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Canadian Journal of Anesthesia

, Volume 47, Issue 12, pp 1253–1255 | Cite as

Pregnancy, labour and delivery in a Jehovah’s Witness with esophageal varices and thrombocytopenia

  • Miriam J. Harnett
  • Andrew D. Miller
  • Ronald J. Hurley
  • Kodali Bhavani-Shankar
Brief Reports

Abstract

Purpose: An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10 – 61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah’s Witness.

Clinical features: A 25-yr-old Jehovah’s Witness parturient with portal hypertension and esophageal varices secondary to crytogenic cirrhosis was referred to our obsetrical unit at eight weeks gestation. In addition she was thrombotyopenic with platelet counts ranging from 42,000–67,000·μl−1. Here esophageal varices were banded prophylactically on three occasions during her pregnancy. Magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from Cesaren section which could result in massive hemorrhage, to elective induction of labour wiht an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery.

Conclusion: Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.

Keywords

Portal Hypertension Esophageal Varix Cell Saving Blood Product Transfusion Amniotic Fluid Embolus 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

Objectif: Un nombre croissant de femmes souffrant de cirrhose deviennent enceintes et mènent leur grossesse à terme. Cependant, la taux de mortalité maternelle demeure élevé (10 – 61%). Le présent article décrit la démarche anesthésique adoptée avec une patiente, Témoin de Jéhovah, qui présente des varices oesophagiennes et une thrombocytopénie.

Élements cliniques: Une parturiente de 25 ans, Témoin de Jéhovah, présentant une hypertension portale et des varices œsophagiennes secondaires à une cirrhose nodulaire postnécrotique, a été dirigée vers notre unité obstétricale à 8 sem de gestation. Elle avait aussi une thrombocytopénie, la numération plaquettaire étant de 42,000–67,000·μl−1. Trois fois pendant la grossesse, des bandes prophylactiques ont été posées sur les varices œsophagiennes. Un examen d’IRM, fait à 32 sem de gestation, a montré une tête de Méduse et une varice médiane dominante. Pour cette raison, on a remplacé la césarienne prévue, qui aurait pu provoquer une hémorrhagie massive, par une induction du travil et une expulsion assistée. La patiente refusait toute transfusion de produit sanguin, sauf une hémodilution et une autotransfusion immédiates, au besoin, pendant le travail et l’accouchement. Malgré les préparatifs élaborés en prévision d’un accouchement par voie vaginale, la patiente a connu un travail rapide imprévu. La rachianalgésie a été administrée pour faciliter un accouchement assisté en douceur.

Conclusion: Le succès de l’accouchement chez les parturientes atteintes de cirrhose repose sur une démarche multidisciplinaire. L’examen périodique et le bandage des varices œsophagiennes sont recommandés pendant la gorssesse. On devrait considérer sérieusement les bénéfices qu’offre l’anesthésie régionale.

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Copyright information

© Canadian Anesthesiologists 2000

Authors and Affiliations

  • Miriam J. Harnett
    • 1
  • Andrew D. Miller
    • 1
  • Ronald J. Hurley
    • 1
  • Kodali Bhavani-Shankar
    • 1
  1. 1.From the Department of Anesthesiology, Perioperative Medicine and Pain ManagementHarvard Medical School, Brigham and Women’s HospitalBostonUSA

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