Case Report A 29 year old woman (G1) at 35 weeks gestation presented with a history of feeling generally unwell. Clinical examination was normal except that she had pedal edema. Initial blood tests revealed abnormal liver function only (ALT 415 iu\l, serum bile acids 59 units). A viral and autoimmune screen was negative. Ultrasound of the liver was normal.

An emergency caesarean section was performed for a pathological CTG two days after admission and a babygirl delivered in good condition. A 1.5l PPH was managed routinely. During post-op period her GCS changed subtly and dropped to 13. She developed marked metabolic acidosis. Intensive Care Unit admission was organised where she had several episodes of hypoglycaemia. Liver function deteriorated (ALT 703 iu\l) and she developed renal compromise. An EEG showed slow waves consistent with metabolic encephalopathy.

A Diagnosis of AFLP with hepatic encephalopathy was made and she was transferred to the regional liver unit 48 h after delivery. There she was intubated, ventilated and needed ionotropic support. After 10 days of conservative management on ITU her liver function improved and she made a good recovery. By 6 weeks post partum her blood tests had returned to normal.

Conclusion Careful examination to assess the level of consciousness/cognitive function is needed in cases of liver dysfunction to pick up early manifestations of hepatic encephalopathy and to improve maternal and fetal out comes.