C0577 - Interdisciplinary Management of a Complicated Pregnancy in a Patient With Cirrhosis

Introduction: We present a unique case of clotting disorder related cirrhosis leading to pregnancy complications.

Case Description/Methods: A 29-year-old Caucasian female with a history of gastrointestinal bleeding, gastroesophageal reflux disease, epistaxis, and alcohol use disorder, goes for a routine gynecologic checkup when the physician notices a concerning enlargement of the caudate lobe on a computed tomography scan. Further evaluation reveals cirrhosis and Budd-Chiari syndrome. The patient starts enoxaparin and warfarin following this diagnosis. Eventually the patient is placed on the liver transplant list with a MELD (model of end-stage liver disease) score of 17 which improves to a score of 7 with sobriety.

The patient attempts pregnancy and is unable to conceive. She is told she has early menopause at the age of 34. She undergoes reproductive endocrinology evaluation and achieves a successful in-vitro fertilization with a donor egg at age 36. This starts her high-risk pregnancy. The high-risk nature of this pregnancy revolves around the patient’s complicated past medical history of hemorrhagic stroke of unclear etiology, cirrhosis complicated by esophageal variceal bleeding, coagulopathy, Budd-Chiari syndrome, and thrombocytopenia.

The patient has close variceal and hepatic vein thrombosis surveillance, labs, and routine checkup for vaginal bleeding with her increased risk of thrombosis during pregnancy. Endoscopy in the 1^st and 3^rd trimesters shows small esophageal varices with no evidence of progression.

Abdominal ultrasound displays vasa previa at approximately 28 weeks with velamentous umbilical cord insertion 2.3 cm from the internal os. After careful monitoring, the vasa previa is noted to resolve with umbilical cord insertion increasing to 4.8 cm from internal os in the following weeks. Repeated fetal echocardiograms present concern for the fetus being large for gestational age with estimated fetal weights ranging between the 95th-98th percentiles. The patient undergoes elective cesarean delivery and gives birth to a baby boy at 34 weeks with no labor complications.

Discussion: We present a unique case of pregnancy during cirrhosis requiring management with multiple specialists. Although the physiologic changes in pregnancy are well understood, the way in which cirrhosis affects pregnancy and its outcomes are not yet well understood given paucity of published data. Certainly, there is complex interplay and physiology involved with increased potential for pregnancy complications.