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Obstetrical considerations and management of labor and delivery of a G1P0 woman with a history of multiple liver transplants.
Abstract Number: RF2BB-207
Abstract Type: Case Report Case Series
From 1988 until the present time, approximately 4000 women in the United States 18 to 34 years of age have received a liver transplant (2). Key issues when counseling and managing a parturient post liver transplantation include optimal timing of pregnancy, contraception methods, and management of immunosuppression. Liver transplant parturients have higher rates of pre-term labor and cesarean delivery. It is hypothesized that increased rates are secondary to increased fetal distress in addition to higher levels of gestational hypertension and pre-eclampsia (1).
A 28-year-old G1P0 Jehovah’s Witness (consented for transfusion) presented at 36w6d gestation with PMH of liver transplant (2006) for type IV choledochal cyst with granular cell tumor of common bile duct, chronic rejection, a second liver transplant (2009) complicated by post-transplant diabetes mellitus, elevated liver enzymes, and post-transplant lymphoproliferative disorder with anemia, and thrombocytopenia secondary to immunosuppression. On the patient’s second day of induction fetal heart tones showed minimal variability with late decelerations which changed to a category two tracing with re-positioning. Decision was made for Cesarean section for failed induction and abnormal fetal heart tones greater than one hour. Labor epidural was placed and dosed to a T4 bilateral level with 15 ml of 2% lidocaine with epinephrine 1:200,000. Primary low transverse Cesarean section was uncomplicated and resulted in delivery of a 2940 g female child with Apgars 1 min: 8 and 5 min: 9. During the delivery 1100 ml of plasmalyte was used, 200 ml of urine output produced, and estimated blood loss was 880 ml. The patient did not require a PRBC transfusion and received neuroaxial preservative free morphine and IV ketorolac for postoperative analgesia.
Timing of conception is important to reduce complications from immunosuppression. A two-year gap between liver transplantation and pregnancy is recommended to prevent medication induced rejection of the pregnancy. Parturients should meet with subspecialists prior to delivery. More frequent follow up should be considered especially if gestational complications arise. Patient’s should be encouraged to have a two-year gap between liver transplantation and pregnancy to prevent medication induced rejection of the pregnancy; in particular a suppression of NK cells necessary for trophoblast invasion of the uterus. Providers should monitor for gestational hypertension and diabetes along with anticipating a Cesarean delivery with intrabdominal adhesions requiring repletion with blood products.
KS Parhar, PS Gibson, CS Coffin. Pregnancy following liver transplantation: Review of outcomes and recommendations for management. Can J Gastroenterol 2012;26(9):621-626
US Organ Procurement and Transplantation Network and the Scientic Registry of Transplant Recipients http://optn.transplant.hrsa.gov/ (October 18, 2011)