At Sinai Hospital in Baltimore we had two patients with acute fatty liver of pregnancy within four months.  The clinical presentation of each woman had some distinct similarities and fortunately these were recognized quickly enough that we had good out comes for both mothers and their babies.  Through the analysis of these case presentations, we determined several "red flag" symptoms that might help other clinicians more quickly recognize and diagnose acute fatty liver of pregancny.  Both patients presented to the hospital after a previous admission for preterm labor which had included tocolysis with terbutaline and subsequent magesium sulfate.  Both had also developed pulmonary edema during those initial hospitalizations.  When they returned to the hospital both ladies presented with flu-like symptoms, nausea, vomiting, and contractions.  The first case additionally presented with complaints of extreme thirst and an inability to tolerate any solid food for almost two weeks.  She initially was being ruled out for preeclampsia, which appeared to be an unlikely diagnosis given that it was her third pregnancy with the same partner and she had no other risk factors.  It was the critical glucose level of 25 that alerted the team to  include a differential diagnosis of acute fatty liver of pregnancy.  In the second case, the differential diagnosis of preeclampsia seemed more likely given the history of a 37 year old nullip pregnant with twins as a result of IVF.  She began abrupting at 31 5/7 weeks and it wasn't until lab results came back while they were performing an emergency c-section that the team was notified of AST/ALT levels of 1931 and 1594 respectively and a platelet count of 25.

From these two cases, the "red flag" symptoms of acute fatty liver of pregnancy became  apparent:  flu-like symptoms, nausea, extreme thirst, and a general dusky appearance.

"Red flag" laboratory values included significantly elevated liver enzymes (above 1000) and critically low platelets and glucose levels.