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Successful Pregnancy after Liver Transplant

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Journal of Medical Case Reports

Case Presentation

A 19-year-old European primigravida woman was admitted to the hospital at 27 weeks and 6 days due to a deterioration in her health. She was married and practised safe sex. There was no history of chronic or oncological diseases in her family. She was transferred from a regional hospital to a tertiary facility and complained of moderate, dull abdominal pain, primarily in the right upper quadrant, and progressive jaundice. Despite these issues, fetal movements were reported as normal. Notably, she had been using a lower dose of immunosuppressive therapy than prescribed by gastroenterologists for a liver transplant she had had.

Past Medical History: Liver Transplant

On obtaining the patient’s medical history, she revealed a domino-type liver transplant of the right lobe five years earlier due to autoimmune hepatitis-induced cirrhosis. Nonadherence to immunosuppressive therapy led to a relapse of autoimmune hepatitis in the graft. Resulting in hospitalization with hyperbilirubinemia (221 μmol/L) one year before the current admission. Doctors prescribed her methylprednisolone pulse therapy (1000 mg intravenously for three consecutive days), which was successful. However, the doctors suggested that the patient follow the prescribed immunosuppressive medication. Her liver function tests were normal for the next 10 months.

At week 12, during an outpatient visit with a gastroenterologist, her blood, liver function tests, and tacrolimus trough levels were within the normal range. Doctors informed her of the high-risk nature of her pregnancy due to nonadherence to immunosuppressive therapy and recommended that she strictly follows the prescribed regimen.

Despite recommendations, the patient did not attend subsequent outpatient control visits. Upon admission to the hospital, she irregularly took tacrolimus, azathioprine, ursodeoxycholic acid, and vitamin D with calcium supplements. On physical examination, she appeared conscious, active, and responsive, with slightly icteric skin and mucous membranes. She was hemodynamically stable with normal respiration; her abdomen was soft but diffusely sensitive. Doctors observed no signs of peritoneal irritation, and they reported urination as unhindered but slightly darker in colour.

Fetal assessments showed a heart rate of 146 beats per minute, rhythmic movements, healthy amniotic fluid, and a normotonic uterus. A fetal ultrasound on the third day indicated that the fetus’ size corresponded to 28 weeks and 2 days, with the head recumbent. The heart rate was 143 beats per minute, and amniotic fluid was normal. The placenta was high on the anterior wall, and the cervix was closed and 43 mm long.

Management

The doctors commenced oral therapy with methylprednisolonum of 32 mg daily. On the fourth day, doctors administered 500 mg of methylprednisolone intravenously for three consecutive days. On the fifth day, the patient experienced diffuse abdominal pain and was treated with anti-analgesic therapy. Abdominal ultrasound revealed signs of portal hypertension, including splenomegaly, portal vein dilatation, small ascites, and mild (grade 1) bilateral urostasis associated with advanced pregnancy. However, her condition worsened, and hepatic encephalopathy progressed, leading to sluggishness and drowsiness. On the sixth day, due to the progression of hepatic encephalopathy, doctors transferred the patient to the intensive care unit (ICU).

A multidisciplinary council, including an obstetrician, gastroenterologist, infectologist, ICU physician, and anesthesiologist, concluded that an urgent cesarean section was necessary due to the rapid deterioration of the patient’s liver function, including hyperbilirubinemia, coagulopathy, and encephalopathy. Doctors deemed the operation high-risk, requiring pre-preparation with blood components. Although the fetus was viable at 27–28 weeks, predicting further development was challenging due to the mother’s high hyperbilirubinemia and the potential for fetal brain damage.

Fetal Outcome

On the same day, the patient underwent a lower laparotomy caesarean section under general anaesthesia, resulting in the birth of a live baby girl with an Apgar score of 6/6. The newborn weighed 1120 g. The placenta separated spontaneously, weighing 405 g, with a blood loss of 800 ml. Post-operatively, doctors transferred the patient to the intensive care department. The newborn, initially experiencing irregular breathing, received respiratory support, including positive end-expiratory pressure (PEEP) and assisted ventilation. Due to planned surfactant administration, doctors moved the child to the ICU and intubated the child. They also started the child on enteral feeding, a Passy Muir valve on the second day, and phototherapy, along with a partial blood transfusion exchange operation.

On the third day, doctors introduced sedation with fentanyl, but they noted oxygen saturation fluctuations and a heart murmur. A large patent ductus arteriosus (PDA) was seen in echocardiography. Anaemia and other complications led to the diagnosis of respiratory distress syndrome (RDS), chronic intrauterine fetal hypoxia, anaesthesia depression. Moreover, doctors observed hyperbilirubinemia, bilateral intraventricular grade II haemorrhages, and anaemia on the eighth day. Unfortunately, the child passed away at three weeks old.

Post-partum

In the postpartum period, the patient, recovering from kidney failure and hyperbilirubinemia through hemodialysis, underwent bilirubin hemoadsorption. Immunosuppressive therapy continued, and a liver biopsy on the eighth day revealed cirrhosis and a relapse of autoimmune hepatitis. Despite clinical stability, hyperbilirubinemia persisted, prompting methylprednisolone pulse therapy on the 12th day. Due to the poor prognosis, doctors listed the patient for liver transplantation. Viral tests were negative, but cytomegalovirus was detected and treated with valganciclovir.

Doctors discharged the patient on the 56th day and provided outpatient care. The emphasis was placed on the avoidance of pregnancy and adherence to medical therapy.

Second pregnancy

In her second pregnancy, occurring a year later, a multidisciplinary team recommended termination due to potential complications. However, the patient chose to continue and was monitored in the gastroenterology department. Throughout the pregnancy, she received methylprednisolone therapy and continued her medications. An elective caesarean section at 37 weeks resulted in the birth of a healthy baby girl. Mother and child were discharged on the fourth day and referred to outpatient care with various specialists.

Chronic liver disease

Chronic liver disease in women can significantly impact reproductive health, diminishing the likelihood of conception and a successful pregnancy. The disruption of the hypothalamic-pituitary-ovarian axis, a regulator of the menstrual cycle and hormonal balance, is a common culprit. Severe chronic liver disease can lead to amenorrhea, affecting up to 50% of women of childbearing age. This condition results in hormonal imbalances like hypogonadotropic hypogonadism and elevated estrogen levels, further reducing the chances of successful conception and pregnancy.

Liver Transplant

Liver transplantation emerges as a hopeful solution for women facing challenges in conceiving due to chronic liver disease. Post-transplantation, fertility is often restored, with studies indicating a return to regular menstrual periods as early as 6 weeks post-surgery. Approximately 90% of female transplant recipients report improved reproductive health within a year, offering a potential resolution for those previously struggling to become mothers.

Pregnancy for organ transplant recipients has complexities and uncertainties, encompassing risks to the mother’s long-term health, potential allograft dysfunction, changes in drug metabolism during pregnancy, and risks to the fetus, including teratogenic effects.

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