Authors: Meng J et al.
Cureus. 17(11): e98092, November 29, 2025. DOI: 10.7759/cureus.98092
Summary:
This case report describes a 41-year-old woman at 38 weeks’ gestation with acute fatty liver of pregnancy (AFLP) and significant laboratory coagulopathy who underwent urgent cesarean delivery under spinal anesthesia without neuraxial bleeding complications. The case is used to challenge the reflex use of abnormal coagulation tests as an absolute contraindication to neuraxial anesthesia in liver disease.
The patient presented with nausea, vomiting, and heartburn. Fetal monitoring revealed recurrent late decelerations and minimal variability, prompting an urgent cesarean. Because of the emergent situation, spinal anesthesia (hyperbaric bupivacaine 0.75%, 12 mg) was administered before lab results were available; the choice of neuraxial rather than general anesthesia was driven in part by active vomiting and aspiration risk. A stillborn fetus was delivered, and the team prepared for massive transfusion while closely monitoring for spinal/epidural hematoma.
Postoperative labs revealed severe liver dysfunction and coagulopathy meeting Swansea criteria for AFLP: marked transaminitis, hyperbilirubinemia, prolonged PT/INR and aPTT, acute kidney injury, hypoglycemia, and falling fibrinogen. Ultrasound confirmed fatty liver. Over subsequent days, the patient developed pancreatitis, disseminated intravascular coagulation, renal failure, and a rectus sheath hematoma, with hemoglobin and platelets dropping substantially. Despite the abnormal coagulation profile, no spinal or epidural hematoma occurred, and the patient recovered with supportive care, being discharged on postoperative day 13.
The authors place this case in the context of evolving understanding of liver disease-associated coagulopathy. Traditional teaching and ASRA-type guidance (e.g., INR ≤1.4) frame elevated PT/INR as a bleeding diathesis and a contraindication to neuraxial techniques. However, modern data suggest that liver disease produces a “rebalanced” hemostatic system with parallel reductions in pro- and anticoagulant factors, such that standard PT/aPTT tests do not reliably predict bleeding risk and may even coexist with a prothrombotic state. Pregnancy adds a hypercoagulable milieu and younger obstetric patients may have a relatively capacious epidural space, further complicating risk assessment.
Literature reviewed by the authors notes that spinal epidural hematoma (SEH) is exceedingly rare in obstetric populations and has only rarely been linked to liver disease-associated coagulopathy. SEH can occur even with normal laboratory values, while large cohorts (including lumbar puncture data) show no clear increase in neuraxial hematoma risk among patients with laboratory coagulopathy. An interdisciplinary task force (ASRA/ACOG/SMFM/ASH) has already argued that PT/aPTT offer limited value in judging neuraxial safety for obstetric patients; history and clinical bleeding phenotype may be more informative.
The case has important limitations: this was not a massive hemorrhage situation; the patient’s platelet count was adequate at the time of spinal placement; and the findings may not generalize to patients with different comorbidities or on anticoagulants. The authors stress that, regardless of lab values, meticulous neurological monitoring after neuraxial block is essential.
Overall, the report argues that abnormal coagulation tests in liver disease, including pregnancy-related liver failure, should not automatically preclude neuraxial anesthesia. Instead, clinicians should integrate laboratory data with clinical bleeding history, physical exam, urgency of delivery, airway risk, and the practical risks of general anesthesia.
What You Should Know
• AFLP frequently produces laboratory coagulopathy, but standard tests (PT/INR, aPTT) poorly reflect true hemostatic balance in liver disease.
• In this case, spinal anesthesia was performed in a patient later found to have marked coagulopathy, with no spinal or epidural hematoma.
• The same patient later developed a rectus sheath hematoma when coagulation tests had normalized but platelets were at their nadir, underscoring the imperfect correlation between labs and bleeding risk.
• Modern concepts of “rebalanced” hemostasis in liver disease challenge the assumption that prolonged PT/INR automatically implies high procedural bleeding risk.
• Large obstetric datasets show an extremely low incidence of SEH, and SEH can occur even with normal coagulation studies.
• Anesthesia decision-making in such patients should emphasize bleeding history, clinical context, and the relative risks of neuraxial versus general anesthesia, not labs alone.
Key Points
• Liver disease-associated coagulopathy is not a simple bleeding disorder; PT/INR and aPTT alone may overestimate neuraxial bleeding risk.
• This case supports the possibility of safely performing spinal anesthesia in selected AFLP patients with abnormal coagulation tests when clinical factors favor neuraxial techniques.
• Pregnancy’s hypercoagulable state and the rarity of SEH in obstetrics further complicate conventional risk thresholds.
• Guidelines and practice should shift toward individualized, physiology- and history-based assessment rather than rigid lab cutoffs.
• Vigilant postoperative neurologic monitoring remains critical whenever neuraxial anesthesia is used in patients with any suspected coagulopathy.
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