///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-06:00


Abstract Number: 20
Abstract Type: Case Report/Case Series

Amarjeet Singh DA,FRCA1 ; Maggie Mechlin MD2; Lesley Gilbertson MD3

Introduction: The perioperative management of the coagulopathic patient is a challenge for anesthesiologists especially when the patient is also pregnant, preterm, and needs an emergency Cesarean section. Case Report: A 25 year old G3P2002 at 30 3/7 weeks gestation presented to an outside hospital with fever, headache and flu like symptoms of five days duration. She was transferred to our hospital for further evaluation of new onset thrombocytopenia and management of her pregnancy. On transfer to our hospital, she had intermittent uterine contractions, was febrile to 101.2oF, with pancytopenia and elevated liver enzymes. For the next two days she remained febrile to 103.2 oF. Consulting services thought that a viral infection was the likely cause of her symptoms since serial bacterial cultures were negative. Viral cultures were pending. On day 3, the patient experienced labored respirations and received supplemental oxygen with a facemask. Her liver function tests worsened and coagulation studies were consistent with disseminated intravascular coagulation. She was started on intravenous Acyclovir to treat the presumptive viremia. Cesarean section under general anesthesia was performed for late decelerations noted on fetal monitoring. Perioperatively, the patient received seven units of fresh frozen plasma and four 6-packs of platelets, as well as Factor VIII, as per recommendations of the hematologist. Following delivery and closure of the uterus, examination of the liver revealed significant areas of necrosis and ischemia and multiple liver biopsies were performed. Postoperatively, the patient was transferred to the intensive care unit. Test results revealed herpes hepatitis and HSV-2 infection. The patients liver function and coagulation parameters slowly improved, returning to baseline over the next10 days. Infant was positive for HSV-2 and received treatment with Acyclovir and did well. Discussion: Herpes hepatitis is rare, seen mostly in immunocompromised patients, with a small subset of pregnant patients manifesting fulminant anicteric hepatic failure in their third trimester. These women typically do not display any orogenital lesions prior to hepatic seeding with the virus. Many do not survive due to delay in the diagnosis and initiation of therapy. Given the rarity of this clinical syndrome, clinical suspicion of herpes as a cause of hepatic failure and DIC in the parturient usually is low. Published reports share a few features: a previously healthy female currently in her third trimester, liver failure with marked elevation of transaminases but without significant elevation of bilirubin, and a prodrome of a febrile illness with nonspecific associated symptoms. There is scant data on long term prognosis. Of the patients who survived the illness, only one case report details the patients clinical condition beyond discharge, but it seems those who are treated in the appropriate time frame do eventually recover fully.

SOAP 2009