///2015 Abstract Details
2015 Abstract Details2019-08-02T16:54:43-06:00

Management of a pre-eclamptic parturient with a Liver transplant, chronic rejection and thrombocytopenia

Abstract Number: S-63
Abstract Type: Case Report/Case Series

Neil A Logan MBCHB, BSc (Hons), FRCA1 ; Therese Murphy MBCHB, FRCA2

Background:Pregnancy in women who are recipients of liver

transplants is generally associated with a good outcome.

However, they carry high risk to the patient, fetus and

allograft. A meta-analysis of studies from the UK, USA, Italy

and Poland showed higher rates of pre -eclampsia, pre-term

births,caesarean section rates and lower birth weight(1).

Case: 20 year old primigravid women at 27 weeks.She had

previously received a liver transplant 3 years ago for auto-

immune hepatitis with one episode of acute rejection due to

poor compliance with her medication.This had continued and

she had evidence of chronic rejection.Furthermore, she had

chronic thrombocytopenia with platelet counts of 80-100x10

/L. Her immunosuppressant therapy was prednisolone and

tacrolimus. During routine obstetric review she was found to

be pre-eclamptic which necessitated transfer to a tertiary

centre.She was commenced on oral Labetalol and a

magnesium infusion to reduce the risk of fetal cerebral palsy.

The national liver unit was contacted who recommended

increasing her prednisolone. Fetal ultrasound demonstrated

absent end-diastolic flow and therefore caesarean section(CS)

was required. Blood results - Hb132g/l, WCC 6.4 x 10 /l,

platelets 76x10 /l, bilirubin 10,ALT82,AST 90, urate 0.66,

urea 9.6 and creatinine 64, coagulation screen normal.

The decision was taken to perform a general anaesthetic due

to her thrombocytopenia.A rapid seuquence induction was

performed with alfentanil 1mg, thiopentone 375mg and

suxamethonium 100mg and her airway was secured

uneventfully.CS was uncomplicated and a live boy was

delivered weighing 810g.Formal apgars were not recorded.

Blood loss was 300ml. For analgesia she received 15mg

morphine and ultrasound guided TAP blocks prior to

extubation. Insertion of a nasal temperature probe resulted in

an epistaxis which settled. Her post -operative recovery was

complicated by a wound infection, which was treated

successfully with co-amoxiclav.

Discussion: This case highlights the importance of an

effective multi-disciplinary approach to complex patients.

Transfer to a tertiary centre and telephone advice from a

national centre contributed to good outcomes for mother and

baby. With rising transplant rates it is likely that more

patients who have received an organ will become pregnant

and require mulit-disciplinary input during their pregnancy.

A platelet count of 80x10 /l is used as a surrogate safety

marker for regional anaesthesia in the obstetric population.

However, there is no specific evidence base to support this

and some anaesthetists may have opted for a regional

technique for the caesarean section, particularly with the

normal coagulation screen.

References

1. Deshpande NA, James NT, Kucirka LM. Pregnancy outcomes of

liver transplant recipients: a systematic review and meta -analysis.

Liver Transplantation. 2012; 18(6): 621 -629

2. Warren A, Bellamy M. Organ donation and transplantation activity

report 2013/14. NHS Blood and transplant

SOAP 2015