|LETTER TO THE EDITOR
|Year : 2011 | Volume
| Issue : 2 | Page : 96-97
Budd-Chiari syndrome in pregnancy
Sarita Singh, Ritu Verma, Rajni Gupta, Monica Kohli
Department of Anesthesia, CSM Medical University (Erstwhile King George's Medical University), Lucknow, India
|Date of Web Publication||17-Mar-2012|
Department of Anesthesia, CSM Medical University (Erstwhile King George's Medical University), Lucknow - 226 003
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh S, Verma R, Gupta R, Kohli M. Budd-Chiari syndrome in pregnancy. J Obstet Anaesth Crit Care 2011;1:96-7
A 24-year-old lady, weighing 46 kg, was scheduled for elective hysterotomy for intrauterine fetal death at 20 th week. She had been diagnosed as a case of Budd-Chiari syndrome More Details (BCS) 4 years back. For the last 2 years, she had been on 5 mg of warfarin. The patient was switched over from warfarin to low molecular weight heparin (inj. enoxaparin 1 mg/kg s/c bd) with twice daily regimen, 5 days prior to surgery.
The patient was planned for elective hysterotomy under general anesthesia. After premedication, she was induced with inj. propofol 100 mg and inj. atracurium 25 mg, and then intubated. A careful and gentle laryngoscopy was performed to minimize any traumatic bleeding. Balanced general anesthesia was maintained with O 2 and N 2 O inhalational agents. Inj. fentanyl 1 μg/kg was given for intraoperative and postop analgesia. The patient was extubated, maintaining saturation, and remained hemodynamically stable postoperatively. Rest of the intraoperative course was uneventful. Postoperatively, anticoagulation with inj. enoxaparin 1 mg/kg was continued.
BCS is an uncommon condition caused by thrombotic or nonthrombotic obstruction to hepatic venous outflow. Hepatomegaly, ascites and abdominal pain characterize it.  Pregnancy-related BCS is well recognized.  Presentation may be acute liver disease, subacute liver disease, fulminant liver disease or liver failure.
BCS remains one of the rarest causes of liver disease of pregnancy. Liver disease is rare in pregnancy and accounts for only 0.1% that includes viral hepatitis, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy and HELLP syndrome. Sometimes, despite anticoagulation therapy, pregnancy may flare up BCS. These patients may present with complications like fulminant hepatic failure, bleeding esophageal varices, portal hypertension, hepatic encephalopathy and ascites. Rarely, the patient may require orthotopic liver transplantation.
The treatment of BCS depends on the underlying cause, anatomic location, extent of thrombotic process and functional capacity of the liver. It can be medical treatment, including anticoagulation and thrombolysis, and radiological interventions. Orthotopic liver transplantation is the treatment of choice in fulminant variant of the syndrome and in patients with end-stage liver disease. 
These women tolerate laparotomy poorly, so it is preferable for them to deliver vaginally rather than cesarean section. These patients are very high risk for anesthesia and leave no room for error.
In our case, use of anticoagulants contraindicated spinal anesthesia.  Succinylcholine may be avoided for intubation, as both pregnancy and hepatic failure are associated with pseudocholinesterase deficiency and an unpredictable duration of neuromuscular block. For maintenance of anesthesia, we used atracurium instead of vecuronium. Intramuscular injections were also avoided.
To conclude, pregnancy with BCS may pose a great challenge to anesthesiologists in view of its varied presentations. Proper evaluation and careful monitoring increase the chances of success.
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