthesia for the unstable or coagulopathic; avoid NSAIDs in hepatic failure.
• Postpartum recovery. Serial LFTs, coagulation, glucose and ammonia every 6-12 hours for 48 hours then daily; clinical improvement typically begins within 2-4 days, biochemical resolution over 2-4 weeks.^[2][4]

(d) Day 5 deterioration — next step (4 marks)

One mark each for the referral, the criteria cited, the evidence cited, and the structural plan.^[3]

• Refer urgently to a specialist liver unit for liver transplant assessment. Arrange transfer with the hepatology and transplant teams; continue all supportive measures in transit.
• The criteria: encephalopathy (she is somnolent) plus a lactate above 2.8 mg/dL (hers is 3.2 mg/dL).
• The evidence: Westbrook 2010 King's College Hospital series of severe pregnancy-related liver disease — an admission lactate over 2.8 mg/dL plus encephalopathy had 90% sensitivity and 86% specificity for death or transplant. The classical King's College Criteria do not perform well in AFLP.
• Continued supportive care while awaiting transfer: IV dextrose, FFP and cryoprecipitate to correct coagulopathy, lactulose for encephalopathy, head-up positioning, neuro-observations. The transplant centre will decide between continued medical support and listing for transplant.^[3]