Spinal Anesthesia in the setting of Acute Fatty Liver of Pregnancy
Abstract Number: 127
Abstract Type: Case Report/Case Series
Acute Fatty Liver of Pregnancy (AFLP) is a potentially fatal condition that can manifest in the 3rd trimester. It represents an obstetric emergency and requires immediate delivery of the fetus. (1) This case report describes management of a patient who presented for an emergent Cesarean section and was only diagnosed post-operatively with AFLP. Due to the urgent nature of her condition and difficult airway, the patient received a spinal anesthetic despite unknown, but severe coagulopathy.
A previously healthy, 36 year-old female presented with repeated, prolonged fetal decelerations in OB triage. The patient was noted to have icteric sclera. In the OR, after an awake direct laryngoscopy failed to visualize any laryngeal structures, the decision was made to proceed with a spinal anesthetic. The rest of the case proceeded without difficulty with delivery of a male infant who was transferred to the NICU for cord blood pH of 6.7 and APGAR scores of 1 and 6.
In the post-operative period, there were several concerning trends in the patient’s lab values, as outlined in Table 1. The patient was transferred to the ICU. An ultrasound of the liver was consistent with acute fatty infiltration. After 11 days, the patient was discharged home in stable condition.
Regional anesthesia is desirable in emergent situations that involve difficult airways and is also thought to be largely responsible for the decrease in maternal mortality during a Cesarean section. (2) However, a spinal hematoma is a known catastrophic risk, and the incidence is greatly increased with coagulation abnormalities.
In this case, an emergent Cesarean section was deemed necessary before optimal evaluation was complete. The seriousness of the patient’s condition was only appreciated after the procedure. This report is not an endorsement of neuraxial anesthetics in coagulopathic patients, and if placed in a similar situation, the authors would recommend general anesthesia with advanced airway management. Fortunately, the patient suffered from no anesthesia-related adverse events.
1. Gregory TL, Hughes S, Coleman A, et al. Acute fatty liver of pregnancy; three cases and discussion of analgesia and anaesthesia. International Journal of Obstetric Anesthesia. 2007. 16: 175-179
2. Hawkins JL, Koonin LM, Palmer SK, et al. Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990. Anesthesiology. 1997. 86:277-284.