Bleeding from oesophageal varices in pregnancy

Abstract

SUMMARYBleeding from oesophageal varices is the most fearful event in pregnant women with cirrhosis and is the main cause of death in this group. Its approach and treatment are controversial, with ligation, sclerosis and β-blockers as possible choices. Follow-up must be multidisciplinary and delivery programmed because of the high risk of bleeding. Delivery route is also controversial. We present a case of a pregnant woman, with alcoholic cirrhosis and upper tract bleeding during the second trimester of pregnancy. She was submitted to an oesophagogastroduodenoscopy (OGD), which revealed varices grade II/III in the lower third of the oesophagus. She was transfused and was haemodynamically stable. It was decided not to start β-blockers. The pregnancy went well, with regular follow-up in obstetrics and hepatology. A deficiency of α-1 antitrypsin was detected. Delivery was programmed at 39 weeks of gestation, and a caesarean section was performed, with good maternal and fetal outcome. BACKGROUND

Embarazo en una adolescente con cirrosis e hipertensión portal: prevención de la hemorragia por várices esofágicas

“…El embarazo es considerado un evento poco frecuente en pacientes cirróticas debido a que los ciclos anovulatorios, las alteraciones del metabolismo endócrino y la edad avanzada con la que se presenta la mayoría de ellas impactan negativamente en la fertilidad. [1][2][3] Sin embargo, en los últimos años este concepto está siendo cuestionado como resultado de las mejoras en las técnicas reproductivas disponibles y los avances en los tratamientos de las hepatopatías crónicas, lo que podría determinar que este escenario sea cada vez más frecuente en el futuro inmediato. 4 Estimaciones actuales han reportado una prevalencia de 45 cirróticas por cada 100.000 mujeres embarazadas.…”

“…1,6 En estudios retrospectivos y series de casos, la tasa de complicaciones alcanza a más de la mitad de las pacientes, con una mortalidad materna que varía entre el 2% y 10%. [3][4][5] La gestación origina importantes cambios, expresados en un estado circulatorio hiperdinámico con aumento del flujo esplácnico, lo que determina que hasta dos tercios de las mujeres embarazadas saludables experimenten una HTP transitoria. 1 Estos cambios se producen principalmente a expensas del aumento del volumen plasmático (que puede llegar hasta el 50%), del volumen minuto cardíaco (que se incrementa alrededor del 40%) y de la disminución de la resistencia vascular periférica.…”

Successful pregnancy with autoimmune cirrhosis

“…It is more frequent in the second half of gestation and during delivery, because maximum blood volume is achieved and the larger uterus causes elevation of venous pressure due to compression of the inferior vena cava 12 18…”

“…The risks associated with pregnancy with chronic liver diseases are increased when cirrhosis and portal hypertension are present 11. Rupture of oesophageal varices is the most fearful event in pregnant women with cirrhosis, representing the leading cause of death in these patients 12 13. These patients usually also need medical treatment with immune modulating drugs, such as azathioprine, the safety profile of which, during pregnancy, is not yet fully defined 14…”

Beyond the lungs: Alpha-1 antitrypsin’s potential role in human gestation

“…14 Furthermore, AAT may play a role in fertility regulation, pregnancy loss and other obstetric pathologies. [15][16][17][18][19][20][21][22] Finally, there is data from maternal serum protein profiling showing that alpha-1-antitrypsin is among the markers for non-invasive prenatal diagnoses of trisomy 21, 18 and 13. 23…”