Anesthetic concerns for Cesarean delivery of twin pregnancy after multiple orthotopic liver transplants.
Abstract Number: 248
Abstract Type: Case Report/Case Series
The success of orthotopic liver transplant has led to increasing numbers of singleton and multiple pregnancies being carried to maturity. In 2009, 162 transplants were performed in women of ages 16-34.
The physiologic, pharmacologic and medical problems in transplant recipients raise particular concerns for safe administration of anesthesia.
We detail the challenges of providing anesthesia to a 35 year-old liver transplant patient with twin gestation at 33 weeks. Her first liver transplant was for hepatic failure from Wilson's disease, and the second one for graft rejection. Cesarean section was performed owing to worsening renal function.
She had achieved pregnancy via IVF-ET, experienced cholestasis, altered renal function and preeclampsia during this pregnancy.
Immunosuppressants are key to continued graft survival, but have many side effects. They can cause renal dysfunction, reduce seizure threshold and precipitate severe electrolyte imbalance affecting cardiac rhythm. Renal dysfunction may augment toxicity of local anesthetics as well as narcotics.
Bone marrow suppression, thrombocytopenia and leucopenia are important considerations for regional anesthesia. Maintenance of strict asepsis becomes essential. Steroids can cause gastrointestinal bleeding and anemia.
Rapid and large fluid infusions cause subtherapeutic immunosuppressant levels and affect graft survival. Anesthetic drugs enhance immunosuppressant metabolism decreasing their bioavailability.
Evaluation of graft function is essential to rule out the presence of rejection. Surgery during rejection is associated with higher morbidity. Post-operative pain relief may prove challenging due to opioid tolerance. Nonsterioidal anti-inflammatory agents may have adverse renal effects.
We performed a subarachnoid block with hyperbaric bupivacaine, fentanyl and preservative-free morphine in consultation with the obstetric team. The cesarean section proceeded uneventfully with the delivery of two male infants with normal APGAR scores.
Her post-operative course was uncomplicated except for a mild alteration in LFTs and renal function that normalized a few days post-partum.
We believe that comprehensive health care to pregnant transplant patients is best achieved by the team approach so as to ensure a safe outcome for both the mother and infant.
We will also append relevant reference material to the presentation that helped to guide our planning of the anesthetic for our patient.