Abstract
BACKGROUND: Acute fatty liver of pregnancy (AFLP) is a rare but serious complication in the third trimester, characterized by microvesicular hepatic steatosis and risk of rapid progression to liver failure and multi-organ dysfunction. Despite improved care, maternal and perinatal mortality remain significant. Acetaminophen is commonly used during pregnancy with a good safety profile, but hepatotoxicity can occur. This report highlights the successful treatment of AFLP during therapeutic acetaminophen use, emphasizing the need for timely, multidisciplinary management. CASE PRESENTATION: We report the case of a 37-year-old primigravida at 36 + 3 weeks’ gestation who presented with nausea, vomiting, abdominal pain, jaundice, and clinical signs of fetal growth restriction. Notably, she had been intermittently taking therapeutic doses of acetaminophen specifically for dental pain. Laboratory investigations revealed marked hepatic dysfunction, coagulopathy, and acute kidney injury. As her clinical condition deteriorated rapidly, an emergency cesarean section was performed, resulting in the birth of a healthy female neonate at 36 weeks of gestation, weighing 2220 g, corresponding to the 7.6th percentile for gestational age according to locally derived reference standards. Postoperatively, her liver failure worsened, requiring plasma exchange, artificial liver support, and intensive care. Multidisciplinary management led to her full recovery, and she was discharged in stable condition. Both the mother and the infant remained in good health during the one‑year follow‑up period. CONCLUSION: AFLP is a rare but potentially life threatening complication of late gestation that can rapidly progress to acute hepatic dysfunction with coagulopathy and multiorgan involvement. This case highlights the diagnostic complexity of AFLP in late gestation, particularly when recent therapeutic acetaminophen use may confound clinical assessment despite the absence of overdose. In pregnant patients with acetaminophen exposure, careful differentiation between AFLP and drug induced liver injury is critical. Further studies are warranted to clarify whether therapeutic dose acetaminophen use contributes to AFLP risk in metabolically susceptible patients. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12884-026-08844-5.