Esophageal Varices in Pregnancy
Patient Presentation:
The pt was a 35 y/o female with term pregnancy (39 weeks). Pt came in through the ER complaining of contractions every six minutes and vomiting for three days. The pt was Hep C positive and had a past history of alcoholism and IV drug use. This was her first pregnancy. The patient was placed on labetalol for management of pregnancy-induced hypertension. The patient was diaphoretic with a BP of 90/50 on admission to L&D. Contractions were noted every 6 minutes by monitor, the fetus was noted to be in distress. The patient’s husband reported that she had been vomiting blood since last night. The blood was described to be “bright red.” Pt was prepared for a stat C-section. Pt was bolused with 1000 mL LR and taken back for a C-section. Anesthesia attempted to intubate, and stopped when he noted the blood pooling in the pt’s esophagus. A code was called and the code team responded to the OR and a GI consult was paged overhead.
Differential Diagnosis:
The patient’s positive HepC status coupled with pregnancy-induced hypertension and the bright red blood noted in the patient’s throat led to the diagnosis of esophageal varices rupture.
Diagnosis:
Pt was diagnosed with esophageal varices.
Hemoglobin: 6, Hematocrit: 16, Platelets: 50,
PT: 20 PTT: 40 (both indicate prolonged clotting times associated with low platelets)
Albumin: 2.4 AST: 223 ALT: 256 (These labs indicate liver dysfunction)
Treatment:
A spinal was preformed in order to get the baby out while it was possible. An emergency C-section was performed while anesthesia hung two units of blood. GI then inserted a Blakemore tube (A wide tube with two separate balloons, one for esophagus and the other for the stomach, balloons are inflated in order to stop bleeding). Two more units of packed RBC were given and then vasopressin was given IV in order to stabilize blood pressure. Patient was then taken to Radiology for a TIPS in an attempt to lower the hepatic portal pressure in order to slow the amount of blood flowing to the varices. Pt was then taken to ICU where the Blakemore balloons were deflated and the varices were visualized, Sclerotherapy was preformed (a clotting agent is injected directly into the varices). Patient continued to receive packed RBCs to stabilize her hemoglobin and hematocrit. Additionally, she was given platelets and fresh frozen plasma to stabilize her bleeding and clotting times. Patient was given D5W to stabilize blood sugar. The vasopressin drip was continued in the ICU. CBC, blood gases, clotting times and BMP were drawn every two hours. Pt was also given PPI because of the bleeding into her stomach. Pt was started post-op C-section on a morphine PCA per L&D protocol of stat C-sections; this was later switched to a fentanyl drip in ICU. Pt was given gentamycin 80mg and clindamycin 900 mg every six hours per L&D emergency C-section protocol; this was maintained in the ICU for the standard 24 hours.
Outcome:
The patient stabilized 72 hours after the event. She was placed on a liver transplant list and instructed by her OB that any future pregnancies would be life threatening. The baby was transferred to NICU following delivery for monitoring, but was released to regular care nursery 4 hours after delivery. Both Mom and Baby went home.
Case created by Erin-Ellen Dillon, 2011.