J Clin Gynecol Obstet

Journal of Clinical Gynecology and Obstetrics, ISSN 1927-1271 print, 1927-128X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Gynecol Obstet and Elmer Press Inc

Journal website https://jcgo.elmerpub.com

Case Report

Volume 14, Number 3, October 2025, pages 100-105

Acute Fatty Liver of Pregnancy or Atypical Presentation of Homolysis, Elevated Liver Enzymes, Low Platelets Syndrome: The Dilemma Continues

**Table 1.** Blood Test at Initial Presentation
FBC		LFT		U&E
ALP: alkaline phosphatase; ALT: alanine transaminase; CRP: C-reactive protein; eGFR: estimated glomerular filtration rate; FBC: full blood count; LFT: liver function test; PLT: platelet; U&E: urea and electrolytes; WBC: white blood cell.
Hb	116 g/L	Bilirubin	190 µmol/L	Na	130 mmol/L
WBC	14.9 × 10⁹/L	ALT	144 IU/L	K	Hemolyzed
PLT	141 × 10⁹/L	ALP	370 IU/L	Urea	6.7 mmol/L
CRP	31.4 mg/L	Albumin	21 g/L	Cr	251 µmol/L
		Amylase	40 IU/L	eGFR	19 mL/min

Table 1. Blood Test at Initial Presentation

FBC

LFT

U&E

ALP: alkaline phosphatase; ALT: alanine transaminase; CRP: C-reactive protein; eGFR: estimated glomerular filtration rate; FBC: full blood count; LFT: liver function test; PLT: platelet; U&E: urea and electrolytes; WBC: white blood cell.

116 g/L

Bilirubin

190 µmol/L

130 mmol/L

WBC

14.9 × 10⁹/L

ALT

144 IU/L

Hemolyzed

PLT

141 × 10⁹/L

ALP

370 IU/L

Urea

6.7 mmol/L

CRP

31.4 mg/L

Albumin

21 g/L

251 µmol/L

Amylase

40 IU/L

eGFR

19 mL/min

**Table 2.** Maternal Clotting Results
	Result	Reference range
aPTT: activated partial thromboplastin time; INR: international normalized ratio.
Prothrombin time	22.1	9.7 - 14.1
INR	1.8	0.9 - 1.1
aPTT	44	25.1 - 36.5
Fibrinogen	1.5	2.7 - 5.6

Table 2. Maternal Clotting Results

Result

Reference range

aPTT: activated partial thromboplastin time; INR: international normalized ratio.

Prothrombin time

22.1

9.7 - 14.1

INR

1.8

0.9 - 1.1

aPTT

25.1 - 36.5

Fibrinogen

1.5

2.7 - 5.6

**Table 3.** Further Blood Results
	Result	Reference range
Low serum haptoglobin, raised LDH, and conjugated bilirubin indicate hepatocellular damage. LDH: lactate dehydrogenase.
Serum haptoglobin	0.18 g/L	0.35 - 2.50
Serum LDH	404 U/L	125 - 220
Serum bilirubin	163 µmol	< 21
Serum conjugated bilirubin	119.5 µmol/L	< 8.6
Blood morphology	Anisocytosis

Table 3. Further Blood Results

Result

Reference range

Low serum haptoglobin, raised LDH, and conjugated bilirubin indicate hepatocellular damage. LDH: lactate dehydrogenase.

Serum haptoglobin

0.18 g/L

0.35 - 2.50

Serum LDH

404 U/L

125 - 220

Serum bilirubin

163 µmol

< 21

Serum conjugated bilirubin

119.5 µmol/L

< 8.6

Blood morphology

Anisocytosis

**Table 4.** Tennessee Classification for the Diagnosis of HELLP Syndrome According to Ditisheim et al [5]
HELLP: Homolysis, Elevated liver enzymes, low platelets.
Hemolysis, established by at least two of the following:
Peripheral smear with schistocytes and burr cells
Serum bilirubin ≥ 1.2 mg/dL (20.52 µmol/L)
Low serum haptoglobin (≤ 25 mg/dL) or LDH ≥ 2 times the upper level of normal
Severe anemia, unrelated to blood loss
Elevated liver enzymes:
Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) ≥ 2 times the upper level of normal
Low platelets: < 100,000 cells/µL

Table 4. Tennessee Classification for the Diagnosis of HELLP Syndrome According to Ditisheim et al [5]

HELLP: Homolysis, Elevated liver enzymes, low platelets.

Hemolysis, established by at least two of the following:

Peripheral smear with schistocytes and burr cells

Serum bilirubin ≥ 1.2 mg/dL (20.52 µmol/L)

Low serum haptoglobin (≤ 25 mg/dL) or LDH ≥ 2 times the upper level of normal

Severe anemia, unrelated to blood loss

Elevated liver enzymes:

Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) ≥ 2 times the upper level of normal

Low platelets: < 100,000 cells/µL

**Table 5.** Differential Diagnosis in Women With HELLP Syndrome According to Baha [6]
HELLP: Homolysis, Elevated liver enzymes, low platelets.
Acute fatty liver of pregnancy (AFLP)
Thrombotic thrombocytopenic purpura (TTP)
Hemolytic uremic syndrome (HUS)
Immune thrombocytopenic purpura (ITP)
Systemic lupus erythematosus (SLE)
Antiphospholipid syndrome (APS)
Cholecystitis
Fulminant viral hepatitis
Acute pancreatitis
Disseminated herpes simplex
Hemorrhagic or septic shock

Table 5. Differential Diagnosis in Women With HELLP Syndrome According to Baha [6]

HELLP: Homolysis, Elevated liver enzymes, low platelets.

Acute fatty liver of pregnancy (AFLP)

Thrombotic thrombocytopenic purpura (TTP)

Hemolytic uremic syndrome (HUS)

Immune thrombocytopenic purpura (ITP)

Systemic lupus erythematosus (SLE)

Antiphospholipid syndrome (APS)

Cholecystitis

Fulminant viral hepatitis

Acute pancreatitis

Disseminated herpes simplex

Hemorrhagic or septic shock

**Table 6.** Swansea Criteria for the Diagnosis of AFLP [11]
AFLP: acute fatty liver of pregnancy.
Signs and symptoms
Vomiting
Abdominal pain
Polydipsia/polyuria
Encephalopathy
Laboratory findings
Elevated bilirubin (> 0.8 mg/dL or > 14 µmol/L)
Hypoglycemia (glucose < 72 mg/dL or < 4 mmol/L)
Leukocytosis (> 11,000 cells/µL)
Elevated transaminases (AST or ALT) (> 42 international unit/L)
Elevated ammonia (> 47 µmol/L)
Elevated urate (5.7 mg/dL or > 340 µmol/L)
Acute kidney injury, or creatinine > 1.7 mg/dL (150 µmol/L)
Coagulopathy or prothrombin time > 14 s
Imaging: Ascites or bright liver on ultrasound scan
Histology: Microvesicular steatosis on liver biopsy

Table 6. Swansea Criteria for the Diagnosis of AFLP [11]

AFLP: acute fatty liver of pregnancy.

Signs and symptoms

Vomiting

Abdominal pain

Polydipsia/polyuria

Encephalopathy

Laboratory findings

Elevated bilirubin (> 0.8 mg/dL or > 14 µmol/L)

Hypoglycemia (glucose < 72 mg/dL or < 4 mmol/L)

Leukocytosis (> 11,000 cells/µL)

Elevated transaminases (AST or ALT) (> 42 international unit/L)

Elevated ammonia (> 47 µmol/L)

Elevated urate (5.7 mg/dL or > 340 µmol/L)

Acute kidney injury, or creatinine > 1.7 mg/dL (150 µmol/L)

Coagulopathy or prothrombin time > 14 s

Imaging: Ascites or bright liver on ultrasound scan

Histology: Microvesicular steatosis on liver biopsy