Diagnostic Challenges in Acute Fatty Liver of Pregnancy: Fever as a Key Symptom in Case Series from Indonesia

BACKGROUND Acute fatty liver of pregnancy (AFLP) is a rare and catastrophic disease in pregnancy. It is important to distinguish between pathogenic diseases that cause abnormal liver function tests during pregnancy and typical physiological changes. An AFLP diagnosis can be established using Swansea criteria. AFLP typically occurs in the third trimester of pregnancy or postpartum, with a median presentation of 35-37 weeks of pregnancy. AFLP is also an obstetrical and medical emergency that is characterized by rapid deterioration of the patient's condition. CASE REPORT We present 3 cases from a tertiary hospital in Indonesia. The Swansea criteria were met in all 3 cases. Our cases were specifically characterized by complaints of fever. Fever complaints were not included in the Swansea criteria. The complaint of fever served to deceive and disorient the first treating clinician, resulting in a late referral. Delay of referral can lead to inappropriate treatment, prolonged duration of recovery, and the emergence of various complications, even death. In all of the cases reported here, the patients experienced detrimental effects and outcomes of the maternal and fetal condition. This case report also confirms that fever was the main symptom experienced by the patients who were hospitalized. Other common initial symptoms were nausea, vomiting, jaundice, and encephalopathy. CONCLUSIONS We propose that fever complaints be considered as criteria for AFLP diagnosis in Indonesia. However, more research is still needed with a larger number of cases. Prompt and appropriate treatment will result in a significantly more favorable outcome. Prompt identification, early diagnosis, immediate delivery, and comprehensive supportive treatment are important for maternal and infant outcomes in patients with AFLP.