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

Purpose: An increasing number of women with cirrhosis are conceiving and ca rrying their pregnancies to term. However, the maternal mortality rate rema ins high (10 - 61 %). This case report describes the management of a partur ient with esophageal varices and thrombocytopenia. She was also a Jehovah's Witness. Clinical features: A 25-yr-old Jehovah's Witness parturient with portal hyp ertension and esophageal varices secondary to cryptogenic cirrhosis was ref erred to our obstetrical unit at eight weeks gestation. In addition she was thrombocytopenic with platelet counts ranging from 42,000-67,000.mul(-1). Her esophageal varices were banded prophyladically on three occasions durin g her pregnancy. Magnetic resonance imaging at 32 wk gestation showed exten sive caput medusa and dominant midline varix. Therefore, the planned mode o f delivery was changed from Cesarean section which could result in massive hemorrhage, to elective induction of labour with 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 unanticipate d rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery. Conclusion: Multidisciplinary care is the key for a successful outcome in p arturients with cirrhosis. Periodic examination and banding of esophageal v arices is recommended during pregnancy. Active consideration should be give n to availing of the benefits of regional anesthesia.