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Peripartum management of a patient status-post four liver transplants
Abstract Number: S 72
Abstract Type: Case Report/Case Series
Introduction: A recent meta-analysis of 450 pregnancies in liver transplant (LT) recipients concluded that “successful pregnancies are viable” in this population. The vast majority of the 14,000 post-LT women of child bearing age in the United States had a single LT, and, while considered high-risk, pregnancy outcomes have been well documented. To our knowledge there are no reported cases of pregnancy after multiple LTs.
Case: 33 yo G1P0 with history of four orthotopic LTs presented at 35.0 wks EGA in labor. Her first transplant was at age 3 for biliary atresia; she was retransplanted at age 22 for hepC cirrhosis (likely contracted during first LT); at 23 she twice developed hepatic artery thrombosis, requiring third LT and subsequently fourth and final LT. Her medical history was also significant for tracheostomy as a child (subsequently decannulated), prolonged intubation between LT #3 and 4, as well as other surgeries including colostomy and takedown. Complications during pregnancy included perihepatic and intraabdominal abscesses requiring IV antibiotics. Her immunosuppressant regimen (azathioprine and cyclosporine) was continued through pregnancy. On presentation she was diagnosed with preeclampsia with BP elevated to 170s/110s, urinalysis with 3+ proteinuria, and creatinine of 2.1 mg/dl (baseline 1.1). An early combined spinal-epidural was placed, and analgesia was maintained per usual protocol. 3% chloroprocaine was at the bedside in case of emergency cesarean delivery (CD). A magnesium infusion was maintained throughout labor, and blood pressure was controlled with IV labetalol. Her labor was complicated by intermittent variable decelerations, but she vaginally delivered an 1859g male infant. Creatinine peaked at 2.4 on postpartum day 1 but downtrended thereafter, and the patient was discharged home on PPD 2.
Discussion: While outcomes have been studied in post-LT women, we believe our patient is the first report of pregnancy following four LTs. LT recipients are at increased risk of CD, preeclampsia, and preterm birth, and the latter two complications occurred in our patient. Cases of graft rejection, renal failure, and birth defects have also been reported. Our patient’s renal function was of particular concern, as one case series observed eventual need for long-term dialysis in patients whose creatinine rose above 1.5 mg/dl. An emergency CD could have been problematic due to altered anatomy and presumed severe adhesive disease. Previous abdominal surgery is associated with longer CD duration, and the increased time to delivery in patients with previous CD is more pronounced when adhesive disease is present. Her possibly difficult airway added to the potential perils of emergent CD and reinforced the importance of having a functioning epidural. Collaboration between maternal fetal medicine, anesthesiology, nephrology, and transplant surgery led to a favorable outcome in this complex patient.