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To review the presenting signs, symptoms, laboratory findings, clinical courses, complications, and maternal outcomes in women determined on medicolegal review to have had acute fatty liver of pregnancy (AFLP). We retrospectively studied case files from women with medical and/or hypertensive complications of pregnancy which had been reviewed by the first author, deidentified and divested of legal documents so that only medical-related information was retained for later research and teaching purposes. Main outcomes are 12 lessons learned from this review to be offered for the future benefit of clinicians encountering patients with AFLP. Eleven women with AFLP were identified within the 161 file database. Signs and symptoms present in 91–100% of women with AFLP were altered sensorium, a fast resting maternal pulse &gt;100/min, gastrointestinal complaints, muscle pain and evidence of fetal compromise/stillbirth. Laboratory findings in 91–100% revealed abnormal liver, renal and coagulation tests, hyperuricemia, and very low serum glucose and albumin. A correct initial diagnosis of AFLP was made for only three women; the most common incorrect presumptive diagnosis was HELLP syndrome. Four women survived. Twelve major findings are discussed. Rapid, timely and thorough evaluation of third trimester women presenting with  A  (Altered mental status changes/extreme sleepiness),  F  (Fast resting pulse &gt;100 in the absence of fever or heart causation),  L  (Liver-related gastrointestinal complaints) and  P  (Pain as myalgias and body aches), often in association with evidence of fetal compromise or stillbirth, should initiate efforts to investigate a possible diagnosis of AFLP. Adoption of the concepts summarized including core initial laboratory testing, immediate patient transfer to tertiary care, and aggressive correction of consumptive coagulopathy could form the basis of a patient safety bundle to guide future management for patients with AFLP.

Missing or making the timely diagnosis of acute fatty liver of pregnancy (AFLP): lessons learned