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

We report a case of a 28-year-old female in her first pregnancy at 31 + 1 weeks gestation who presented with upper abdominal pain and vomiting. Her pregnancy was complicated with gestational diabetes and she was newly started on metformin. On presentation, she complained of abdominal pain and vomiting. She was hypoglycemic, acidotic and bloods revealed hepatorenal failure and coagulopathy. A differential diagnosis of acute fatty liver of pregnancy (AFLP), atypical homolysis, elevated liver enzymes, low platelets (HELLP) or lactic acidosis from metformin was made. The patient was promptly delivered by cesarean section under general anesthetic. The post-delivery course was complicated with an intensive care unit (ICU) stay with worsening hepatorenal function, hypertension, and encephalopathy. A multidisciplinary approach was employed resulting in significant improvement by the 6-week follow-up, with blood parameters nearly normalized. Despite retrospective analysis, clinicians still face a diagnostic dilemma with varying opinions on the definitive diagnosis.