Consideraciones anestésicas en parturientas con transplante hepático
Anesthetic considerations in parturients with liver transplant.
Agarwal A, Jha A, Baidya DK, Trikha A
J Obstet Anaesth Crit Care 2014;4:4-11
Advances in the surgical technique, safer anesthetic agents, improved hemodynamic monitoring, better pre-operative optimization of cirrhotic patients and postoperative critical care facilities have led to drastic improvement in the outcomes following orthotopic liver transplantation (OLT). Reproductive dysfunction in patients with end-stage liver disease can be corrected within months of successful orthotopic liver transplantation. Consequently, there is a worldwide increase in the number of women of childbearing potential after orthotopic liver transplantation. Successful pregnancies are now increasingly being reported in these patients. These are high-risk pregnancies as increased medical and obstetric complications and adverse maternal and fetal effects of immunosuppressant medications are likely to be encountered in these patients following liver transplantation. Optimal antenatal and perioperative management in these parturients warrant a multidisciplinary approach and meticulous planning. There is little evidence available regarding anesthetic concerns in this high-risk pregnant population. This review is aimed at addressing important perioperative issues in parturients, who have undergone a successful liver transplantation.
Pregnancy in patients with advanced liver disease is uncommon as most women with decompensated cirrhosis are infertile and have high rate of anovulation. However, if gestation ensued; it is very challenging and carries high risks for both the mother and the baby such as higher rates of spontaneous abortion, prematurity, pulmonary hypertension, splenic artery aneurysm rupture, postpartum hemorrhage, and a potential for life-threatening variceal hemorrhage and hepatic decompensation. In contrary, with orthotopic liver transplantation, menstruation resumes and most women of childbearing age are able to conceive, give birth and lead a better quality of life. Women with orthotopic liver transplantation seekingpregnancy should be managed carefully by a team consultation with transplant hepatologist, maternal-fetal medicine specialist and other specialists. Pregnant liver transplant recipients need to stay on immunosuppression medication to prevent allograft rejection. Furthermore, these medications need to be monitored carefully and continued throughout pregnancy to avoid potential adverse effects to mother and baby. Thus delaying pregnancy 1 to 2 years after transplantation minimizes fetal exposure to high doses of immunosuppressants. Pregnant female livertransplant patients have a high rate of cesarean delivery likely due to the high rate of prematurity in this population. Recent reports suggest that with close monitoring and multidisciplinary team approach, most female liver transplant recipient of childbearing age will lead a successfulpregnancy.