Extracorporeal Rescue via Therapeutic Plasma Exchange in Refractory Postpartum Mississippi Class 1 HELLP Syndrome Overlapping with Acute Fatty Liver of Pregnancy: A Longitudinal Observational Analytic Case Study

Background: Postpartum Mississippi Class 1 HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) can overlap with acute fatty liver of pregnancy (AFLP). Delivery may not bring recovery, and multiorgan failure can follow. Objective: To describe the laboratory course of a patient with refractory postpartum HELLP–AFLP overlap treated with therapeutic plasma exchange (TPE). Methods: This case report describes a 36-year-old primipara at 34 weeks 1 day who presented with intrauterine fetal death, scleral icterus, and epigastric pain at Dr. Moewardi Regional General Hospital, Indonesia (ethics protocol CMHC/EC/IRB/2026/0418). Serial values over five hospital days (T0 to T4) are reported with percentage changes (Δ%) and reference-limit ratios. Result: At admission, blood pressure was 140/93 mmHg. Platelets were 47.0 × 10³/μL, AST 425.0 U/L, ALT 265.0 U/L, LDH 549.0 U/L, and total bilirubin 13.60 mg/dL (direct 12.74 mg/dL). A stillborn fetus was delivered vaginally, and magnesium sulfate and methylprednisolone were given. Platelets still fell to 28.0 × 10³/μL at T1 (Δ% = −40.43%). One session of TPE with fresh frozen plasma followed within 24–48 h postpartum. By Day 5 (T4), platelets were 115.0 × 10³/μL (Δ% = +310.71% from T1), AST 41.0 U/L (−90.35%), ALT 36.0 U/L (−86.42%), bilirubin 2.15 mg/dL (−84.19%), and LDH 240.0 U/L (−56.28%). Conclusion: In this patient, TPE within 24–48 h postpartum was followed by laboratory recovery without multiorgan failure. A temporal association in one case does not establish benefit. Further studies are needed.