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ob.acute-fatty-liver-of-pregnancy.v1PRODUCTION
ob.acute-fatty-liver-of-pregnancy.v1

Acute Fatty Liver of Pregnancy (AFLP)

obstetricsacuteadultpregnancy
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12/12 authored

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Detailed

AFLP = rare (~ 5/100,000 maternities; Knight UKOSS 2008 PMID 18332072) 3rd-trimester microvesicular hepatic steatosis caused by impaired fetal/maternal long-chain fatty acid beta-oxidation (LCHAD deficiency in the fetus → maternal hepatic mitochondrial overload). Clinical Swansea-criterion-defined diagnosis (≥ 6/14 criteria; Ch'ng 2002 PMID 12427793). Cornerstone treatment = PROMPT DELIVERY; maternal recovery is rapid once delivered. Maternal mortality with modern care 1.8-12 %; perinatal mortality 10 %. Always consider HELLP/severe pre-eclampsia overlap (LFTs alone do not differentiate); BP + proteinuria + platelets are the pivots.

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GA + multifetal status documented; AFLP clinical suspicion vs HELLP overlap tier set

Patient inputs (21)

Twins/triplets carry ~ 3-fold increased AFLP risk per Knight UKOSS 2008 PMID 18332072 (18% of cohort had twin pregnancies vs ~1.5% population)

Differentiate drug-induced liver injury; acetaminophen exposure history particularly important

AFLP is overwhelmingly a 3rd-trimester disease (typically > 30 wk); peak ~ 35-36 wk; rare in 2nd trimester

Continuous EFM; Category III may force expedited delivery in unstable mother

Hypoglycemia (< 4 mmol/L) is a Swansea criterion with high specificity; q2-4h glucose monitoring; D10W replacement

AST/ALT > 42 IU/L (Swansea criterion); bilirubin > 14 µmol/L (Swansea); marked elevation distinguishes from ICP (mild) and suggests AFLP vs HELLP

Leukocytosis > 11 (Swansea criterion); platelets — low in HELLP; rising hematocrit + AKI raises HUS ddx; baseline for MTP triggers

Creatinine > 150 µmol/L (Swansea); uric acid > 340 µmol/L (Swansea); BUN, electrolytes for renal injury and metabolic acidosis

PT > 14 s or aPTT > 34 s (Swansea); fibrinogen for DIC overlap; PT/INR for vitamin K + FFP triggers; MTP activation thresholds

Ammonia > 47 µmol/L (Swansea); marker of hepatic failure + encephalopathy severity

Shock marker; rising lactate raises concern for septic shock differential or hepatic ischemia

Anticipate need for blood products for MTP given coagulopathy + delivery; have ≥ 4 units PRBC crossmatched on standby

Rule out viral hepatitis differential (especially HEV severe in pregnancy); usually negative in AFLP

HTN + proteinuria + transaminitis = HELLP/severe pre-eclampsia overlap; influences engine routing

Tachycardia from sepsis ddx, hemorrhage, or shock physiology

Fever favors sepsis/chorioamnionitis ddx over AFLP

Encephalopathy grade is a Swansea criterion and severity marker; West Haven grade documentation

Recurrence ~ 20-70% in subsequent pregnancy if confirmed maternal LCHAD heterozygosity + fetal LCHAD deficiency; influences subsequent-pregnancy counseling

Low BMI < 20 was associated with AFLP in Knight UKOSS 2008 cohort (20% had low BMI)

Male fetal sex slightly increases AFLP risk per observational series (~ 1.7:1 M:F)

Bright liver / ascites (Swansea criterion); rule out biliary obstruction; ultrasound preferred in pregnancy

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningaflp_at_presentation_emergent_delivery
    AFLP at presentation — Swansea criteria ≥ 6/14 + 3rd-trimester pregnancy without alternative explanation → emergent delivery as cornerstone (Knight UKOSS 2008 PMID 18332072); ICU + hepatology + neonatology coordination.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaflp_fulminant_with_persistent_failure
    Fulminant AFLP — rising INR > 2 despite FFP, persistent encephalopathy, persistent hypoglycemia despite D10W, ammonia > 150, no improvement by 72-96 h post-delivery → transplant center transfer + transplant evaluation + plasmapheresis/MARS per hepatology (Casey 2020 PMID 31991493 — 16% transplant rate, 11% mortality).
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaflp_hellp_overlap
    AFLP + HELLP overlap — HTN + proteinuria + thrombocytopenia + transaminitis + Swansea features. Manage as both per ob.hellp-syndrome.v1 + this engine; magnesium for seizure prophylaxis; delivery is definitive for both.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaflp_newborn_LCHAD_screening
    Mandatory newborn LCHAD/MCAD/long-chain FAO defect screening for all infants born to mothers with AFLP — cord blood acylcarnitine profile + targeted genetic testing for HADHA G1528C; positive screen → pediatric metabolism specialist + MCT-based dietary management + fasting avoidance.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateaflp_recurrence_subsequent_pregnancy
    AFLP recurrence in subsequent pregnancy — ~ 20-70% if maternal LCHAD heterozygosity confirmed; tertiary-center delivery + early-3rd-trimester biochem surveillance + family planning + genetic counseling.
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

AFLP emergent delivery + ICU supportive care — prompt delivery cornerstone + D10W for hypoglycemia + MTP/cryoprecipitate/vitamin K for coagulopathy + hepatology / transplant referral if fulminant + mandatory newborn LCHAD screening (Knight UKOSS 2008 PMID 18332072 + Ch'ng 2002 PMID 12427793 + Wang 2017 PMID 27923319 + Casey 2020 PMID 31991493)
axis: aflp_emergent_delivery_and_supportive_care
Selected axis "AFLP emergent delivery + ICU supportive care — prompt delivery cornerstone + D10W for hypoglycemia + MTP/cryoprecipitate/vitamin K for coagulopathy + hepatology / transplant referral if fulminant + mandatory newborn LCHAD screening (Knight UKOSS 2008 PMID 18332072 + Ch'ng 2002 PMID 12427793 + Wang 2017 PMID 27923319 + Casey 2020 PMID 31991493)" by default fallback (first axis)
  • prompt delivery (vaginal preferred if feasible; cesarean if expedited delivery required)
    first line
    obstetric_definitive_intervention
    triggers: aflp_swansea_ge_6_clinical_diagnosis
    PregCat: N/A — obstetric intervention, not a drug. | Lactation: N/A — delivery event; lactation establishes postpartum. | CORNERSTONE of AFLP management per Knight UKOSS 2008 (PMID 18332072); maternal hepatic recovery starts within hours of delivery once fetal/placental trigger is removed; vaginal preferred if cervix ripe + coagulopathy correctable; cesarean if expedited delivery required (after FFP + cryoprecipitate correction if possible).
  • glucose (D10W)
    first line
    dextrose_carbohydrate_resuscitation
    D10W 100 mL bolus IV for hypoglycemia < 4 mmol/L then infusion 100-200 mL/h titrated to glucose ≥ 4 mmol/L • IV • continuous infusion titrated
    triggers: maternal_hypoglycemia_lt_4_mmol_per_L
    PregCat: N/A — labeling does not assign for IV dextrose; resuscitation fluid in routine clinical use throughout pregnancy. | Lactation: compatible — physiologic carbohydrate; lactation use not constrained. | Replace impaired hepatic glycogen output; hypoglycemia is a Swansea criterion and an immediately reversible cause of altered mental status; q2-4h glucose monitoring; titrate to glucose ≥ 4 mmol/L.
    rxcui 4850
  • fresh frozen plasma (FFP)
    first line
    blood_product_clotting_factor_replacement
    10-15 mL/kg IV; recheck PT/INR + fibrinogen after each unit batch • IV • as needed to correct coagulopathy
    triggers: aflp_with_coagulopathy_pt_gt_14_or_inr_gt_1.5
    PregCat: N/A — blood product. | Lactation: N/A — does not affect breastfeeding. | Replace depleted clotting factors in hepatic failure; target INR < 2 pre-delivery if possible; combine with cryoprecipitate for fibrinogen and platelets for thrombocytopenia.
  • cryoprecipitate
    first line
    fibrinogen_replacement
    10 units IV; recheck fibrinogen 30 min later; redose if fibrinogen < 200 mg/dL • IV • as needed to target fibrinogen ≥ 200
    triggers: fibrinogen_lt_200_mg_per_dL_in_aflp
    PregCat: N/A — blood product. | Lactation: N/A. | Pregnancy baseline fibrinogen 350-650; < 200 is critical; cryoprecipitate is first-line fibrinogen replacement; framework per Pacheco SMFM 47 obstetric MTP guidance.
  • platelet transfusion
    first line
    blood_product_platelet_replacement
    1 pheresis unit (or 6-pack pooled) IV; target > 50 K intrapartum; > 100 K with active hemorrhage • IV • as needed
    triggers: platelets_lt_50K_pre_delivery_or_active_bleeding
    PregCat: N/A. | Lactation: N/A. | Correct thrombocytopenia from DIC overlap or HELLP-AFLP overlap; framework per Pacheco SMFM 47.
  • massive transfusion protocol 1:1:1 PRBC:FFP:platelets
    rescue
    blood_product_resuscitation
    Per local MTP — activate with anticipated EBL > 1500 mL or active uncontrolled hemorrhage with DIC • IV • as needed
    triggers: aflp_with_active_hemorrhage_uncontrolled_bleeding
    PregCat: N/A. | Lactation: N/A. | Activate early given coagulopathy + delivery setting; framework per Pacheco SMFM 47 obstetric MTP.
  • phytonadione
    first line
    vitamin_k1_fat_soluble_vitamin
    10 mg IV slow push (or PO/SC) daily; recheck PT/INR 12-24 h later • IV/PO/SC • daily until INR < 1.5 or hepatic recovery
    triggers: aflp_with_coagulopathy_or_prolonged_pt
    PregCat: former C — labeling categorises as C; benefit-risk overwhelmingly favors use in coagulopathic AFLP. | Lactation: compatible per LactMed — newborns routinely receive vitamin K at birth; small amounts in maternal milk acceptable. | Replace vitamin-K-dependent factors; lower-yield in severe AFLP than FFP since the deficit is largely synthetic failure not vitamin-K depletion alone, but still standard adjunct.
    rxcui 8308
  • hepatology and transplant center referral
    rescue
    specialist_referral_definitive_care_pathway
    triggers: aflp_fulminant_rising_inr_persistent_encephalopathy_persistent_hypoglycemia
    PregCat: N/A — care-pathway action, not a drug. | Lactation: N/A. | Transfer to liver transplant center if fulminant features (INR > 2 despite FFP, persistent encephalopathy, persistent hypoglycemia, ammonia > 150) — Casey 2020 PMID 31991493 ALFSG cohort had 16 % requiring liver transplant; pre-transplant evaluation; bridge therapies (plasmapheresis, MARS, NAC) per hepatology.
  • plasmapheresis or MARS molecular adsorbent recirculating system
    rescue
    extracorporeal_liver_support
    Per hepatology / nephrology / critical care; typically daily or alternate-day sessions • extracorporeal • per protocol
    triggers: aflp_fulminant_with_specialist_recommendation
    PregCat: N/A. | Lactation: N/A. | Limited evidence base; case-series support as bridge to recovery or transplant in fulminant cases; not routine but selectively used in tertiary/transplant centers.
  • newborn LCHAD / MCAD / long-chain fatty acid oxidation defect screening
    first line
    metabolic_genetic_screening
    triggers: post_delivery_neonate_from_aflp_pregnancy
    PregCat: N/A — neonatal screening. | Lactation: N/A — pertains to newborn. | MANDATORY — cord blood + acylcarnitine profile (newborn screen) + targeted genetic testing for LCHAD HADHA G1528C mutation; positive screen → pediatric metabolism + nutrition specialist + dietary management with MCT-based formula + avoidance of fasting. Maternal LCHAD heterozygosity confers ~ 20-70 % recurrence in subsequent pregnancy.
  • lactulose for hepatic encephalopathy
    add on
    osmotic_laxative_ammonia_reducer
    triggers: aflp_with_encephalopathy_and_elevated_ammonia
    PregCat: former B — long pregnancy experience; minimal systemic absorption. | Lactation: compatible — minimal systemic absorption. | 30-45 mL PO q6h titrated to 3 soft BMs/day; reduces ammonia in hepatic encephalopathy; adjunct to definitive delivery.

ed playbook — drug actions (3)

  1. 1. D10W IV for hypoglycemia
    rxcui 4850
    D10W 100 mL bolus then 100-200 mL/h titrated • IV • continuous infusion
    trigger: Glucose < 4 mmol/L
    Reverse Swansea-criterion hypoglycemia + altered mental status
  2. 2. phytonadione 10 mg IV
    rxcui 8308
    10 mg IV slow push • IV • once now then daily
    trigger: PT prolonged on initial labs
    Vitamin K1 replacement
  3. 3. FFP
    10-15 mL/kg IV • IV • as needed
    trigger: INR > 2 or active bleeding
    Coagulopathy correction pre-delivery

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Third-trimester onset of nausea, vomiting, malaise, RUQ/epigastric abdominal pain — common AFLP prodrome (Knight UKOSS 2008 PMID 18332072); New jaundice + dark urine in third-trimester pregnancy with prodrome — alarm finding for AFLP (Swansea criterion bilirubin > 14 µmol/L); Unexplained maternal hypoglycemia (< 4 mmol/L / 72 mg/dL) in 3rd-trimester pregnant patient — Swansea criterion; high specificity for AFLP.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Fatty Liver of Pregnancy (AFLP)** (ob.acute-fatty-liver-of-pregnancy.v1).
Phenotype framing: HELLP/severe pre-eclampsia (HTN + proteinuria + platelets < 100; sibling engine); viral hepatitis especially HEV (markedly elevated AST/ALT > 1000; serology); ICP (mild transaminitis, no encephalopathy, no hypoglycemia, no coagulopathy beyond vitamin-K-dependent factors; ob.intrahepatic-cholestasis-of-pregnancy.v1); drug-induced liver injury (medication history; acetaminophen level); septic shock with shock liver (fever + hypotension + leukocytosis + procalcitonin); Wilson disease (young, low ceruloplasmin, Kayser-Fleischer rings, hemolytic anemia); autoimmune hepatitis (ANA, SMA, anti-LKM); Reye-like syndrome with salicylates; gallstone disease with cholangitis (US biliary dilation, charcot triad).
Scope: AFLP = rare (~ 5/100,000 maternities; Knight UKOSS 2008 PMID 18332072) 3rd-trimester microvesicular hepatic steatosis caused by impaired fetal/maternal long-chain fatty acid beta-oxidation (LCHAD deficiency in the fetus → maternal hepatic mitochondrial overload). Clinical Swansea-criterion-defined diagnosis (≥ 6/14 criteria; Ch'ng 2002 PMID 12427793). Cornerstone treatment = PROMPT DELIVERY; maternal recovery is rapid once delivered. Maternal mortality with modern care 1.8-12 %; perinatal mortality 10 %. Always consider HELLP/severe pre-eclampsia overlap (LFTs alone do not differentiate); BP + proteinuria + platelets are the pivots.

No severity triggers fired against current inputs.

Plan

Regimen axis: **AFLP emergent delivery + ICU supportive care — prompt delivery cornerstone + D10W for hypoglycemia + MTP/cryoprecipitate/vitamin K for coagulopathy + hepatology / transplant referral if fulminant + mandatory newborn LCHAD screening (Knight UKOSS 2008 PMID 18332072 + Ch'ng 2002 PMID 12427793 + Wang 2017 PMID 27923319 + Casey 2020 PMID 31991493)**.
1. prompt delivery (vaginal preferred if feasible; cesarean if expedited delivery required) (obstetric_definitive_intervention, first line) — PregCat: N/A — obstetric intervention, not a drug. | Lactation: N/A — delivery event; lactation establishes postpartum. | CORNERSTONE of AFLP management per Knight UKOSS 2008 (PMID 18332072); maternal hepatic recovery starts within hours of delivery once fetal/placental trigger is removed; vaginal preferred if cervix ripe + coagulopathy correctable; cesarean if expedited delivery required (after FFP + cryoprecipitate correction if possible).
2. glucose (D10W) D10W 100 mL bolus IV for hypoglycemia < 4 mmol/L then infusion 100-200 mL/h titrated to glucose ≥ 4 mmol/L IV continuous infusion titrated (dextrose_carbohydrate_resuscitation, first line) — PregCat: N/A — labeling does not assign for IV dextrose; resuscitation fluid in routine clinical use throughout pregnancy. | Lactation: compatible — physiologic carbohydrate; lactation use not constrained. | Replace impaired hepatic glycogen output; hypoglycemia is a Swansea criterion and an immediately reversible cause of altered mental status; q2-4h glucose monitoring; titrate to glucose ≥ 4 mmol/L.
3. fresh frozen plasma (FFP) 10-15 mL/kg IV; recheck PT/INR + fibrinogen after each unit batch IV as needed to correct coagulopathy (blood_product_clotting_factor_replacement, first line) — PregCat: N/A — blood product. | Lactation: N/A — does not affect breastfeeding. | Replace depleted clotting factors in hepatic failure; target INR < 2 pre-delivery if possible; combine with cryoprecipitate for fibrinogen and platelets for thrombocytopenia.
4. cryoprecipitate 10 units IV; recheck fibrinogen 30 min later; redose if fibrinogen < 200 mg/dL IV as needed to target fibrinogen ≥ 200 (fibrinogen_replacement, first line) — PregCat: N/A — blood product. | Lactation: N/A. | Pregnancy baseline fibrinogen 350-650; < 200 is critical; cryoprecipitate is first-line fibrinogen replacement; framework per Pacheco SMFM 47 obstetric MTP guidance.
5. platelet transfusion 1 pheresis unit (or 6-pack pooled) IV; target > 50 K intrapartum; > 100 K with active hemorrhage IV as needed (blood_product_platelet_replacement, first line) — PregCat: N/A. | Lactation: N/A. | Correct thrombocytopenia from DIC overlap or HELLP-AFLP overlap; framework per Pacheco SMFM 47.
6. massive transfusion protocol 1:1:1 PRBC:FFP:platelets Per local MTP — activate with anticipated EBL > 1500 mL or active uncontrolled hemorrhage with DIC IV as needed (blood_product_resuscitation, rescue) — PregCat: N/A. | Lactation: N/A. | Activate early given coagulopathy + delivery setting; framework per Pacheco SMFM 47 obstetric MTP.
7. phytonadione 10 mg IV slow push (or PO/SC) daily; recheck PT/INR 12-24 h later IV/PO/SC daily until INR < 1.5 or hepatic recovery (vitamin_k1_fat_soluble_vitamin, first line) — PregCat: former C — labeling categorises as C; benefit-risk overwhelmingly favors use in coagulopathic AFLP. | Lactation: compatible per LactMed — newborns routinely receive vitamin K at birth; small amounts in maternal milk acceptable. | Replace vitamin-K-dependent factors; lower-yield in severe AFLP than FFP since the deficit is largely synthetic failure not vitamin-K depletion alone, but still standard adjunct.
8. hepatology and transplant center referral (specialist_referral_definitive_care_pathway, rescue) — PregCat: N/A — care-pathway action, not a drug. | Lactation: N/A. | Transfer to liver transplant center if fulminant features (INR > 2 despite FFP, persistent encephalopathy, persistent hypoglycemia, ammonia > 150) — Casey 2020 PMID 31991493 ALFSG cohort had 16 % requiring liver transplant; pre-transplant evaluation; bridge therapies (plasmapheresis, MARS, NAC) per hepatology.
9. plasmapheresis or MARS molecular adsorbent recirculating system Per hepatology / nephrology / critical care; typically daily or alternate-day sessions extracorporeal per protocol (extracorporeal_liver_support, rescue) — PregCat: N/A. | Lactation: N/A. | Limited evidence base; case-series support as bridge to recovery or transplant in fulminant cases; not routine but selectively used in tertiary/transplant centers.
10. newborn LCHAD / MCAD / long-chain fatty acid oxidation defect screening (metabolic_genetic_screening, first line) — PregCat: N/A — neonatal screening. | Lactation: N/A — pertains to newborn. | MANDATORY — cord blood + acylcarnitine profile (newborn screen) + targeted genetic testing for LCHAD HADHA G1528C mutation; positive screen → pediatric metabolism + nutrition specialist + dietary management with MCT-based formula + avoidance of fasting. Maternal LCHAD heterozygosity confers ~ 20-70 % recurrence in subsequent pregnancy.
11. lactulose for hepatic encephalopathy (osmotic_laxative_ammonia_reducer, add on) — PregCat: former B — long pregnancy experience; minimal systemic absorption. | Lactation: compatible — minimal systemic absorption. | 30-45 mL PO q6h titrated to 3 soft BMs/day; reduces ammonia in hepatic encephalopathy; adjunct to definitive delivery.

Setting playbook (ed) — Triage third-trimester acute hepatic illness — STAT labs including glucose + ammonia + coag + LFTs, exclude HELLP/PE overlap, initiate D10W for hypoglycemia, activate L&D + ICU + hepatology, decide transfer to transplant center if fulminant
12. D10W IV for hypoglycemia D10W 100 mL bolus then 100-200 mL/h titrated IV continuous infusion — Glucose < 4 mmol/L (Reverse Swansea-criterion hypoglycemia + altered mental status)
13. phytonadione 10 mg IV 10 mg IV slow push IV once now then daily — PT prolonged on initial labs (Vitamin K1 replacement)
14. FFP 10-15 mL/kg IV IV as needed — INR > 2 or active bleeding (Coagulopathy correction pre-delivery)

Non-pharmacologic actions:
- Obstetric + ICU + hepatology consultation immediately
- L&D admission for emergent delivery if Swansea ≥ 6
- Transplant center transfer if fulminant features

AVOID / contraindication checks:
- Do not delay delivery for imaging or biopsy confirmation when swansea criteria met and clinical AFLP (Knight UKOSS 2008 PMID 18332072)
- Avoid acetaminophen postpartum until LFTs improving
- Avoid hepatotoxic drugs statins niacin amiodarone in active AFLP
- Cesarean only if vaginal delivery cannot be expedited coagulopathy permitting
- Mandatory newborn LCHAD MCAD screening cord blood acylcarnitine profile (Knight 2008; LCHAD fetal maternal mechanism)
- Do not give IV fluids without dextrose while hypoglycemic use D10W or D5 NS mixes
- Correct INR to under 2 pre delivery if possible with FFP plus cryoprecipitate (obstetric MTP framework)

Monitoring

Regimen monitoring:
- Glucose q2-4h titrated with D10W; target ≥ 4 mmol/L
- PT/INR + aPTT + fibrinogen + platelets q4-6h while active bleeding then q12h
- Daily LFTs (expect peak within 24-48 h post-delivery then decline)
- Daily ammonia + renal function
- West Haven encephalopathy grade hourly to shift while sedated
- Continuous EFM intrapartum
- Post-delivery uterine tone + EBL (PPH risk from coagulopathy)
- Newborn LCHAD screening result tracking

Setting (ed) monitoring:
- Repeat glucose q15 min during D10W titration
- Continuous EFM
- Reassess GCS + mental status hourly

Follow-up plan: Maternal liver typically recovers within 1-2 weeks post-delivery; full biochemical recovery within 4-6 weeks. NEWBORN: mandatory LCHAD/MCAD/long-chain FAO screening (newborn screen acylcarnitine profile + targeted genetic testing); positive screen → pediatric metabolism specialist + dietary management. MATERNAL genetic counseling — heterozygous LCHAD carrier status confers ~ 20-70 % recurrence in subsequent pregnancy + lifelong implications. Mental-health screen (peripartum PTSD + EPDS — survival from a near-fatal pregnancy event carries significant burden). Subsequent-pregnancy counseling — tertiary-center delivery + early-3rd-trimester surveillance + family planning input.
- Close-out criterion: Maternal recovery confirmed; newborn LCHAD screen result acted upon; genetic counseling delivered; mental-health support arranged; subsequent-pregnancy plan documented

Monitoring phase: Glucose q2-4h (target ≥ 4 mmol/L; D10W if needed); coag panel q4-6h while active bleeding then q12h; daily LFTs (expect peak within 24-48 h post-delivery then steady decline); daily ammonia; renal function daily; serial neuro checks (West Haven grade); intrapartum continuous EFM; post-delivery uterine tone + bleeding (PPH risk from coagulopathy). Continue vitamin K daily.

Disposition

Current setting: ed — Triage third-trimester acute hepatic illness — STAT labs including glucose + ammonia + coag + LFTs, exclude HELLP/PE overlap, initiate D10W for hypoglycemia, activate L&D + ICU + hepatology, decide transfer to transplant center if fulminant

Disposition criteria:
- Swansea ≥ 6 confirmed + initial stabilization → admit L&D + ICU consult + emergent delivery planning
- Fulminant features → transfer to transplant center

Escalation triggers (move to higher acuity):
- Persistent hypoglycemia despite D10W → ICU + transplant center
- Rising INR > 2 → ICU + FFP + transplant center referral
- Encephalopathy deterioration → ICU + emergent delivery
- HELLP features → ob.hellp-syndrome.v1

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] AFLP at presentation — Swansea criteria ≥ 6/14 + 3rd-trimester pregnancy without alternative explanation → emergent delivery as cornerstone (Knight UKOSS 2008 PMID 18332072); ICU + hepatology + neonatology coordination.
- [LIFE_THREATENING] Fulminant AFLP — rising INR > 2 despite FFP, persistent encephalopathy, persistent hypoglycemia despite D10W, ammonia > 150, no improvement by 72-96 h post-delivery → transplant center transfer + transplant evaluation + plasmapheresis/MARS per hepatology (Casey 2020 PMID 31991493 — 16% transplant rate, 11% mortality).
- [LIFE_THREATENING] AFLP + HELLP overlap — HTN + proteinuria + thrombocytopenia + transaminitis + Swansea features. Manage as both per ob.hellp-syndrome.v1 + this engine; magnesium for seizure prophylaxis; delivery is definitive for both.

Citations

- Knight UKOSS 2008 (Gut) prospective national surveillance + Ch'ng 2002 (Gut) Swansea criteria-defining cohort + Wang 2017 (J Matern Fetal Neonatal Med) Swansea validation + Casey 2020 (Hepatology) US ALFSG cohort + obstetric MTP framework + LactMed for phytonadione [PMID:18332072](https://pubmed.ncbi.nlm.nih.gov/18332072/)
- Cited evidence (PMID 12427793) [PMID:12427793](https://pubmed.ncbi.nlm.nih.gov/12427793/)
- Cited evidence (PMID 27923319) [PMID:27923319](https://pubmed.ncbi.nlm.nih.gov/27923319/)
- Cited evidence (PMID 31991493) [PMID:31991493](https://pubmed.ncbi.nlm.nih.gov/31991493/)

Last reconciled with current guidelines: 2026-05-26.
References
  • Knight UKOSS 2008 (Gut) prospective national surveillance + Ch'ng 2002 (Gut) Swansea criteria-defining cohort + Wang 2017 (J Matern Fetal Neonatal Med) Swansea validation + Casey 2020 (Hepatology) US ALFSG cohort + obstetric MTP framework + LactMed for phytonadione — PMID:18332072
  • Cited evidence (PMID 12427793) — PMID:12427793
  • Cited evidence (PMID 27923319) — PMID:27923319
  • Cited evidence (PMID 31991493) — PMID:31991493