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Management of a pre-eclamptic parturient with a Liver transplant, chronic rejection and thrombocytopenia
Abstract Number: S-63
Abstract Type: Case Report/Case Series
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.
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