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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 32-34

Pregnancy and delivery in a parturient with liver transplant


1 Department of Anesthesiology and Resuscitation, Federal State Budget Institution "Research Center for Obstetrics, Gynecology and Perinatology" of Ministry of Healthcare of the Russian Federation, Moscow, Russia
2 Liver Transplant Unit, N. V. Sklifosovsky Science and Research Institute of Emergency Medicine, Moscow, Russia
3 Department of Prevention and Treatment of Pregnancy Pathology, Federal State Budget Institution "Research Center for Obstetrics, Gynecology and Perinatology" of Ministry of Healthcare of the Russian Federation, Moscow, Russia

Date of Web Publication1-Jul-2013

Correspondence Address:
A V Pyregov
Department of Anesthesiology and Resuscitation, Federal State Budget Institution "Research Center for Obstetrics, Gynecology and Perinatology," of Ministry of Healthcare of the Russian Federation Oparina st., 4, Moscow, 117997
Russia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.114287

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  Abstract 

The article presents a case of successful spontaneous vaginal delivery with the use of epidural analgesia in a patient with orthotopic liver transplant. The importance of the multidisciplinary approach is highlighted in management of such cases.

Keywords: Epidural analgesia, liver transplantation, pregnancy, spontaneous delivery


How to cite this article:
Pyregov A V, Andreysteva O I, Khodova S I. Pregnancy and delivery in a parturient with liver transplant. J Obstet Anaesth Crit Care 2013;3:32-4

How to cite this URL:
Pyregov A V, Andreysteva O I, Khodova S I. Pregnancy and delivery in a parturient with liver transplant. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2019 Sep 23];3:32-4. Available from: http://www.joacc.com/text.asp?2013/3/1/32/114287


  Introduction Top


The high rate of cesarean sections (up to 71%,) [1],[2],[3],[4] in liver recipients is associated with a higher incidence of obstetric complications during pregnancy. Safe and uneventful vaginal delivery is possible with growing experience in the management of parturients with organ transplant. We present a case of successful pregnancy and normal vaginal delivery with epidural analgesia in a liver transplant patient.


  Case Report Top


A 26-year-old woman, gravida 2, para 1, was admitted to the hospital at 37 weeks of pregnancy with a cephalic presentation of the fetus. She also was diagnosed with preeclampsia, anemia of pregnancy, and retinal angiopathy following liver transplantation carried out 3 years before.

Earlier she had developed hepatic cirrhosis due to Wilson's disease. Her medical course was further complicated by development of fulminant hepatic failure (Grade III), portal hypertension, splenomegaly, thrombocytopenia, and esophageal varices (Grade I-II). As a result of these, 3 years prior to the present confinement the patient had successfully undergone orthotopic liver transplantation (OLT) and was discharged in a satisfactory condition. She continued to receive a triple immunosuppression regime (Cyclosporin, mycophenolate and prednisolone), which was gradually decreased to single immunosuppression regimen (Cyclosporine A). The patient was on regular follow-up on the out-patient basis.

Three years before OLT, she had a full term normal vaginal delivery. The present pregnancy after OLT was complicated by threatened abortion, anemia, thrombocytopenia, and moderate preeclampsia.

At 13-14 weeks of gestation, the patient had gradual increase in the alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels reaching up to 310-360 U/L. At the same time a decrease in Cyclosporin blood levels was observed, which was probably due to physiological changes associated with pregnancy and the resultant increase in drug volume of distribution. Cyclosporin dose was gradually increased from 200 mg to 350 mg daily leading to normalization of ALT and AST levels.

Antihypertensive therapy was started for a progressive increase in the blood pressure (160/100 mm of Hg) from 23 week of gestation. In addition, a genetic disposition of the blood coagulation system leading to the tendency of decrease of blood fibrinolytic activity associated with the genotype of activator inhibitor type one plasminogen, glycoprotein Ia, and glycoprotein IIIa was found. This polymorphism of thrombophilia genes was clinically irrelevant, thus, no changes to the current therapy were made.

At 38 week of gestation, as no symptoms and signs of the liver decompensation and portal hypertension were present, normal vaginal delivery was planned.

At 40 weeks, the patient went into acute labor, due to labor pains and at four cm cervical dilatation an epidural catheter was inserted for labor analgesia. The catheter was inserted under all aseptic precautions, at L 2 -L 3 level in left lateral position. 6 ml of ropivacaine hydrochloride 0.2% with fentanyl 50 μg was injected into epidural catheter followed by continuous infusion of ropivacaine 0.1% at a rate of 5 mL/h using an infusion pump. At cervical dilatation of seven cm, an amniotomy was performed. After 1 h and 40 min, patient experienced increased pain and a bolus of 6 ml of ropivacaine solution 0.2% was administered through the epidural catheter. A healthy male baby weighing 3445 g was born with an Apgar score of 8-9. The total duration of delivery was 6 h and 40 min, 1 st stage- 6 h and 10 min, 2 nd stage- 15 min, 3 rd stage- 15 min.

Oxytocin was administered as an intravenous infusion starting at the end of the first stage of labor and was continued during the other two stages and early post-partum period. During the labor, 1000 mg of Tranexamic acid and 120 mg of Prednisolone were intravenously administered due to a moderate thrombocytopenia (113 × 10 9 /L). The total blood loss was 400 mL. The epidural catheter was subsequently removed 3 h after the delivery.

In the post-partum period patient continued to receive antibiotic (cephalosporins) for 5 days, suppression of lactation, continued immunodepression by Cyclosporine A 150 mg twice a day, acetylsalicylic acid 100 mg daily was re-introduced and antihypertensive therapy was restarted. After the transplantation surgery, the patient was on acetylsalicylic acid and immunosuppressive therapy for life term. During the pregnancy, she took 50 mg of acetylsalicylic acid daily that was withdrawn 5 days before the planned delivery. The patient was discharged on the post-partum day eight.


  Discussion Top


The majority of patients who make it through the initial months after the liver transplant without developing chronic rejection live a normal life. [1],[2],[5],[6],[7] Female patients might get pregnant and deliver healthy full-term babies. [8]

The optimal time for conception is generally after 1 year post-transplant when the graft rejection risk decreases and the possibility of a favorable outcome increases for the mother and the baby. [3],[4],[9]

The present-day immunosuppressants have no teratogenic activity thus, allowing normal pregnancy in recipients. [10] During the pregnancy increased volume of distribution warrants an increase in the dose of immunosuppressants and frequent monitoring of blood levels of the drugs using the biochemical blood assay. Inadequate drug levels may augment the risk of acute rejection of the graft during the pregnancy. Current clinical practice provides different immunosuppression treatment regimens. In the present case, according to the hospital guidelines, the patient was put on the cyclosporine monotherapy 3 months after the transplantation surgery with the subsequent control of blood cyclosporine level before and during pregnancy. 20 days before the delivery the blood concentrations of cyclosporine were low, so its dose was increased from 300 mg/day to 350 mg/day. It was later reduced to 250 mg/daily (according to the drug blood concentration) in the post-partum period due to removal of volume of distribution.

The main risks in this group of parturients are related to the complications of pregnancy and delivery such as hypertension, preeclampsia, renal dysfunction, bacterial and viral infections, premature labor, fetal growth retardation syndrome and intrapartum and post-partum hemorrhage. Our patient developed a thrombocytopenia; in order to prevent a hemorrhage, tranexamic acid and prednisolone were administered.

During the course of pregnancy in such patients there is a higher possibility to develop cholestasis and liver dysfunction. In the present case, the patient experienced moderate preeclampsia responsive to conventional treatment.

A higher incidence of maternal mortality and venous thromboembolism has been also reported in patients after successful liver transplant. [1],[2],[3],[4] We detected some minor hemostasis abnormalities in the present case, thereby, as a preventive measure, the patient received acetylsalicylic acid before and after the delivery.

The main indications for cesarean section in such parturients are fetal distress, breech presentation and fetal growth retardation, prematurity. The higher incidences of prematurity and increased maternal and perinatal mortality are observed in liver transplant recipients compared to the general population. Neither liver graft dysfunction nor any pregnancy complications were present in this case allowing the normal delivery at term. The management of pregnancy in a liver transplant patient needs a multidisciplinary approach where the prime responsibility, complementary to obstetricians-gynecologists, anesthesiologists and transplant surgeons, involves intensivists, cardiologists, and endocrinologists. [5],[6],[7],[8],[9],[10] In conclusion, parturients with transplant liver can safely undergo vaginal delivery. Epidural analgesia can be administered for the labor pain relief if the hemostatic profile is nearly normal.

 
  References Top

1.Armenti VT, Radomski JS, Moritz MJ, Gaughan WJ, Hecker WP, Lavelanet A, et al. Report from the National Transplantation Pregnancy Registry (NTPR): Outcomes of pregnancy after transplantation. Clin Transpl 2004;103-14.  Back to cited text no. 1
    
2.Xia D, He HY, Xu L, Quan Y, Zuo HQ, Yan LN, et al. Pregnancy after liver transplantation: Four-year follow-up of the first case in mainland China. World J Gastroenterol 2008;14:7264-6.  Back to cited text no. 2
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3.Jabiry-Zieniewicz Z, Kamiñski P, Pietrzak B, Cyganek A, Bobrowska K, Zió³kowski J, et al. Outcome of four high-risk pregnancies in female liver transplant recipients on tacrolimus immunosuppression. Clin Hepatol 2009;7:1367-72.  Back to cited text no. 3
    
4.Sibanda N, Briggs JD, Davison JM, Johnson RJ, Rudge CJ. Pregnancy after organ transplantation: A report from the UK Transplant pregnancy registry. Transplantation 2007;83:1301-7.  Back to cited text no. 4
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5.Clavien PA. Liver transplantation for pregnancy-related liver diseases, pregnancy and sexual function after liver transplantation: What do we know? J Hepatol 2008;49:505-6.  Back to cited text no. 5
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6.De Gottardi A, Morard I, Dumortier J, Majno P, Mentha G, Giostra E. Management of patients after liver transplantation. Rev Med Suisse 2006;2:1952-4, 1957-9.  Back to cited text no. 6
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7.Dei Malatesta MF, Rossi M, Rocca B, Iappelli M, Giorno MP, Berloco P, et al. Pregnancy after liver transplantation: Report of 8 new cases and review of the literature. Transpl Immunol 2006;15:297-302.  Back to cited text no. 7
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8.Goarin AC, Homer L. Liver transplantation and pregnancy. J Gynecol Obstet Biol Reprod (Paris) 2010;39:529-36.  Back to cited text no. 8
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9.Heneghan MA, Selzner M, Yoshida EM, Mullhaupt B. Pregnancy and sexual function in liver transplantation. J Hepatol 2008;49:507-19.  Back to cited text no. 9
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10.Surti B, Tan J, Saab S. Pregnancy and liver transplantation. Liver Int 2008;28:1200-6.  Back to cited text no. 10
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