Acute fatty liver of pregnancy (AFLP) is rare and can present in a similar way to other causes of liver function abnormality both in pregnancy and non-pregnancy related. It may present with signs and symptoms of acute hepatitis, classically nausea, vomiting, and abdominal pain. Two of the most distinctive features of AFLP are profound hypoglycemia and hyperuricemia, which is more marked than the presenting pre-eclamptic features. General anesthesia is frequently preferred for patients with AFLP, given the often severe coagulopathy. Renal and respiratory failure as well as liver failure, encephalopathy and coagulopathies are seen in AFLP. Women who develop fulminant hepatic failure and encephalopathy require transfer to a specialist liver unit. Women who develop renal failure will require optimal fluid resuscitation guided by invasive monitoring in conjunction with treatment for associated morbidity. The risk of bleeding and of venous thromboembolism needs to be balanced.