Presentation : Any pregnant patient in the late second or third trimester who has elevated liver enzyme levels, especially in the presence of hypoglycemia. Also if patient presents with altered mental status and altered liver function in the postpartum period.
Preop optimisation : early recognition of liver dysfunction and aggressive resuscitation and treatment of hypoglycemia, DIC, and other associated complications.
Check the drug chart of the patient. Avoid / reduce dose of medications with substantial hepatic metabolism to prevent worsening encephalopathy
Consider reversal agents if the patient has received narcotics (ie, morphine)
If cesarean section is required, coagulopathy and thrombocytopenia should be corrected before surgery when possible
Anesthetist should be prepared for massive blood loss (eg, 2 large-bore intravenous catheters, blood products in room, fluid warmer and level 1 transfuser available, arterial line, and central line available).
Choice of anesthesia:
General anaesthesia may worsen or confuse the clinical appearance of encephalopathy. Regional techniques, however, may not be appropriate in those patients with worsening coagulation, and waiting for correction of any coagulopathy could lead to further deterioration in clinical condition. Regional anaesthesia can also cause hypotension and decrease hepatic blood flow.
If epidural analgesia is used for vaginal delivery, the epidural should be left in place until correction of coagulopathy.
High index of suspicion for epidural hematoma should be maintained :
Hourly neurological examinations and early surgical consultation should be made if deficits are identified.
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