Emergency liver transplantation during early second-trimester pregnancy guided by an obstetric decision algorithm: a case report and review of the literature

Acute liver failure during pregnancy is an exceptionally rare and life-threatening condition associated with high maternal and fetal mortality. When progressive hepatic failure develops despite supportive therapy, liver transplantation may represent the only life-saving intervention for the mother. However, performing liver transplantation during pregnancy, particularly in the early second trimester, poses substantial clinical, surgical, anesthetic, and ethical challenges. Data regarding optimal timing, perioperative management, and fetal outcomes remain limited, and most reported cases are associated with unfavorable fetal prognosis. Reporting successful maternal and fetal outcomes in such rare clinical scenarios is essential to inform multidisciplinary decision-making and improve future care strategies. A 26-year-old primigravid woman at 14 weeks of gestation was referred with severe transaminase elevation, hyperbilirubinemia, and coagulopathy following recent exposure to antiemetic and vitamin-based intravenous medications. Despite intensive supportive treatment and plasmapheresis, her clinical condition deteriorated with recurrent hepatic encephalopathy and worsening liver function, necessitating urgent transplant evaluation. At 16 weeks of gestation, emergency orthotopic liver transplantation was performed using a living donor graft, with meticulous perioperative management aimed at maintaining maternal hemodynamic stability and uteroplacental perfusion. Postoperatively, liver function rapidly normalized, and immunosuppressive therapy with tacrolimus and low-dose steroids was initiated. The pregnancy was closely monitored without obstetric complications. At 37 weeks of gestation, a healthy male infant was delivered by cesarean section. Both maternal graft function and neonatal outcomes remained favorable during follow-up. This case demonstrates that emergency liver transplantation during the early second trimester of pregnancy can result in successful maternal recovery and favorable fetal outcome when managed in an experienced center with close multidisciplinary collaboration. Early recognition of disease progression, timely transplant referral, individualized perioperative planning, and vigilant obstetric surveillance are critical determinants of success. This report contributes valuable evidence supporting the feasibility of pregnancy continuation after early second-trimester liver transplantation and underscores the importance of a mother-centered, multidisciplinary decision-making framework in similar high-risk cases.