title: Pregnancy, labour and delivery in a Jehovah's Witness with esophageal varices and thrombocytopenia.
abstract: OBJECTIVE
  An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10-61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah's Witness.
  
  
  METHODS
  A 25-yr-old Jehovah's Witness parturient with portal hypertension and esophageal varices secondary to cryptogenic cirrhosis was referred to our obstetrical unit at eight weeks gestation. In addition she was thrombocytopenic with platelet counts ranging from 42,000-67,000 x microl(-1). Her esophageal varices were banded prophylactically on three occasions during her pregnancy. Magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from Cesarean section which could result in massive hemorrhage, to elective induction of labour with an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery.
  
  
  CONCLUSIONS
  Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.
authors.affiliation: Department of Anesthesiology, Perioperative Medicine and Pain Management, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA. mharnett@bics.bwh.harvard.edu
authors.forename: M J
authors.initials: MJ
authors.lastname: Harnett
authors.forename: A D
authors.initials: AD
authors.lastname: Miller
authors.forename: R J
authors.initials: RJ
authors.lastname: Hurley
authors.forename: K
authors.initials: K
authors.lastname: Bhavani-Shankar
mesh_terms: D000328:Adult; D001803:Blood Transfusion; D002835:Christianity; D036861:Delivery, Obstetric; D004932:Esophageal and Gastric Varices / Q000150:complications*; D005260:Female; D006801:Humans; D007743:Labor, Obstetric; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000097:blood / Q000503:physiopathology*; D011250:Pregnancy Complications, Hematologic / Q000097:blood / Q000503:physiopathology*; D013921:Thrombocytopenia / Q000097:blood / Q000150:complications*