Differentiating Acute Fatty Liver of Pregnancy From HELLP Syndrome in Jaundice in Pregnancies: A Comprehensive Clinical–Laboratory Characterization and Diagnostic Algorithm

Abstract

To distinguish Acute Fatty Liver of Pregnancy (AFLP) from HELLP syndrome in pregnancies presenting with jaundice by characterizing their clinical presentation, laboratory features, maternal complications, and perinatal outcomes, and to develop a practical diagnostic algorithm. This retrospective study reviewed medical records of pregnant women with jaundice in pregnancy treated at Dr. Soetomo General Academic Hospital, Indonesia (2010–2023). Women diagnosed with AFLP or HELLP were identified using Swansea criteria and the Tennessee/Mississippi classifications. Clinical symptoms, laboratory findings, and maternal–fetal outcomes were extracted from electronic records. Group differences were analyzed using Mann–Whitney U tests for continuous variables and χ² or Fisher’s exact tests for categorical variables. Logistic regression determined independent predictors, and predictive accuracy was assessed using receiver-operating characteristic analysis. Of 64 eligible cases, 25 (39.1%) had AFLP and 39 (60.9%) had HELLP. AFLP cases showed higher rates of jaundice, hypoglycemia, coagulopathy, encephalopathy, and elevated bilirubin compared with HELLP. In contrast, thrombocytopenia, marked transaminase elevation, and hemolysis-related markers predominated in HELLP. Maternal mortality was comparable between groups (28.0% vs. 25.6%), gestational age at delivery and birth weight did not differ significantly. Multivariate analysis identified hypoglycemia, elevated bilirubin, INR > 1.5, creatinine elevation, and clinical jaundice as predictors of AFLP, while low platelet count favored HELLP. The diagnostic model achieved an AUC of 0.82. Although AFLP and HELLP share overlapping clinical features, distinctive laboratory patterns allow reliable differentiation. Recognition of these predictors offers a practical tool to assist clinicians in early diagnosis and triage in resource-limited settings, though several parameters may have limited availability and require external validation.