SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Liver transplantation (LT) for acute liver failure (ALF) is an uncommon occurrence in the setting of pregnancy, and carries a high risk of fetal demise in the first and second trimesters. Furthermore, maternal hyperthyroidism increases fetal risk in the setting of LT, and the medical literature contains a single case report in this context that reported fetal demise (1). We report a case of a hyperthyroid pregnant patient who underwent successful LT at 19 weeks gestation for ALF due to propylthiouracil hepatotoxicity, followed by a subsequent delivery of a healthy infant at 38 weeks gestation.
CASE PRESENTATION: The patient was a 36-year-old pregnant woman with a past medical history of Graves disease, who was initiated on PTU therapy 3 months prior. Her initial presentation was characterized by complaints of fatigue, pruritis and jaundice. Her initial serum workup revealed a total billirubin 19.6 mg/dl (direct billirubin 17.5) , INR 2.99, AST 2549 U/l, ALT 1427 U/l. An extensive serum workup for potential etiologies for her hepatic dysfunction was unrevealing. Her initial mental status was normal, but over the next 24 hours, she rapidly progressed to advanced hepatic encephalopathy, which necessitated elective intubation for airway protection. Intracranial pressure (ICP) monitoring revealed normal ICP levels. Given her worsening coagulopathy and encephalopathy, a decision was made to list her for transplantation with a presumptive diagnosis of PTU induced ALF. In preparation for surgery, cold iodine therapy was administered to minimize the risk of an intraoperative thyroid storm. She subsequently underwent a successful LT within the next 36 hours; specific intraoperative interventions included the use of an esmolol intravenous drip for thyroid storm prophylaxis, and continuous fetal monitoring. Two weeks after her LT, the patient underwent a total thryoidectomy. Eventually, the patient had a successful full term pregnancy.
DISCUSSION: This case highlights a multi-organ system based approach to maternal and fetal management in the setting of maternal acute liver failure and hyperthyroidism. In addition, it demonstrates the issues that need to be addressed in preparation for liver transplantation in this setting, with specific focus on the peri-operative endocrine management of hyperthyroidism.
CONCLUSIONS: In summary, this case illustrates the successful multi-disciplinary intensive care management of a complex case involving liver transplantation for acute liver failure of a hyperthyroid pregnant patient in her second trimester, with favorable outcomes for the patient and her infant.
1) Morris CV, Goldstein RM, Cofer JB, Solomon H, Klintmalm GB. An unusual presentation of fulminant hepatic failure secondary to propylthiouracil therapy. Clin Transplants. 1989 : 311.
DISCLOSURE: The following authors have nothing to disclose: Milan Patel, Ram Subramanian
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