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Anesthetic management of parturient with HELLP syndrome and post liver transplant with chronic rejection.
Abstract Number: SU-78
Abstract Type: Case Report/Case Series
Approximately 14,000 women of childbearing age within the United States have received liver transplants (1). Those receiving pediatric liver transplants make up only 15% of all female liver transplant patients and approximately 70% of those go on to reproductive age (2). With the increase in successful liver transplants, health care providers must deal with increased pregnancy related pathologies in post liver transplant patients. We present a case of a parturient post liver transplant with chronic rejection and HELLP syndrome for cesarean section.
25 yr old G3P1 at 27 weeks gestation with a past medical history of orthotopic liver transplant at age 3 months due to giant cell hepatitis and chronic liver rejection due to medication non-compliance. Immunosuppression included prednisone and tacrolimus daily. The patient was admitted due to possible worsening liver rejection. Transplant team was immediately consulted on patient admission and followed for the remaining hospital course adjusting immunosuppressive therapy as needed. The possibility of HELLP syndrome on top of liver rejection was entertained due to precipitous drop in platelet count - 65 x10/L in addition to elevated liver enzymes. She was then brought to OR for caesarean section. General anesthesia was planned due to her thrombocytopenia. A rapid sequence induction was performed with propofol and succinylcholine. Intraoperatively, packed RBCs transfusion were administered due to low pre-operatic hematocrit (28%) and moderate surgical blood loss. A male infant was delivered weighing 960g with Apgar score of 1&6. During her postoperative course she received additional packed RBCs, platelets, FFP, and cryoprecipitate. The patient was discharged on post op day 5 with stable hematocrit, platelets and Liver Function Test (LFT). Subsequently, she was readmitted five days later due to elevated LFTs found on routine follow-up. Liver biopsy was performed which showed worsening chronic liver rejection.
Pregnancy in post liver transplant patients is increasingly common. Post liver transplant patients have higher rates of preeclampsia, preterm birth and cesarean section (1). This case demonstrates the need for better understanding of the management of pregnancy complications in these increasingly common complex patients. It also underscores the importance of preoperative, operative and postoperative communication between healthcare providers along with careful follow-up.
1.Deshpande NA et al. Pregnancy outcomes of liver transplant recipients: a systematic review and meta-analysis. Liver Transpl. 2012;18:621–629
2.Casele HL, Laifer SA. Pregnancy after liver transplantation. Semin Perinatol 1998;22:149-155.