Anaesthetic Management of Caesarean Section in Hepatitis C Positive Patient With Portal
Hypertension - A Case report
Introduction
Viral hepatitis is not so uncommon in pregnancy. The presentation may be in any form, but
association with viral hepatic infections predisposes to increased risk of complications like
jaundice, coagulopathy, hepatic failure, bleeding from esophageal varices and hepatorenal
syndrome apart from risks of vertical transmission. In the chronic cases there is increased
incidence of spontaneous abortions and premature labour. Maternal mortality is attributed to
massive bleeding from esophageal varices, hepatic or renal failure. The patient may present with
portal hypertension, ascites, cirrhosis, encephalopathy, variceal bleeding, coagulopathy and liver
failure.
Case Report
We present a case of 26 yr old female, primigravida, who presented with episodes of
hematemesis at 20 weeks of gestation. She had no history of fever, malena, altered mental
status. On physical examination, CVS, respiratory, CNS examinations were normal. She was
referred to a gastroenterologist. The investigations reported were total bilirubin.- 2.56mg/dl,
SGOT- 70IU/ml, SGPT- 75IU/ml, alkaline phosphatase 320 Anti HCV antibody + ve, HIV –ve,
HBsAg –ve and INR was 1.6. Rest other investigations were in normal limits. On
ultrasonography there was moderate hepatosplenomegaly. Esophagogastroscopy revealed grade
II varices in lower part of esophagus with mild portal hypertension. She was managed
conservatively and was followed in OPD. She was not started on beta-blockers in view of their
fetopathic effects.
At 32 weeks again she again had few bouts of hemetemesis associated with minimal bleeding,
so she was sent home with advice to report back to hospital in case of further bleeding. Then
the patient remained stable till 38 weeks, when she experienced pain in abdomen and presented
to hospital. Elective LSCS was planned in view of breech presentation of fetus. The
anaesthetic goals were correction of coagulation, thrombocytopenia, prophylactic variceal band
ligation if possible, management of ascites, maintain adequate intavascular volume and
correction of any electrolyte abnormality. On preanaesthetic evaluation, systemic examination
was normal and investigations were Hb- 9.9g/dl, TLC- 6300/mm3, platelet count- 1.8 lac/mm3,
blood urea- 28, S. creatinine- 0.56, Na- 137meq/l, K- 3.7meq/l, T. bil.- 0.68, SGOT- 21.3,
SGPT- 30.4, PT- 13.6, PTTK- 28.9, and INR- 1. Pre-operatively patient received routine
aspiration prophylaxis and adequate blood was arranged. Once taken in operation theatre, two
large bore intravenous lines were secured and routine non invasive monitoring was instituted.
The entire staff took adequate universal precautions. In view of mild portal hypertension with
esophageal varices, regional anaesthesia was considered definitely a better choice.
Subarachnoid block was planned and surgery was performed uneventfully. After delivery the
baby cried immediately with Apgar 9/10. Post-operatively patient was kept under observation
in HDU and was safely transferred to ward after 24 hours. So the case was successfully
managed with good maternal and fetal outcome.
Discussion
In chronic liver diseases, the fertility rate decreases. [1] Though pre-existing liver disease is not
a contra-indication for pregnancy, still it requires intensive monitoring throughout the antenatal
period. The patient is predisposed to numerous complications in view of physiological changes
accompanying pregnancy in addition to preexisting liver pathology. Such patients require
multidisciplinary consultation for medical optimization of the patient. Aggarwal et al reviewed 9
pregnancies out of which 7 had cirrhosis complicated with jaundice, ascites with and without
hemetemesis out of which only 2 patients underwent endoscopic sclerotherapy. [2] Successful
outcome of a pregnancy in a woman with advanced cirrhosis due to hepatitis B infection, delta
super-infection and hepatitis C co-infection has been reported by Subhan et al[3].The patient had
normal vaginal delivery with healthy baby.
Acute viral hepatitis can occur in any trimester of pregnancy, but is most severe in third
trimester of the pregnancy. Prevalence of hepatitis A, B and C is similar in obstetric as well as
non-obstetric females and incidence of Hepatitis E is more in pregnancy. Hepatitis C affects 0.51.4% of population. [4] Chronic hepatitis C requires no more than symptomatic management, but
definitely predisposes to risk of transmission to offspring. The risk of transmission of hepatitis C
is 6–10% and depends on the mother’s level of blood viremia that is if RNA titres are more than
106 [5]. HIV co-infection is also considered to increase the risk of vertical transmission. The
incidence of hepatitis C and D doubles with hepatitis B coinfection and combined incidence was
reported to be 3.1%.[6] In spite of fast progressing technology, no effective immunoprophylaxis
is available till this date for lowering this risk. Even administration of gamma globulins also
provides no protection against transmission. It has been clearly demonstrated by Lin et al that
breast feeding is safe for the offspring of mothers with hepatitis B as well as hepatitis C once
appropriately immunized. [7]
In our case, presence of portal hypertension along with hemetemesis from esophageal varices
further complicated the case. Portal hypertension with cirrhosis compounds the physiological
increase in circulating blood volume associated with pregnancy. Any elevation in portal pressure
with added pressure from the gravid uterus on the IVC predisposed the patient for hemetemesis.
In fact massive bleeding is most common during the second trimester with 20–27% chance of
bleeding from esophageal varices, which is amplified to 62–78% if there are demonstrable
varices. [2,8]. With HCV infection, the patients remain asymptomatic in 75%, present with
acute manifestations in 24% and fulminant hepatitis in only 1%.[2] Further incidence of chronic
hepatitis is 80%, of cirrhosis is 35% and only 5% may progress to hepatocellular carcinoma. The
diagnostic tests include anti HCV antibodies (ELISA and RIBA) and HCV RNA PCR. The
treatment includes interferon and ribavirin but is contraindicated in pregnancy. At present no
vaccine is available. Massive bleeding from esophageal varices is one of the most common
cause of maternal death. [9]. It may be further aggravated by deranged co-agulation and
thrombocytopenia. In non obstetric population, variceal band ligation [10], sclerotherapy,
portosystemic shunting, somatostatin and beta-blockers definitely play a role.
The mode of delivery, vaginal or caesarean section, have no effect on risk of transmission. And
in fact it is the stage of the liver disease which is most important determinant of outcome of
pregnancy. The plan for caesarean section in such females mandates proper pre-anaesthetic
evaluation, relevant history, related investigations and optimization depending on time of
presentation. The anaesthesiologist, gastro-enterologist and surgeons should be consulted as
soon as patient presents in antenatal period. It not only ensures maternal and fetal well being, but
also helps in prevention of complications. During regular follow – ups, early detection of
complications if any leads to better optimization, hence decreased morbidity and mortality. If
the antenatal period is uneventful and condition of mother is good, the fetal outcome is generally
good. The anaesthetic concerns include correction of coagulation, thrombocytopenia, electrolyte
imbalance if any, maintain adequate intravascular volume and hematocrit. Consideration has
been given to pharmacokinetic and pharmacodynamic changes which may include altered
volume of distribution due to decreased serum albumin, increased globulins and unpredictable
intravascular volume. [8] Portosystemic shunted blood bypasses liver, so drugs highly extracted
by liver are generally affected. There may be increased sensitivity to sedative medications.
Under all circumstances preserve hepatic blood flow. Avoid halothane and isoflurane is
considered to be better as far as hepatic circulation is concerned. Consider regional anesthesia,
where ever feasible. Avoid medications with potential hepatotoxicity like halothane,
acetaminophen, sulfonamides and amiodarone. In presence of esophageal varices, avoid blind
instrumentation of esophagus. There is no way to decrease the incidence of fetal transmission
and there are chances that infected neonates may develop chronic hepatitis. So, one must
perform postoperative surveillance clinically as well as biochemically.
References
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BMJ Case Reports 2013
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