High-risk third trimester pregnancy with decompensated cirrhosis safely delivered following emergent preoperative interventional radiology for mitigation of variceal bleeding

• Published in: Clinical imaging 2020-12, Vol.68, p.143-147
• Main Authors: Park, Christine, Patel, Yuval A., Suhocki, Paul, Dorsey, Claire, Kapila, Nikhil, Tang, Linnan, Gilner, Jennifer
• Format: Article
• Language: English
• Subjects: Abdomen; Bleeding; Cesarean delivery; Cesarean section; Cirrhosis; Coagulopathy; Complications; Decompensated cirrhosis; Ectopic varices; Embolization; Esophageal and Gastric Varices - complications; Esophageal and Gastric Varices - diagnostic imaging; Esophageal and Gastric Varices - therapy; Esophagus; Female; Fetuses; Gastrointestinal Hemorrhage - diagnostic imaging; Gastrointestinal Hemorrhage - therapy; General anesthesia; Gestation; Humans; Hypertension; Laboratories; Liver; Liver cirrhosis; Liver Cirrhosis - complications; Liver Cirrhosis - diagnostic imaging; Medical imaging; Optimization; Portasystemic Shunt, Transjugular Intrahepatic; Postpartum; Pregnancy; Pregnancy complications; Pregnancy Trimester, Third; Radiology; Radiology, Interventional; Surgery; Thrombocytopenia; Transjugular intrahepatic portosystemic shunt; Treatment Outcome; Ultrasonic imaging; Uterus; Veins & arteries; Womens health
• ISSN: 0899-7071; 1873-4499
• DOI: 10.1016/j.clinimag.2020.06.032

Coagulopathy coupled with severe portal hypertension in the setting of cirrhosis increases the risk of mortality from variceal bleeding in pregnant women. Studies suggest transjugular intrahepatic portosystemic shunt (TIPS) creation to be a safe procedure during pregnancy in preventing variceal bleeding complications; however, it is not typically employed in severely decompensated cirrhosis. This case report of a pregnant woman presenting at 34.7 weeks' gestation demonstrates successful variceal mapping, emergent TIPS creation and variceal embolization to allow safe cesarean delivery despite severe hypofibrinogenemia and decompensated alcoholic cirrhosis. With careful medical optimization, angiographic imaging and vascular interventional radiology may be employed outside of usual indications to achieve safe pregnancy delivery and postpartum recovery. •Cirrhosis in the setting of pregnancy puts patients at risk for abdominal wall variceal rupture during cesarean section that significantly increases the risk of mortality.•Transjugular intrahepatic portosystemic shunt (TIPS) procedure and variceal embolization can be utilized in late preterm gestation to stabilize the abdominal wall varices prior to cesarean delivery.•Multidisciplinary collaboration is critical for successful optimization of coagulopathy to ensure the success of TIPS and safe delivery.