Acute Fatty Liver of Pregnancy (AFLP)

Acute fatty liver of pregnancy is a rare but serious obstetric emergency characterised by microvesicular fatty infiltration of hepatocytes, typically presenting in the third trimester. Let us analyse each statement:

• Statement 1: It is typically present in first trimester — Incorrect.
  AFLP classically presents in the third trimester (usually after 30–34 weeks), not the first trimester. Early presentation would be atypical and is not a recognised feature of this condition.
• Statement 2: It is more common in multiple pregnancies — Correct.
  Multiple gestation (twin/triplet pregnancies) is a well-established risk factor for AFLP, along with primiparity, male fetus, and low maternal BMI. The larger placental mass in multiple pregnancies is thought to increase the metabolic burden on maternal fatty-acid oxidation pathways, especially in fetuses with LCHAD (long-chain 3-hydroxyacyl-CoA dehydrogenase) deficiency.
• Statement 3: Liver biopsy is rarely needed — Correct.
  The diagnosis of AFLP is largely clinical, supported by the Swansea criteria, laboratory abnormalities (elevated transaminases, hyperuricemia, hypoglycemia, coagulopathy, raised ammonia), and imaging. Liver biopsy carries significant bleeding risk in a patient who is often coagulopathic, so it is reserved only for atypical or diagnostically uncertain cases and is not routinely required.
• Statement 4: Delivery of fetus is indicated — Correct.
  Prompt delivery, regardless of gestational age once the diagnosis is made, is the cornerstone and definitive treatment of AFLP. Maternal condition typically improves rapidly following delivery, whereas continuation of pregnancy risks progression to fulminant hepatic failure, DIC, and maternal/fetal death.

Conclusion

Statements 2, 3, and 4 are correct, while statement 1 is false because AFLP presents in the third trimester, not the first. Therefore, the correct answer is 2, 3 and 4.