Obstetric critical care

HELLP syndrome and acute fatty liver of pregnancy

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

Distinguish HELLP from AFLP (Swansea), deliver, support coagulation and glucose, and watch for hepatic haematoma and acute liver failure.

Definition
HELLP: Haemolysis (LDH > 600 U/L, schistocytes), Elevated Liver enzymes (AST/ALT > 2× normal, ~> 70 U/L), Low Platelets (< 100,000/mm³), usually with pre-eclampsia. AFLP: third-trimester microvesicular fatty liver with hypoglycaemia, coagulopathy, encephalopathy and AKI; diagnosed by Swansea criteria (≥ 6 of 14).

At the bedside

  1. 1

    Stabilise and treat as severe pre-eclampsia

    BP control and magnesium sulfate for HELLP.

  2. 2

    Work-up

    FBC with smear, LDH, bilirubin, AST/ALT, glucose, coagulation including fibrinogen, ammonia, creatinine, uric acid; ultrasound liver (haematoma).

  3. 3

    Deliver

    Both HELLP (≥ 34 weeks or deteriorating) and AFLP require prompt delivery after maternal stabilisation.

  4. 4

    Correct coagulation

    Platelets > 50,000 before caesarean (transfuse if lower); FFP/cryoprecipitate for AFLP coagulopathy guided by fibrinogen and bleeding.

  5. 5

    Glucose

    AFLP: hourly glucose; dextrose infusion (10-20%) for hypoglycaemia.

  6. 6

    Liver failure care

    Encephalopathy, rising INR, lactate: manage as acute liver failure, contact transplant centre; plasma exchange in selected cases.

  7. 7

    Watch for haematoma

    Right upper quadrant/shoulder pain with shock: subcapsular liver haematoma/rupture - CT, interventional radiology or surgery.

HELLP vs AFLP vs TTP/HUS

FeatureHELLPAFLP
TimingThird trimester or postpartumThird trimester (30-38 weeks)
HypertensionUsually~50%
HypoglycaemiaUncommonCommon
Coagulopathy (raised INR, low fibrinogen)Late/with DICEarly and marked
EncephalopathyRareCommon
PlateletsLow (defining)Normal or mildly low
AmmoniaNormalRaised

Swansea criteria for AFLP (≥ 6 without other cause)

Clinical/labLab/imaging
VomitingBilirubin > 0.8 mg/dL (14 µmol/L)
Abdominal painHypoglycaemia < 72 mg/dL (4 mmol/L)
Polydipsia/polyuriaUric acid > 5.7 mg/dL (340 µmol/L)
EncephalopathyWBC > 11,000/mm³
Ascites or bright liver on ultrasoundAST/ALT > 42 U/L
Microvesicular steatosis on biopsyAmmonia > 47 µmol/L; creatinine > 1.7 mg/dL (150 µmol/L); PT > 14 s or aPTT > 34 s

14 criteria in total.

Red flag · call your senior now
Sudden shoulder-tip pain and hypotension in HELLP: liver haematoma rupture - surgical emergency.
Pitfall
Missing hypoglycaemia in AFLP presenting as drowsiness.
Pitfall
Labelling AFLP as viral hepatitis and delaying delivery.
Pearl
In India, also exclude hepatitis E (very high mortality in pregnancy) and malaria/dengue when liver enzymes and platelets are abnormal.

References

  1. 1

    American College of Obstetricians and Gynecologists. Gestational hypertension and preeclampsia: ACOG Practice Bulletin No. 222. Obstet Gynecol 2020;135:e237-60.

  2. 2

    Ch'ng CL, Morgan M, Hainsworth I, Kingham JG. Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut 2002;51:876-80.

  3. 3

    European Association for the Study of the Liver. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017;66:1047-81.

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